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May 10, 2006
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| The physicians and staff of The Neuroscience Group are providing this physician and provider communication to help you stay abreast of issues and updates in the dynamic field of neurosciences, with the goal of helping you provide better overall healthcare services to your patients. |
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Practice Parameter: Diagnosis and Prognosis of new onset Parkinson’s Disease |
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| Joining the ranks of the almost 1.2 million people in the United Sates with Parkinson’s disease, patients are faced with adaptations that differ from other chronic diseases. The incidence of Parkinson’s disease, as well as other neurological diseases, is estimated to increase significantly as older persons become a substantially larger portion of the population. Alzheimer’s disease and stroke lead the list of the most prevalent neurological diseases. There are presently over 4 million Americans with dementia due to Alzheimer’s disease or related disorders. It is estimated that the incidence of strokes will increase by 118% from 2000-2015, Alzheimer’s disease by 32% , Epilepsy by 15%, Parkinson’s disease by 24%, and Primary Brain Cancer by 73%. |
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The American Academy of Neurology Quality Standards Subcommittee recently released practice parameters for the diagnosis and prognosis of new onset Parkinson’s disease (PD). Two clinical questions were addressed: 1) Which clinical features and diagnostic modalities distinguish PD from other parkinsonian syndromes? 2) Which clinical features predict the rate of disease progression? As a neurodegenerative disorder, loss of dopaminergic neurons is responsible for the signs and symptoms used to diagnose PD. PD is a progressive disorder that eventually results in significant morbidity. According to Suchowersky, et al, AAN April, 2006, between 5 and 10% of patients with PD are misdiagnosed. Almost 20% of those diagnosed with PD have an alternative diagnoses at autopsy. The underlying task is to rule out drug-induced parkinsonism as well as diseases that mimic PD, such as essential tremor, progressive supranuclear palsy, multiple system atrophy and cortical basal ganglionic degeneration.
Establishing a diagnosis of PD requires a meticulous clinical exam and a working knowledge of the differential diagnosis relative to other movement disorders. The 4 hallmark features have always been resting tremor, bradykinesia, cogwheel rigidity and postural instability. The conclusions from this intensive literature review indicate that 1) early falls, poor response to levodopa, symmetry of motor manifestations, lack of tremor and early autonomic dysfunction are probably useful in distinguishing other parkinsonian syndromes from PD. Drug challenges with levodopa or apomorphine were effective ways to distinguish PD from parkinsonian syndrome. Olfaction is frequently impaired in early PD. Three class 2 studies yielded a 77% sensitivity and 85% specificity in distinguishing PD from other parkisonian syndromes using “Sniffin’ Sticks.” |
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Clinical features that predict the rate of disease progression were reviewed. Age of onset over 57-78 years and rigidity/hypokinesia as presenting symptoms were indicative of more rapid disease progression. Co-morbidities (stroke, auditory deficits and visual impairments), being male, having postural instability or gait disturbance were predictive of a more rapid progression of disease. Tremor on initial presentation has been linked to a slower disease progression and longer response to levodopa. |
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| Providers must be cognizant of the adaptations required in living with PD. Realistic, caring, education-based strategies must be incorporated into the diagnosis and follow-up care required as the disease progresses regardless of the pace of progression. Treatment options will be outlined in the next issues of Neuroscience Provider Insights. Dr. Lisa Kokontis has established a sub-specialty practice caring for patients with Parkinson’s disease and other movement disorders. |
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