PARKINSON’S DISEASE :

DIAGNOSTIC CRITERIA AND

EARLY MANAGEMENT

Andradi S.
Department of Neurology, University of Indonesia,
Jakarta, Indonesia
 CURRICULUM VITAE
Nama : Dr ANDRADI SURYAMIHARJA SpS (K)

Tempat/tanggal lahir : Tangerang, 13-11-1938

Pendidikan :

• 1964 Dokter , FKUI

• 1972 Dokter Spesialis Saraf, FKUI, Jakarta
• 1985 University of New South Wales,Sydney, Australia.
• Workshops/courses: Parkinson’s disease and Movement Disorders
• Botox injections, Stroke, Pain, Vertigo
• EEG, Epilepsy

Pekerjaan :

• 1963 - 2003 Staf Pengajar Bagian Saraf FKUI

• 2002 - 2003 Koordinator Penelitian Bagian Saraf FKUI
• 1986 - 2003 Ketua Sub-Bagian Neuro-otologi Bagian Saraf FKUI
• 1975 - 2003 Staf Sub-Bagian Neuro-oftalmologi Bagian Sara FKUI
• 2001 - 2003 Staf Pengajar International Class FKUI
Organisasi :

• Anggota IDI
• Anggota/Pengurus PERDOSSI (Perhimpunan Dokter Spesialis Saraf Indonesia)
• Ketua Komisi Ujian Nasional, Kolegium Neurologi Indonesia
(sampai dengan tahun 2011)
• Anggota WFN ( World Federation of Neurology)
• Anggota ASNOS ( Asian Neuro-ophthalmology Society)
• Anggota / Anggota Pengurus Pokdi Nyeri, Pokdi Vertigo, Pokdi Stroke,
Pokdi Parkinson dan Movement Disorders
• Anggota/Pengurus Ikatan Keseminatan Kardioserebrovaskular Indonesia
(IKKI)
• Anggota AAN (American Academy of Neurology)
 PARKINSON’S DISEASE:
CLINICAL DIAGNOSTIC CRITERIA

1. Historical Diagnostic Criteria

Symptoms: Tremor, Rigidity, Akinesia, Postural Instability (TRAP)

• Two of three cardinal symptoms (2/3 TRA)

- Tremor, Rigidity, A kinesia / bradykinesia
OR
• Three of four symptoms (3/4 TRAP)
Tremor, Rigidity, Akinesia, Postural instability
OR
• Responsive to L-DOPA.
 PARKINSON’S DISEASE:
NEW CLINICAL DIAGNOSTIC CRITERIA

(UK Parkinson’s Disease Society Brain Bank / UKPDSBB)

Step 1. Diagnosis of Parkinsonism

Step 2. Exclusion criteria for Parkinson’s disease

Step 3. Supportive prospective positive criteria for

Parkinson’s disease
 UKPDSBB CLINICAL DIAGNOSTIC CRITERIA

Step 1. Diagnosis of PARKINSONISM

√ BRADYKINESIA
+
At least ONE of the following:
√ RIGIDITY
√ REST TREMOR (4-6 Hz)
√ POSTURAL INSTABILITY not caused by primary
visual, vestibular, cerebellar, or proprioceptive
dysfunction
 UKPDSBB Clinical Diagnostic Criteria

Step 2 Exclusion criteria for Parkinson’s disease

• History of repeated strokes with stepwise progression of
parkinsonian features
• History of repeated head injury
• History of definite encephalitis
• Oculogyric crises
• Neuroleptic treatment at onset of symptoms
• More than one affected relative
• Sustained remission
 Step 2 Exclusion criteria for Parkinson’s disease (cont’d)
• Strictly unilateral features after 3 years
• Supranuclear gaze palsy
• Cerebellar signs
• Early severe autonomic involvement
• Early severe dementia with disturbances of memory, language,
and praxis
• Babinski sign
• Presence of cerebral tumor or communication hydrocephalus
on imaging study
• Negative response to large doses of levodopa in absence of
malabsorption
• MPTP exposure
 CBD
(Corticobasal Degeneration)
Asymmetric Parkinsonism with Poor Response to
Levodopa
Apraxia and Alien Limb
Spasticity, Rigidity, Dystonia
Gait and Balance Problem
Dementia always occurs, but may be a late feature
 MSA
(Multiple System Atrophy)
 Cardinal Findings
 Parkinsonism that is poorly responsive to Levodopa
 Autonomic Failure (Low Blood Pressure)
 Cerebellar Signs
 Long Tract Signs (Spasticity)
 Striato-Nigral Type (Parkinsonism First)
 Shy-Drager Syndrome (Autonomic Failure First)
 Olivo-ponto-cerebellar Type (OPCA-Ataxia First)
 Ataxia
Symptomatic Interruption of the Cerebellar Pathways
Dysmetria (Poor targeting of planned movements)
Dysdiadochokinesia (Poor sequencing of planned
movements)
Intention Tremor (Past Pointing)
 Gait Abnormalities
Wide based gait
Poor balance
*Drunken Sailor’s Walk*
 LBD
(Diffuse Lewy Body Disease)

Unlike PD, Lewy Bodies rapidly spread throughout

the brain, including the cerebral cortex
Levodopa Responsive Parkinsonism
Rapidly Progressive Dementia
 Hallucinations
 PSP
(Progressive Supranuclear Palsy)

Early Postural Instability and Falls

Parkinsonism (Unresponsive to Levodopa)
“Stone Face”
Dementia
Ocular Signs
 Drug Related Parkinsonism
Haldol and other antipsychotic medication cause
symmetric findings that are indistinguishable at
times from Idiopathic Parkinson’s Disease
Reglan is a dopamine blocker and is an important
cause of Parkinsonism in elderly patients (currently
used as an anti-nausea medication)
 UK PDSBB CLINICAL DIAGNOSTIC CRITERIA

Step 3. Supportive prospective positive criteria for

Parkinson’s disease
Three or more required for diagnosis of definite Parkinson’s disease in
combination with step one
• Unilateral onset
• Rest tremor present
• Progressive disorder
• Persistent asymmetry affecting side of onset most
• Excellent response (70-100%) to levodopa
• Severe levodopa-induced chorea
• Levodopa response for 5 years or more
• Clinical course of ten years or more
 CONCLUSIONS
Diagnostic Criteria
1. Parkinson’s disease is one of the types of
Parkinsonism which is characterized by Tremor,
Rigidity, Akinesia, and Postural Instability (TRAP)

2. Diagnosis of PD is based on clinical findings,

comprising of 3 steps: diagnosis of Parkinsonism,
differentiating Parkinsonism types, and positive
symptoms supporting PD
 TREATMENT STRATEGIES IN PD

Parkinson’s Disease

Idiopathic Progressive Degenerative

Underlying cause ? Neuroprotection ? Neurorestoration ?

Symptomatic
 SYMPTOMATIC TREATMENT

I. MEDICAL
1. Pharmacologic
a. Dopaminergic agents
b. Cholinergic agents
c. Non-motor symptoms therapy

2. Non-pharmacologic
Education, self-help group, exercise, speech therapy

II. SURGICAL
1. Ablative / Lesioning
Thalamotomy, pallidectomy.

2. Deep Brain Stimulation

Pallidum, nucleus subthalamicum
 SYMPTOMATIC TREATMENT

I. MEDICAL
1. Dopaminergic:
- L-Dopa/benserazide
- Dopamine agonist: oral  bromocryptine, ropinirole,pramipexole, apomorphin,
patch  rotigotine
- MAOB inhibitor: selegilline, rasagiline
- COMT inhibitor: entacapone, tolcapone.
- NMDA receptor antagonist: amantadine.

2. Cholinergic:
trihexyphenidyl.
 BRAIN
Ganglia basalis
Dopamin Acetylcholin Normal
MAO MAO I ( selegiline )
Anticholinergic
Perokside Radical H (Trihexylphenidyl)
Dopamin Tissue
Receptor D2 Dopamin damage
Decarboxylase
Levodopa Acetylcholin PD
BLOOD BRAIN BARIER
Levodopa 3 OMD
COMT Inhibitor
COMT
Dopamin Agonist (entacapone)
Decarboxylase

Ergot
Decarboxylase Inhibitor
Non Ergot Dopamin
(bromocryptin) (pramipexole, (Benzeraside)
rotigotine) PERIFER (carbidopa)
 PHARMACOLOGIC TREATMENT

When to initiate therapy ? Which agent for which patient?

● When to initiate therapy ?

Pharmacologic therapy is initiated when functional impairment appears.

● Which agent to choose ?

Benserazide/L-Dopa, DA agonist (oral, patch), MAOB-I, COMT-I, or Anticholinergic ?

● For which patient ?

- Age : < 60 yo, > 60 yo
- Stage: early, advanced
- Drug adverse effect
- Cost
 Algoritma Penatalaksanaan Penyakit Parkinson

Gangguan Fungsional
Ya Tidak

Terapi Neuroprotektif
Terapi simptomatik
Antioksidan
Tremor dominan ?

Ya Tidak

Antikolinergik Usia < 60 tahun Usia > 60 tahun

Dopamin Agonis (oral: Pramipexole
patch: Rotigotine)
Dopamin agonis (oral: Pramipexole Levodopa
patch: Rotigotine)
Dopamine agonis+levodopa dosis rendah
Dosis levodopa optimal

Respon terhadap pengobatan

Baik Tidak respon Wearing off Diskinesia

COMT-Inhibitor Turunkan dosis levodopa

Maintenance dosis Tingkatkan dosis
Kombinasi Dopamin Tingkatkan dosis dopamine
rendah Diagnosa lain
agonis+ levodopa agonis
tambah levodopa Beralih ke dopamine agonis
antikolinergik Pembedahan
TREATMENT OF EARLY PD
 INITIAL THERAPY FOR EARLY PD

IN YOUNG PATIENTS ( < 60 yrs )

● Agents
Anticholinergic, DA agonist (oral, patch), amantadine, or MAOB-I.

● Benefit
- mild symptomatic control for 6-8 months
- less than L-Dopa

● Motor complications: < L-Dopa

Non-motor complications : > L-Dopa
(Hallucination, somnolence, orthostatic hypotension)
 INITIAL THERAPY FOR EARLY PD

IN OLD PATIENT ( > 60 yrs )

● Agents: - L-Dopa , or
- DA agonist (oral, patch) / other dopaminergics

• Options (both are acceptable):

1. L-Dopa
- The most effective
- Motor and non-motor complications after few years
 add DA agonist (oral, patch) / other DA-ergics

2. DA agonist or other dopaminergics

- Less effective  later needs L-Dopa
- Adverse effects: hallucination, somnolent, orthostatic hypotension.
 CONCLUSION
Early Treatment
- Current treatment of Parkinson’s disease is mainly
symptomatic, since therapeutic modalities to slow the
progression of this disease are not yet proven efficacious.
- To initiate symptomatic treatment consider:
- Functional impairment
- Patient age
- Disease stage
- Severity of clinical symptom
- Drug profile
THANK YOU..