CLINICAL DECISIONS IN THE PARKINSONíS SYNDROME

Dr. Mathew Abraham MD DM

Senior Consultant Neurologist, Kochi

The clinical description of the disease by James Parkinson in 1817 still remains unsurpassed. Rest Tremor, Rigidity and Bradykinesia are the characteristic features of PD. Two new symptoms are now included in the clinical criteria - loss of postoral responses, and a good response to L-dopa. There are still no specific tests or markers for the diagnosis of PD - it therefore still remains a clinical one. A correct diagnosis at the earliest is vital for proper treatment and prognosis. Drug induced Parkinsonism differs from PD in that it is more symmetrical than PD and usually bradykinetic. In Benign Essential Tremor, there is no bradykinesia, and the Tremor is an intentional one, not present at rest. In PD, it is a rest tremor that characteristically reduces or disappears on intentional movement. Other diagnoses that come to mind at this stage are Atherosclerotic Parkinsonism, Bilateral Subdural Hametoma, Normal Pressure Hydrocephalus, and Depression. It is very important to differentiate the Parkinsonís plus syndrome from idiopathic PD, as the prognosis and response to L-dopa are totally

different in these. Progressive suprananuclear palsy is characterised by its symmetrical akinetic nature in the relative absence of tremor, the slow eye movement and tendency to early repeated talk. Multi System Atrophy (MSA) has a predominant autonomic component, with a spectrum of extrapyramidal and cerebellar signs. Corticobasal Degeneration has a characteristic persisting asymmetry, with cortical aphasia and sensory signs, along with the alien hand phenomenon. The treatment of PD is to be highly individualised. A small group of patients with early PD do not require drug treatment. In those patients whose quality of life is affected, treatment may be initiated with Selegellin anticholinergics or Amantadine. There is now a window of opportunity for the use of Dopamine agonists in early PD, where drugs like Pramipaxole and Ropinerole can be started with good effect. The general principle - start low and go slow - holds true with all drug treatment in PD. In general the treatment of early PD is very gratifying, but advanced PD still remains a great challenge for the physician.