What Can Mimic Parkinson’s Disease

Parkinsons And Other Movement Disorders

Parkinsons disease is a brain disorder that leads to shaking and difficulty with walking, movement, and coordination. PD encompasses a variety of syndromes, all of which are progressive and degenerative.

Sample Scan Progressive metabolic reduction from within reference range at baseline , through stages of mild cognitive impairment , and clinical diagnosis of dementia in PDD converter. 3D-SSP t statistic maps comparing single PDD converter to controls with 18F-FDG PET data normalized to pons. Progressive metabolic reductions in cuneus and precuneus occur before less severe, but more widespread, cortical reductions. Sparing of primary sensorimotor cortical strip is present. LLAT = left lateral LMED = left medial RLAT = right lateral RMED = right medial Yr = year.

In individuals with PD, dopamine- and noradrenaline-producing neurons that normally send signals that coordinate muscle movement are destroyed. As a result, the primary symptoms of the disorder are trembling in hands, arms, legs, jaw, and face rigidity, or stiffness slowness of movement and impaired balance and coordination. The disease most often develops after age 50 and symptoms vary from patient to patient.

PD is the most common among a group of movement disorders called Parkinsonian syndromes, all of which have similar symptoms.

The Connection Between Pd And Drug

In addition to potentially causing parkinsonism in the general population, these medications should definitely be avoided in people who have parkinsonism from other causes, such as PD. APDA has created a list of Medications to be Avoided or Used With Caution in Parkinsons Disease. It is important to note that there are anti-psychotics and anti-nausea medications which do not cause parkinsonism and can be used safely by people with PD.

Sometimes, a person without a diagnosis of PD is prescribed a medication which leads to a side effect of drug-induced parkinsonism. The prescribing physician may stop the new medication, but the parkinsonism does not resolve. The patient remains off the medication with continuing symptoms, and eventually is given a diagnosis of PD. In this scenario, that person most likely had dopamine depletion in the brain which had not yet manifested as a clinical symptom. The prescription medication that blocked the dopamine receptor, was the proverbial straw that broke the camels back, inducing the full-fledged symptoms of dopamine depletion and revealing that the person did in fact have PD.

The differences of PD vs drug-induced parkinsonism

There are key differences to note between parkinsonism from PD and parkinsonism as a side effect of medication.

Imaging Biomarkers In Parkinsonism

DaTscan: dopamine-active transporter scans showing binding of 123I-fluoropropyl to DaT protein in the nigrostriatal nerve endings of the striatum. Normal: symmetrical normal specific binding of FPCIT in striatum. Parkinson’s disease: reduced specific binding of FPCIT in the posterior striatum, particularly on the left .

Further imaging approaches are in development on a research basis. 7-T MR scanning can detect structural nigral abnormalities. Diffusion-tensor MRI and diffusion-weighted imaging have shown some promise in diagnosing PD and its mimics. Transcranial sonography can detect hyperechogenicity in the midbrain of patients with PD. Although this is not specific, it may be a marker of susceptibility to PD.,,

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Hypothyroidism And Parkinsons Disease

Abstract

Although it is commonly recognised that diseases of the thyroids can simulate extrapyramidal disorders, a review of the causes of Parkinsonism in the neurology literature shows that they are not usually mentioned or, if so, only very briefly. The development of hypothyroidism in a patient with Parkinson s disease can go undetected, since the course of both diseases can involve similar clinical features. Generally speaking there is always an insistence on the need to conduct a thyroidal hormone study in any patient with symptoms of Parkinson, but no emphasis is put on the need to continue to rule out dysthyroidism throughout the natural course of the disease, in spite of the fact that the concurrence of both pathological conditions can be high and that, in the same way hypothyroidism can simulate Parkinson s disease, the latter can also conceal hypothyroidism.

CASE REPORT:

We report the case of a female patient who had been suffering from Parkinson s disease for 17 years and started to present on off fluctuations that did not respond to therapy. Hypothyroidism was observed and the hormone replacement therapy used to resolve the problem allowed the Parkinsonian fluctuations to be controlled.

How Is Depression Diagnosed

Most people with PD will go undiagnosed or undertreated for depression therefore, being diagnosed is a critical first step towards effective treatment and recovery. To be diagnosed with depression, a person must experience one of the following symptoms most of the time over the previous two weeks:

• Depressed mood
• Loss of interest or pleasure in activities once enjoyed

In addition, some of the following symptoms must be present:

• Changes in sleep or appetite
• Increased fatigue
• Feeling slowed down or restless
• Feeling worthless and guilty
• Suicidal thoughts or a wish for death

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Is There A Link

Some people have MS and Parkinsonâs, but it could be a coincidence.

Research suggests that the damage that MS causes to your brain can lead some people to develop Parkinsonâs later on.

If you have MS, your immune system triggers ongoing inflammation. This can create lesions in your brain that cause Parkinsonâs disease. If lesions form in certain spots in your brain, they can affect how it makes dopamine.

Molecular Imaging And Parkinsons Disease

Because multiple neurological disorders mimic Parkinsons disease and there can be overlaps in multiple conditions, it can be difficult to diagnose. SPECT scanning with the FDA approved radiotracer I-123-ioflupane injection may allow for earlier and more accurate diagnosis of Parkinsons disease. A scan using DaTscan is able to detect dopamine transporters . The distribution of DaTs is abnormal in patients with Parkinsonian syndromes but normal in patients with other conditions, such as essential tremor and Alzheimers disease.

PET scanning with the radiotracer fluorine-18-dihydroxyphenylalanine is a marker of dopamine activity. By revealing a dopamine deficiency, F-18-DOPA PET scanning is used to help diagnose Parkinsons disease and distinguish it from other neurological conditions. PET with F-18-DOPA has also been used to measure the effectiveness of dopamine-producing stem cell transplantation. F-18 DOPA is used in clinical trials but is not FDA-approved.

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What Causes Parkinsons Disease

Parkinsons disease causes are still unknown. However, there is a vast amount of research directed at getting answers to its origin, treatment and prevention.

Parkinsons has been linked to declining levels of dopamine, an important brain chemical. Dopamine is a neurotransmitter. It plays a role in controlling movement and coordination. Parkinsons also causes the nerve endings to die on another neurotransmitter called norepinephrine. Norepinephrine controls automatic functions of the body, which contributes to Parkinsons symptoms such as fatigue, constipation and blood pressure changes .

Testing For Parkinsons Disease

There is no lab or imaging test that is recommended or definitive for Parkinsons disease. However, in 2011, the U.S. Food and Drug Administration approved an imaging scan called the DaTscan. This technique allows doctors to see detailed pictures of the brains dopamine system.

A DaTscan involves an injection of a small amount of a radioactive drug and a machine called a single-photon emission computed tomography scanner, similar to an MRI.

The drug binds to dopamine transmitters in the brain, showing where in the brain dopaminergic neurons are.

The results of a DaTscan cant show that you have Parkinsons, but they can help your doctor confirm a diagnosis or rule out a Parkinsons mimic.

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What Is The Treatment For Parkinsons Disease

There is currently no treatment to cure Parkinsons disease. Several therapies are available to delay the onset of motor symptoms and to ameliorate motor symptoms. All of these therapies are designed to increase the amount of dopamine in the brain either by replacing dopamine, mimicking dopamine, or prolonging the effect of dopamine by inhibiting its breakdown. Studies have shown that early therapy in the non-motor stage can delay the onset of motor symptoms, thereby extending quality of life.

The most effective therapy for Parkinsons disease is levodopa , which is converted to dopamine in the brain. However, because long-term treatment with levodopa can lead to unpleasant side effects , its use is often delayed until motor impairment is more severe. Levodopa is frequently prescribed together with carbidopa , which prevents levodopa from being broken down before it reaches the brain. Co-treatment with carbidopa allows for a lower levodopa dose, thereby reducing side effects.

In earlier stages of Parkinsons disease, substances that mimic the action of dopamine , and substances that reduce the breakdown of dopamine inhibitors) can be very efficacious in relieving motor symptoms. Unpleasant side effects of these preparations are quite common, including swelling caused by fluid accumulation in body tissues, drowsiness, constipation, dizziness, hallucinations, and nausea.

The Right Diagnosis Can Save Time

Because the symptoms of Parkinsons vary and often overlap other conditions, it is misdiagnosed up to 30% of the time, Dr. Fernandez says. Misdiagnosis is even more common in the early stages.

Patients who dont know where to turn may make appointments with a rheumatologist, or an orthopaedic or heart specialist, and undergo MRIs, EMGs and other expensive tests.

But only a neurologist can distinguish Parkinsons from essential tremor, drug-induced Parkinsons and Parkinsons plus syndromes, he says.

If patients come to us with typical signs of Parkinsons, we dont need to order expensive tests, he says.

Instead, neurologists base their diagnosis on a detailed patient exam and medical history, along with other information from the patient, family members or caregivers.

Thats all stirred into the pot, he says. Sometimes we can diagnose Parkinsons with one visit. Other times, several follow-up visits are necessary.

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Drugs And Medication Used To Treat Parkinsons Disease

A number of different drugs can be used to treat Parkinsons.

Levodopa

Levodopa is the most common treatment for Parkinsons. It helps to replenish dopamine.

About 75 percent of cases respond to levodopa, but not all symptoms are improved. Levodopa is generally given with carbidopa.

Carbidopa delays the breakdown of levodopa which in turn increases the availability of levodopa at the blood-brain barrier.

Dopamine agonists

Dopamine agonists can imitate the action of dopamine in the brain. Theyre less effective than levodopa, but they can be useful as bridge medications when levodopa is less effective.

Drugs in this class include bromocriptine, pramipexole, and ropinirole.

Anticholinergics

Anticholinergics are used to block the parasympathetic nervous system. They can help with rigidity.

Benztropine and trihexyphenidyl are anticholinergics used to treat Parkinsons.

Amantadine

Amantadine can be used along with carbidopa-levodopa. Its a glutamate-blocking drug . It offers short-term relief for the involuntary movements that can be a side effect of levodopa.

COMT inhibitors

Catechol O-methyltransferase inhibitors prolong the effect of levodopa. Entacapone and tolcapone are examples of COMT inhibitors.

Tolcapone can cause liver damage. Its usually saved for people who do not respond to other therapies.

Ectacapone does not cause liver damage.

Stalevo is a drug that combines ectacapone and carbidopa-levodopa in one pill.

MAO-B inhibitors

Parkinson Disease & Mimics

Parkinson disease is a complex progressive neurological disease involving the loss of neurons in a part of the brain called the substantia nigra. This results in a reduction in the amount of dopamine, a chemical messenger or neurotransmitter. When this important chemical in the brain is depleted, the symptoms of Parkinsons disease develop.

There are two types of symptoms: motor and non-motor . Common motor symptoms include: essential tremor, slowness of movement, stiffness and impairment of balance later.

Non-motor symptoms vary from person-to-person and more so than the motor symptoms. They can include, low-blood pressure, constipation, speech difficulties , depression, Fatigue, Sleep problems, osteoporosis etc

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Knowing That It Is Msa And Not Parkinsons Is Important

Over the years MSA Coalition Board Members have heard the frustration about a slow diagnosis after the initial diagnosis of Parkinsons.While MSA is fatal, knowing the correct diagnosis, is still important.

Multiple system atrophy affects multiple systems in the body.As a result, while there are not MSA specific treatments, treating the various symptoms from sleep disorders, urinary and bowel issues, blood pressure control, etc. can vastly improve quality of life. The earlier an MSA patient is diagnosed, the earlier doctors can establish a plan of action to improve symptoms that can be very disabling. Another factor is that Parkinsons medications typically stop working in MSA patients.

An early diagnosis also allows patients and their families to spend quality time together while they are still able.It also provides time to prepare for end-of-life issues, such as preparing wills and living wills.

Parkinson’s Disease Caused By Stroke: Vascular Parkinsonism

A stroke involving the substantia nigra or basal ganglia is called vascular Parkinsonism. Similar to other strokes, damage is caused primarily by a lack of blood supply to these regions of the brain. Generally, the strokes associated with Parkinsonism are termed small vessel strokes as they aren’t normally catastrophic. Diagnosis of small vessel strokes can be confirmed with diagnostic tests such as CT or MRI of the brain.

It typically takes several small strokes to produce the symptoms of vascular Parkinsonism. In some cases, small vessel strokes can also produce a type of dementia called vascular dementia. As such, it is not unusual for people who have vascular Parkinsonism to also have vascular dementia.

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Difficulties In Diagnosing Depression In Patients With Parkinsons

• Certain symptoms of depression overlap with symptoms of PD ? for example, sleep problems and feeling slowed down occur in both conditions.
• Some experts think that depression in PD often involves frequent, shorter changes in mood versus a constant state of sadness daily.
• Many people with PD express less emotion due to the effect the disease has on the muscles of the face. This symptom, called facial masking, makes a person unable to express emotion through facial expressions.
• Many people with Parkinsons do not seek treatment because they often do not recognize they have a mood problem or are unable to explain symptoms. For these reasons, it is helpful to ask a caregiver or loved one if he or she has noticed any changes commonly reported in depression.

Living With Parkinsons Disease

Coping with Parkinsons disease, the motor system disorder, can be frustrating because of its common symptomstrembling, stiffness , slow movements, and the loss of balance and coordination. A good deal of that frustration comes from the loss of control that you once had over your body. It can also be emotionally overwhelming to know that there is currently no cure for the disease.

Nonetheless, people have a number of tools at their disposal for better managing the symptoms of Parkinsons disease and living a healthy, enjoyable life.

Heres what can help:

• Speaking and communicating with others
• Being able to solve problems
• Understanding abstract concepts

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Same Day Tests Assessments

There is no single test to diagnosis Parkinsons and reaching a conclusive diagnosis can take time. At Dementech Neurosciences London clinic we offer different levels of care to treat patients with Parkinsons. Because it is far more effective to prevent a disease, our approach involves risk assessments, prevention strategies and tools to manage symptoms and treat the condition and lessen its impact.

However, in cases where a diagnosis of a disease has been established, our multidisciplinary team will do everything possible to treat symptoms and prevent them from progressing further, improving the patients quality of life, emotional health and well-being.

Which Test Can Be Done When The Diagnosis Is In Doubt

I request a small set of tests on almost all patients I diagnose with Parkinsons. These detect some mimics of Parkinsons disease.

Some doctors dont request all these tests. And for a good reason.

The diagnosis of Parkinsons mimics is primarily based on a careful history and examination. Even in my practice, these tests change the diagnosis only in a minority of patients.

I like the additional confirmation provided by these tests. They also have other benefits. For example, they help me determine the proper dosages of medications like Amantadine.

Simple tests to detect Parkinsons Mimics
1. MRI-Brain with size measurements of brain parts called the midbrain and pons. I usually also request a unique picture called SWI, which shows iron inside the brain. 2. Blood tests: Ceruloplasmin level & eye examination to look for a ring of copper Ferritin level HIV VDRL

But when the diagnosis s really in doubt, there is another brain scan that can be done.

A Trodat scan. Or even better an F-DOPA scan. Both these scans measure dopamine activity inside the brain.

You can read more about Trodat & F-DOPA scans by clicking here.

These scans are not perfect. Let me tell you why very quickly:

In Parkinsons disease, dopamine activity inside the brain is deficient. This deficiency produces an abnormal scan. If the Trodat/F-DOPA scan is normal, it is unlikely that you have Parkinsons disease.

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Movement Disorders Similar To Parkinsons

Conditions causing excess movement or decreased movement that are sometimes associated with Parkinson’s disease-like symptoms include:

What Movement Disorder Could I Have?

When making a Parkinson’s diagnosis, your doctor will review your medical history and symptoms, perform a careful neurological exam, and, if necessary, carry out further tests to rule out other movement disorders.

Your symptoms may be caused by a movement disorder other than Parkinson’s disease if:

• You display Parkinson’s disease symptoms and features that are characteristic of an additional movement disorder.
• The results of a brain imaging study or laboratory test, such as a blood test, confirm the presence of another movement disorder.
• Your symptoms do not respond to Parkinson’s disease medication.

Because movement disorders are not all treated the same way, it is important to get a proper diagnosis as early as possible so you can formulate the right treatment plan with your doctor.