Early signs of Parkinson’s disease: making the diagnosis

Early signs of  Parkinson’s  disease: making the diagnosis

Nitin K Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY 10065

 

Well it is the start of a new year and a new decade. Welcome twenty ten. I wish all the readers of my blog a very happy new year. Recently I saw a patient in my office and he shall be the subject of my post. He came to see because of his tremor. Actually I should not say he came to see me, the patient infact felt there was nothing wrong with him.

Dr. Sethi, I have noticed a tremor in my right hand for the past 3 months. It does not bother me. I feel fine. It is my wife who wants me to come and get this checked out” he said.

As I examined him I realised his ” hand shakes” problem was something more sinister as I found tell tale signs suggestive of Parkinson’s disease. That is what I shall discuss here, how does one go about making the diagnosis of Parkinson’s disease ? What are the points in the history and examination that make me as a doctor consider this diagnosis?

Parkinson’s disease may start off very innocuously. All my patient had noticed was that for the past3 months he had a tremor in his right hand. The tremor did not bother him and did not interfere with any activity of daily living such as writing, getting dressed, eating and so forth.  He in fact would not have sought a neurological consultation if his wife had not insisted.  That said and done, there are certain characteristics of the tremor which can aid in the diagnosis. The classical tremor described with Parkinson’s disease is what is called a resting tremor. Now pray what does that mean? Simple the tremor is most prominent when the hands are rest. Let me explain with the aid of an example. While I was talking to my patient and eliciting his medical history, my visual attention was focussed at his hands which were at rest on his lap. I noticed his right hand to have a tremor, the tremor became more prominent when he was distracted. If I asked him to look at his right hand, he could stop the tremor for a few seconds but then the tremor came back. He did not have  a tremor in his left hand or in his legs. When the arms were extended (held up in front of him), the tremor  abated.

So point number 1:  Sporadic Parkinson’s disease usually starts of in the sixth to seventh decade of life. The initial presentation may be quite subtle with only a mild tremor. The tremor initially is asymmetrical (that is it may only be in one hand) and classically it is a resting tremor (most prominent when the hands are completely at rest). The tremor becomes less prominent when the hands are doing something (in motion) and completely abates when the patient falls asleep. Remember the tremor at least initially during the disease course may not be bothersome for the patient and may not impair his quality of life. Hence the patient may not seek attention and the diagnosis may be delayed.

There are some other early signs of Parkinson’s disease. On close inspection I was able to document them in my patient too. When he spoke to me, his face lacked the usual emotions. What do I mean by that. Well when we speak our face show a variety of emotions, we frown, we roll our eyes, sometimes our eyes smile and so forth. A Parkinson’s disease patient has what is called a “mask-like” face-there is a paucity of normal facial expressions.

So point number 2.  Mask like face

Parkinson’s disease patients have a characteristic gait. For want of better words, they walk stiffly. The classical gait is described as bent forward, walking with short quick steps (as if they are going to topple over) and the arms are held by the side (they do not have the usual arm swing).

So point number 3. Gait (They walk funny!!!)

So if you or any of your loved ones show these signs, make sure you get a neurological opinion. Your doctor shall be able to elicit further points in the history and examination which shall help secure the diagnosis of sporadic Parkinson’s disease. Remember the diagnosis of Parkinson’s disease remains a clinical diagnosis (one made by a doctor after history and examination). There are no confirmatory tests (at least none that are used in the office setting).

 

 

 

Falls in neurodegenerative conditions: what can be done?

               Nitin K Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY 10065

FALLS ARE COMMON IN THE ELDERLY!!!

Falls are common in neurodegenerative conditions so that is what I shall discuss in this post. Patients with diseases like Alzheimer’s dementia, fronto-temporal dementia (Pick’s disease), multi-infarct dementia (vascular dementia), Parkinson’s disease, multiple sclerosis, Progressive Supranuclear Palsy and some post stroke patients are all prone to falls either early or sometime in their disease course.

FALLS CAUSE MORBIDITY AND MORTALITY!!!

Falls are an important cause of morbidity and mortality in this vulnerable population. Imagine a-85-year old man with Alzheimer’s dementia. Even though he has cognitive deficits (decreased memory and problems with other cognitive skills like calculation, abstract thinking and language) he is still relatively mobile. Every day he takes a 30 min walk in his immediate neighbourhood. One day while walking, he trips over and falls when his foot gets caught in a crack in the side-walk. He is unable to get up by himself . Help only reaches him after an hour when his family comes looking for him. He is rushed to the nearest hospital where an X-ray reveals fracture of the hip and the pelvis. Surgical management is indicated for fracture stabilization.  He is admitted to the hospital and the hospital course gets complicated by development of pressure sores (bed sores), deep venous thrombosis (blood clots in the veins of the legs) and pulmonary embolism (blood clot in the lung vasculature).  All these are directly related to his forced immobilization due to hip and pelvic fractures. He gets progressively more disoriented during his prolonged hospital stay though survives and makes a slow recovery and is discharged to a sub-acute facility.

FALLS HURT AND CAUSE INJURIES!!!

Falls may lead to various injuries:

1) Fractures of the hips, long bones: tibia, fibula, femur, neck of femur, radius, ulna

2) Neurotrauma: head injuries: subdural and epidural hematomas, sub arachnoid hemorrhage, intracranial hemorrhage (bleeding into the brain)

3) Craniofacial injuries: injuries to the face, eyes, the orbit

4) Fractures of the ribs

5) Back injuries

THE STATISTICS ARE SCARY!!!!

The incidence of hip fracture increases as the population ages. One in five persons dies in the first year after sustaining a hip fracture, and of those who survive past one year many have significant functional limitation. Of those who survive one year after hip fracture, only 40 percent can perform all routine activities of daily living and only 54 percent can walk without an aid.

WHY DO THE ELDERLY FALL???

Why are falls common in the elderly and more so in the elderly population with a neurodegenerative condition? The causes are many:

1) Poor eye-sight (as we age cataracts and other retinal degenerative conditions become common contributing to poor eye-sight). They have poor depth perception and visual contrast sensitivity.

2) decreased acuity of hearing

3) concomitant neuropathy (many of the elderly population may have a condition like diabetes giving rise to a concomitant peripheral neuropathy. Persons with a sensory motor polyneuropathy are not able to sense the ground and thus their righting reflex is off). RIGHTING REFLEX: various reflexes that tend to bring the body into normal position in space and resist forces acting to displace it out of normal position.

4) Neurological conditions like Parkinson’s disease and Alzheimer’s dementia impair these postural reflexes/ righting reflexes making patients even more prone to falls and resultant injuries.

5) The elderly are on multiple medications like  benzodiazepines, anticonvulsants, sedatives and  antihypertensives which may contribute to the falls. 

6) Risk of osteoporosis and osteopenia increases as we age: when the elderly fall they are more likely to hurt themselves or fracture their bones.

7) Other concomitant medical conditions like diabetes, kidney problems, thyroid problems, blood pressure problems and cardiac problems may contribute to the falls.

WHAT CAN BE DONE?

The big question is how to prevent falls in the elderly. A number of interventions may help.

1) Treat the neurodegenerative/ underlying condition contributing to the falls. Gait and postural reflexes of patients with Parkinson’s disease improve when they are treated with medications like Levodopa-carbidopa and dopamine agonist. The response though varies, their tremor may improve though their gait may still remain off.

Good control of blood sugar in a diabetic patient helps and may halt the progression of the neuropathy.

Alzheimer’s disease patients also gain some benefit in their gait and mobility when they are treated with medications like Aricept.

2) Correct visual/ eye problems: timely cataract surgery, corrective lenses and glasses all help in improving stability and confidence of the elderly patient.

3) Hearing aids may be of help in those who have hearing loss.

4) Restriction of outdoor activities may be advisable in a patient who is at high risk of falls. If that is not acceptable, these activities should be carried out under direct supervision. Keep a walking partner etc.

5) Correct mechanical/ musculoskeletal gait problems such as ingrown toe nail, back and hip pain, foot drop etc.

6) Regular exercise is helpful. By keeping muscles supple and maintaining their tone it ensures that righting reflexes are not lost.

7) Physical therapy may be immensely helpful in some patients (laying emphasis on gait retraining).

8) Use of assist devices like canes (single point, four point), walker is helpful.

9) Fall proof the home and immediate patient surroundings: remove anything which may cause injury if the patient falls-this includes sharp objects, tables with sharp edges, loose carpets.

have fall prevention devices at the top of stairs.

have a bed whose sides can be put at night (just like in the hospital).

have an alarm or some other call device set-up at home so that help can be summoned.

Last but not least” MOST FALLS OCCUR TO AND FROM THE BED TO THE BATHROOM AT NIGHT, SO LEAVE THE BATHROOM LIGHT ON AT NIGHT!!!”

 

Falls in the elderly: making sense of the numerous causes

Today I consulted on a 90-year-old lady who had been admitted to the hospital for evaluation of frequent falls. Even though she was 90, she was a young 90. Very alert and interactive and with normal strength in bed and mentation.

Since falls in elderly is a common problem, I thought why not discuss about this here. Falls are an important cause of morbidity and mortality especially in the elderly. This is a complicated topic and I shall tackle it by first discussing about how we maintain our balance.

Balance in humans is maintained due to a complex interaction of various neurological and muscular systems. There are added inputs from the visual and auditory systems which help in maintaining stability.

Hence problems with balance and stability may arise from primary neurological conditions, either problems involving the central nervous system such as the cerebellum or the peripheral nerves as in neuropathies. The peripheral nerves carry the sensation of joint sense (where the joints are with respect to space, vibration sense and position sense (suppose you are standing on a cold floor. Even with your eyes closed you are able to make out that the floor is cold, is it even or uneven, is it soft or hard. Now if you had a severe neuropathy and had no joint sense or position sense, then if your eyes were closed you shall be unstable and liable to fall).

We also need visual and auditory cues to maintain balance  (imagine trying to walk to the bathroom at night in a pitch dark room. You shall be unsteady and liable to fall and hurt yourself).

Then there can be mechanical, neuromuscular and othopedic causes of gait instability.Example you have had a stroke in the past and hence you are weak in one leg, have had a fracture of one of the long bones of the leg or you have a myopathy, all these conditions make you prone to falls.

So how does one make sense of the numerous causes of falls in the elderly? Diagnosing the etiology of falls can be one of the toughest tasks in clincal medicine. At times in a given patient the etiology is multifactorial (combination of old age and general deconditioning, poor eyesight as we age, poor hearing as we age, superimposed neuropathy etc).

You need to see an astute physician who is willing to spend time to pinpoint the problem. The workup starts with a good history and a thorough neurological examination. Is the problem confined to the central nervous system or is it coming from the peripheral nervous system? Are there any orthopedic causes contributing to the problem? Does the patient have poor eye sight?

Your doctor shall make you walk to see your balance, test your reflexes, test your coordination with the eyes open and then closed. Further workup may include an imaging study of the brain or spinal cord and nerve conduction studies.

So if falls are your problem or that of a loved one, please do see a doctor. You can be helped!!!

Personal Regards,

Nitin Sethi, MD