PADRECC NATIONAL VANTS AUDIO CONFERENCE Atypical Parkinsonian Disorders Eugene C. Lai, M.D., Ph.D. May 14, 2009 Welcome everyone. So, today we are going to spend a little time talking about conditions that we almost see every day in the clinic. A person is a little slow, a little stiff from walking and balance. How are we going to distinguish what kind of a problem a patient has? So, I would try and go through that. There is a quite a bit of material. It will help if you have the slides, but if you don’t, in case you get lost, just tell me to slow down and I will try to accommodate. I would talk for the next 45 minutes and then we will open up for questions in the last 10 minutes or so. So, I think most of you have the handout already and for technical reasons, I am not at the VA right now, I am at my university office, so I don’t actually see the handout, directly myself, I have my own slides, so I will just kind of go through that. If you get lost at which slide I am at, again, please mention that and I will tell you what it is. So, Parkinsonism is an akinetic-rigidity syndrome. So, Parkinsonism means that a person has symptoms of Parkinson’s Disease. It includes Parkinson’s Disease and a whole group of disorders. The most common symptoms are akinesia Or lack of movement or bradykinesia, slowness of movement or rigidity, stiffness of muscles. Postural instability, they lose the muscle tone, gait impairment, they are imbalanced and tremor. So, these are what we call Parkinsonism symptoms. It is a common age related syndrome. I said it is a syndrome because it has quite a number of specific disorders. When we talk about atypical Parkinsonism, it includes several conditions. One as a bigger group, it’s called Parkinson Plus Syndromes and I will explain what they are in a little bit. The second one is called Secondary Parkinsonism. Usually, the Parkinsonism, the symptom is due to some acquired disorder and the features are early falling, early dementia, cognitive decline or early autonomic dysfunction, which allows a particular condition to be distinguishable from the regular idiopathic Parkinson’s Disease. Next slide. Let me start by kind of going through some of the essential features of Parkinson’s Disease. So, in general consideration, Parkinson’s Disease is the second most common progressive neurodegenerative disorder that we see, the most common one, of course, is Alzheimer’s Disease. It is the most common neurodegenerative movement disorder. So, when we see patients in the movement disorder clinic, Parkinson’s Disease is the most common condition that we see. It is a complex disease with really a whole host of variable symptoms and we have to be attentive to all of them. The symptoms of Parkinson’s Disease and its neuropathology are well characterized. We know that it is due to a lack of cells in the substantia nigra due to a lack of Padopamine and symptoms as I mentioned earlier. We know that. However, the pathogenesis of Parkinson’s Disease is really not very clear. We don’t know how it starts, why it starts and so on. A lot of research is going on at this time. It may be multifactorial heterogeneous in etiology. It may be genetics, that’s one contribution, environmental in fact is also a contribute to it. One important thing also, is that Parkinson’s Disease is often misdiagnosed to about 10 – 25% of the time. That’s why we have the topic today because a lot of times, the atypical Parkinsonian Disorders are thought of as just regular Parkinson’s Disease, but they may not be. They may be due to some other conditions, as I will explain in the following. Next slide. So, Parkinson’s Disease, the main features of Parkinson’s Disease is tremor. It is very characteristic of rest tremor, a person shakes when they are not moving. Often times, we ask the person to relax, put their hands on their laps and close their eyes and if we still see that they are shaking, then it is rest tremor as opposed to an action tremor. That would be when they try to do things, hold a cup or you know, try to use their hands, that is not typical of Parkinson’s tremors. Parkinson’s tremors are a resting tremor. Rigidity is a significant component of how when you move the arm MODERATOR IS UNINTELLIGBLE, click, click type of a feeling to it is called wheeling rigidity. Bradykinesia or akinesia and postural instability, so these are the cognitive symptoms of Parkinson’s Disease. We teach our residents to remember TRAP as the four cognitive symptoms. And there are also associate symptoms because people usually don’t come to you and say oh, I have bradykinesia, postural instability. Next slide. So, what do they usually tell us in people with the beginnings of Parkinson’s Disease, they might complain of micrographia. The handwriting is becoming smaller and smaller in the last year or two or hypophonia. That their voice and their projection is much lower of hypomimia is that their face is a little bit blanked with less expression. Not uncommonly, these are actually mentioned by their spouse or caregiver. And then, they feel they are a little unsteady because they are walking smaller steps and sometimes, they can walk faster and couldn’t stop. These are shuffling gaits and the way that they walk, faster and faster is called festination. They have a little bit of drooling, especially when they sleep at night. They have some difficulty swallowing, dysphagia. They have some autonomic dysfunction that when they stand up, they might feel a little dizzy, their blood pressure drops some. When they eat, they might sweat a lot because they are not well controlled in the temperature. And then when they get to be a little bit more advanced, they have depression and dementia too. Next slide. So, in Parkinson’s Disease on the slide it says “Features Supporting Diagnosis” and these are the essential things that we look for when we examine a patient initially. Parkinson’s Disease often has a unilateral symptom onset. One side is a little stiffer, a little slower, maybe a little shakier than the other side. That’s a common sign that we see and it has a characteristic resting tremor, as I mentioned. They walk with a gait that is quite characteristic. They flex their knee, although they are a little unsteady and shuffling, their base is real narrow. It’s not like an older person that is unsteady that spread out their knees. So, they have a narrow base gait, flexed the knees and with a stooped posture, very characteristic. And then they have a reduced arm swing with a little tremor when they walk. More importantly, features of pulling the diagnosis, eventually, we decide that this patient has etiopathic Parkinson’s Disease is that they receive benefits from the levodopa treatment and as you can see, a lot of the atypical Parkinson’s disorders, although they look like Parkinson’s Disease, when we give them levodopa, they do not respond very well. They don’t really benefit from it and that kind of will raise the red flag that that may not be regular Parkinson’s Disease. It could be one of the atypical ones. Next slide. So, let’s then talk about these atypical Parkinsonism. So, diseases associated with Parkinsonism. A little slow, a little stiff in walking, a little shuffling, a little imbalance. They kind of easily topple over. So, because there’s a large number of them, so we will kind of group them into three main groups. One is the sporadic diseases, sporadic disorders. Parkinson’s, of course is the most common. Then we have these conditions. I am just going to run down them very quick. You have your handout and you can look at it later. It’s multiple system atrophy, dementia with lewy bodies, progressive supranuclear palsy, Corticobasal degeneration, prion diseases and there’s a condition called Amyotrophic-Parkinson-dementia complex of Guam and then we have Pallidal degeneration and Hemiatrophy hemiparkinsonism and these are kind of sporadic of neurodegenerative conditions. Next slide. Then we have a whole group that again, they could present as slow and stiff and somewhat imbalanced, but they are hereditary disorders. They are like Huntington’s Disease, Wilson’s Disease, Juvenile onset Parkinsonism, Hallervorden-Spatz disease, Dentatorubropallidoluysian atrophy (DRPLA), Frontotemporal dementia with parkinsonism, Hereditary prion diseases, Lubag, Machado-Joseph disease (SCA 3), Neuroacanthocytosis, Type 3 GM1 gangliosidosis. So, these are hereditary ones and usually people exhibit symptoms as a child or in their early teens and so on. Next slide. The last one group is the acquired disorders. We also have to be aware of them. They are the drug induced Parkinsonism, Vascular parkinsonism, Toxic parkinsonism, people taking toxins, Post-traumatic parkinsonism after head injuries, Post-encephalitic parkinsonism, after infection, so encephalitis, Prion diseases, Extrapontine myelinolysis due to incorrect, correction of hyponetphemia, Space occupying lesions and Hydrocephalus. So, as you can see, there are many, many disorders. Today, because of time limitations, I only can go through some of the common ones and I want to share some of their features with you. Next slide. This slide may be of some use to some of you. There is the American Academy of Neurology, AAN Practice Parameter to tell us what clinical features really distinguish in other Parkinsonism syndromes from Parkinson’s Disease. How do we separate atypical Parkinsonism Disorders with Parkinson’s Disease? So, these again, are the things that we pay attention to or whether these people fall at presentation, just the initial symptoms or early in the disease course. These are not typical of the regular etiopathic Parkinson’s Disease. Poor response to levodopa, I mentioned that already. If they don’t respond, then I’ll have a question in my mind whether they are the regular Parkinson’s Disease. Symmetry and onset, both sides are very equal. As I mentioned before, Parkinson’s typically starts the shaking and the stiffness in one side more than the other. Rapid progression, Parkinson’s Disease will be slowly progressive and it goes on for 15 – 20 years. But, some of the typical Parkinson’s Disease can be quite rapid and they can go from what we call an H&Y stage for a person that starts with both sides with the falling with postural instability like three years of symptom onset. That’s not very common in Parkinson’s Disease. If they don’t have a tremor, we again are worried that there could be some other things or other dysautonomia. They have a lot of hypotension. They have constipation, irregular heartbeats or inappropriate sweating. Next slide. So, I just want to say a few words about the basil ganglia. All these diseases, the Parkinsonian Disorders are all because of due to some abnormality in the basil ganglia. So, the basil ganglia is a group of nuclei in the deep part of the brain, the cerebrum and upper brainstem that includes these structures. I know it just lists here, caudate, putamen, globus pallidus, subthalamic nucleus, substantia nigra are the basic components. It coordinates the muscle actions and voluntary movement. It also controls the higher order cognitive aspects of voluntary movement. The planning and the execution of complex motor strategies. I think a simple one is a person sitting down and just wants to stand up, so you have to coordinate all of the muscles and some muscle has to contract. Some muscle has to relax in order for a person to be able to stand up. Otherwise, even if you are very strong, the muscles are not going to just stand up with ease there. Cognitive functions such as procedural memory. You know, a person learns a skills and habits an you almost automatically can perform them. The basil ganglia has some memory to it and structure defects of the basil ganglia or the neurotransmitter imbalance that are produced by the basil ganglia, specifically the citicoline and the dopamine will cause movement disorders. They are either hypokinetic, a person becomes slow and stiff or hyperkinetic, just too much movement, such as ?? or dystonia and tremor and so on. Next slide. Next is a quick picture. I have this picture from the principals of Neuro Science, a very nice book by ?? Schwartz, indicating that before we actually move, just as you can take your hand to hold a cup for example, to pick up a cup from the table, then a message has to be sent from the premotor area to the basil ganglia, usually, initially to the putamen and then to the globus pallidus, the globus pallidus receives input from the subthalamic nucleus and the substantia nigra to coordinate the movement, then finally, the decision is sent to the thalamus and from the thalamus go back to the cortex before a movement can be enacted. So, it is what we call a close loop. It doesn’t cause movement, but it has to coordinate movement before a movement can be enacted. So, you know, in very simple terms, I just want to mention to you that the basil ganglia, essentially, is a close loop, a message has to pass from the brain through the basil ganglia back to the brain before an action can be done and it estimates which muscle is supposed to contract and which muscle is supposed to relax and so on. Next slide. So, this shows atypical Parkinsonian Disorders. I am going to discuss briefly today. They are the Multiple system atrophy, Dementia with Lewy bodies, Progressive supranuclear palsy, Cortical basal degeneration, Vascular parkinsonism, Drug-induced parkinsonism, Normal pressure hydrocephalus. So, these are the common ones that sometimes get confused with etiopathic Parkinson’s Disease that are more common, but again, it is not the only Parkinson-like Disorder that we see. Next slide. The Neurodegenerative Parkinson’s Disorders, I am going to list the five. These five can also be grouped into two different groups. One is called an Alpha-synucleinopathies, because these diseases, when we take a look at the brain cells, the pathology shows that they are actually inclusions that is a collection in the nerve cell that contains this protein called alpha-synuclein. So, because of that, we think that these conditions are somewhat related because they kind of have a similar pathology. So, these are the Parkinson’s disease (PD), Dementia with Lewy bodies (DLB) and Multiple system atrophy (MSA). And then there’s another group called Tauopathies. Tauo protein is a forceforated microtubules in the brain cells. Again, they are abnormal. They appear in these two conditions, the PSP or Progressive supranuclear palsy, or the CBD, the Corticobasal degeneration (CBD). So, we could kind of separate them into two so we could understand a little bit of their ultimate pathology. Hopefully, that would lead to a better understanding and eventually figuring out what is the cause of these conditions. Next slide. Then the three other ones I want to mention, the acquired Parkinsonian Disorders that we commonly see in our clinics. One is vascular parkinsonism, they become Parkinsonian because they have these multiple strokes usually. Normal pressure hydrocephalus, the enlargement of the ventricles and also drug induced parkinsonism. There are quite a few drugs that cause stiffness and such. Next slide. The first one that I want to mention is the dementia with lewy bodies. So, the clinical feature is such that it is the second most common form of degenerative dementia in the older population. Besides Alzheimer’s Disease, we now find that DOB, dementia with lewy bodies is quite common also. It has a feature and when you talk to the patient and their caregiver and get a history, you know that it doesn’t sound like typical Alzheimer’s Disease, for example, and it doesn’t sound like typical Parkinson’s Disease. These have early psychotic features, they have hallucinations and delusions. They have mild extrapyramidal dysfunction, they look like Parkinsonian, but very mild though. Fluctuations in their attention levels or levels of arousal. Sometimes, they can be perfectly normal. Sometimes they are just totally lethargic and would not pay attention, cannot concentrate and so on. It could vary from week to week, sometimes even from morning versus the evening. They have Orthostatic hypotension, very prominently. They would sometimes pass out, simply because of their orthostatic hypotension. They have depression. They also could have diurnal variation in behavior. So, in the morning for example, they could be perfectly normal, but toward the end of the day, they are hallucinating, they are somewhat psychotic and so on. And then, they are very sensitive to neuroleptic treatment, so not uncommonly, because the early features of psychotic features they go to see a psychiatrist, but then when the psychiatrist gives them the psychiatrist doses of neuroleptic, they got a lot worse. They are just solemn, they can’t do anything, they are incontinent and so forth. They are very sensitive to neuroleptics and if we take them down a very small amounts of neuroleptics, their psychotic features can be controlled very well. They also have REM sleep behavior disorder, vivid dreams and nightmares and move around during sleep and so on. Next slide. So, the diagnosis, according to the accepted criteria, it’s called the McKeith Criteria, established recently in 2005, probably DOB is that they have dementia according to DSM 4 Criteria and then they have to have two or more of these three, marked fluctuations, typical visual hallucinations, parkinsonism. They have to have two out of the three. But, it is possible DOB to have the dementia and one of the three very typical features of DOB. So, this criteria, the specificity is pretty high, but sensitivity is so-so only. But, it is a working criteria. So, in these we can distinguish these group of patients from Parkinson’s Disease and Alzheimer’s Disease. And treatment, I just want to mention very briefly for the dementia we could use cholinesterase inhibitors, such as rivastigmine or donepezil . Anti-psychotic agents, we really use very low dose of atypical psychotics, quetiapine is the one that we use most often. And then for the Parkinsonian symptoms, we could use again, small doses of carbidopa/levodopa. Do not use any other Parkinson’s medicine like agatis or other things, just stick with carbidopa/levodopa, so they won’t have other side effects. So, a combination of cholinesterase inhibitors in a low dose atypical anti-psychotic and a little carbidopa/levodopa may maintain your patients pretty well. Next slide. It tells about the clinical features of multiple system atrophy. Again, much less common than Parkinson’s Disease. Prevalence is 2 – 4 per 100,000. Remember, the Parkinson’s Disease is about 180 – 200 for 100,000. So, it’s like 100 of Parkinson’s Disease. Its median age is younger, about 55. Men are a little bit more at risk than women to have the condition. The mean survival though is, as you can see, 6 – 9 years and much shorter than Parkinson’s Disease. We mentioned that Parkinson’s Disease, easily 15 – 20 years if they start having the disease in their 60’s for example. It doesn’t really cause death. It would cause them some disability, but it doesn’t cause them the life expectancy to change that much. But, these people have shorter life expectancy. Half the people are disabled and wheelchair bound in about 5 years after motor symptom onset. So, they have a group of symptoms we will particularly pay attention to. Autonomic dysfunction, cerebellar signs, which does not appear in Parkinson’s patients. Parkinsonism, of course, poor or transiently responsive to levodopa therapy, that again raises a red flag, sleep apnea or REM behavior disorder, or stimulus sensitive myoclonus . These are kind of the subtle clinical features that we see as to be more common in the multiple system atrophy. They could have dysarthria, they could have anterocollis. So, they would stoop down and they would dip down their head and it’s kind of a quite a strange posture there. Now what is not comparable with multiple system atrophy? A lot of times when we see a patients, so is this Parkinson’s Disease or is this the multiple system atrophy? If they are asymmetric of the symptoms, if they have a resting tremor. If they either have a MODERATOR IS UNINTELLIGBLE, it is more comparable with Parkinson’s Disease. If they have early dementia, then they are more compatible with the dementia with lewy bodies, as I just mentioned. If they have prominent eye movement disorders or ophthalmoplegia, then it could be another condition that I will go through later the PSP or progressive supernuclear palsy. If they have a lot of apraxia and cortical sensory loss, then that could be another disorder I will go through, again later. The cortical basil degeneration. So, these are the symptoms then we try to find if they are present, then it might point us to another condition. Then, there are three subtypes of multiple system atrophy. The first one I think most of you have heard of before, Shy-Drager syndrome, now we call MSA-A, is a Parkinsonian symptom, but very prominently they have autostatic hypotension. As soon as they get up, they are dizzy, they are passing out and so on. So, these together with Parkinson’s Disease will point to us this condition. There’s another one called striatonigral degeneration that looks very much like Parkinson’s Disease, but they are symmentrical. They are not one-sided onset and they don’t respond to treatment with levodopa that well. So, this is again, not a typical Parkinson’s Disease. These are the MSA-P’s. And the third one is what we call olivopontocerebellar atrophy or MSA-C. These people will have a lot of cerebellar functions when they are getting a little slow, a little stiff, but at the same time, they have ataxia when they point to things, they are very dissymmetric or they kind of miss their pocket a lot and that’s not typical of Parkinson’s. Next slide. And the treatment for multiple system atrophy, unfortunately, is kind of limited. So, we could use levodopa for Parkinsonian features for people that have a lot of orthostatic hypotension. We could use salt, we use fluid intake, pressure stockings, then there are a couple of medications we could use. One is called midodrine, the other one is called fludrocortisone for the orthostatic hypotension. For the frequency and incontinence of urine, we could use the oxybutinin or tolterodine as commonly use. For impotence we could use sildenafil or Viagra. We could use the SSRI’s for the depression. Unfortunately, for their dementia and ataxia, there’s not very good treatment for that, but at least, we could symptomatically help them a little bit specifically. Next slide. We are going to go into PSP or progressive super nuclear palsy. It is a condition that’s maybe twice as common as the MSA’s, about 6 for 100,000. Still about 1/50th or 1/60th as common as Parkinson’s Disease. The median age is mid 60’s, about the same as the onset age as Parkinson’s Disease. Survival again, is 5 – 9 years, so shorter than Parkinson’s Disease. Half of the patients are disabled or wheelchair bound within 3 – 4 years of the onset of their movement. So, these people have a lot of imbalance, a lot of postural instability and so forth. So, their features are Parkinsonism, a little slowness or stiffness or shuffling gait. But, one of the main features of this condition is their early falling. They start falling a lot in the first few months of getting slower and getting stiff. That’s not common of Parkinson’s Disease. They just have very poor or just brief response to levodopa treatment. And, because it’s called supernuclear palsy that we see marked slowing of vertical gait. Up gaits and down gaits. Up gaits, when a person gets older, there is some deficits there, but people should be able to look down without too much of a problem, even though when they are old. So, if a person cannot move their eyes and especially cannot look down toward their feet and the floor, then there’s an indicator they have this condition called PSP. And in looking at our Parkinson’s patients, we always check their eye movements because we don’t want to miss this condition, which even though it’s 1/50th of Parkinson’s, it does pop up every now and then and treatment is somewhat different. Interestingly, they have another feature called eyelid apraxia. If you ask them to close their eyes, they cannot open their eyes right away and there’s a delay and sometimes they even have difficulty opening their eyes and they have a very specific type of rigidity in their neck and their back and their legs are very stiff and they axial plain. And their arms and legs though are not as rigid, which is kind of different in the early stages of Parkinson’s Disease. Parkinson’s Disease, their arms and legs are more stiff, but their neck and back are not as stiff. So, again, we utilize these subtle features to distinguish Parkinson’s Disease from PSP. They have retrocollis and their neck kind of tends to bend backwards, again because of the stiffness of the neck muscles and they have perseveration of motor functions. For example, if you ask them to clap your hands three times, they would just keep on clapping and they are not able to stop. Again, it is due to the programming to the repetitive movement. They also have early difficulty talking, dysarthria, dysphagia, they could have stuttering and palilalia early, repeating themselves and laryngeal stridor. So, when they breathe, especially when they sleep, they make a loud noise as if they are struggling and have MODERATOR IS UNINTELLIGBLE. Again, features that are not comparable with that, the asymmetric symptoms, rest tremor, which indicates the more common type of Parkinson’s Disease, early dementia indicates the dementia with lewy bodies and cortical sensory loss. People, other than cortical basil degeneration, they are slow, they are stiff, their sensory exam should be normal, but then, so if they are abnormal, we have to worry about that. Next slide. There is a NIH, Probably PSP diagnostic criteria, so that kind of points out the special features of progressive supernuclear palsy. So, in order to make a probable PSP, we have to have the presence of a gradual progressive disorder, onset at age 40 or older and then it has either, both actually, for probable. The person has to have supernuclear limitation of vertical gaits. What does that mean? It is that they cannot look downward voluntarily. But, if we tilt their head, they can actually, their eyes can move downward. That means it is not due to the muscle condition, they are not moving their eyes, it is due to the nerve control in the mid-brain that’s controlling the eye movements that are not working well. And then, together with the limitation of downward gait, they also have to have a history of prominent postural instability in early falls in the first year of onset and there’s no evidence of other diseases that can explain the above because they didn’t have a stroke or they didn’t have other things that can cause this condition. And then the possible PSP also has to have A, B and D, but for C, you can have either/or. Either the supernuclear palsy or they have a specific prominent postural instability. The reason that we do that is that sometimes the patients very early in the conditions of PSP, they keep falling, but their eyes are still able to move quite well and it’s until maybe about two or three years into the disease that their eye movements start showing up to be abnormal. Next slide. The next one is cortical basil degeneration. Clinical features, again, approximately the same 5 – 7 for 100,000, just like PSP. Median age is about 60’s or 70’s. Survival, again, is shorter, 7 years, just like PSP and MSA. It’s insidious onset and progressive decline. Now, this particular condition has asymmetry. It also has both cortical and basil ganglia features. So, that’s why we call it cortical basil degeneration. So, the cortical features, I’m sorry, the basil ganglia features are the slowness and the stiffness and the tremor and the dystonia or sustained spasms of muscles. Myoclonus, they have a very specific condition called alien limb syndrome, that side of the limb that’s more affected, the arm for example, or the leg can move on its own as if it’s a different part of, it’s not belonging to the body and it will start going by itself, touching things without the persons consciousness. It’s very specific symptom. Always ask the person if we see these kinds of asymmetry, they are very stiff in the arms and whether or not sometimes the arm moves on its own without their conscious effort. They have speech impairment, gait disorders, postural instability and eye movement, they have slow horizontal movements. Not vertical movements, but horizontal movements. Now, for the cortical dysfunction, they have dementia, they have ataxia, they cannot really do a lot of the learned things like turning on the TV, working on the computer, typing, writing, cooking sometimes. Even doing their daily activities like brushing their teeth and cleaning their face and so on. They also have cortical sensory disturbance is that they feel numb on one side of the body. So, as if they actually had a stroke on that side, but when you get an MRI scan, there’s no stroke. But, at the same time, they also have Parkinsonian features. So, that kind of rings a bell for us that whether or not they could have this condition called cortical basil degeneration. Again, not typical of that is then if a person has features of the other conditions that I mentioned. I am going to skip that a little bit. Next slide. For pharmacological treatments, I am going to the PSP and CBD pharmacological treatment slide now. That levodopa again, they don’t work very well, but it helps a little bit. So, we could still give the patients as they tolerate for their Parkinsonian features. We could give clonazepam, which is a longer acting basil bendoasopine for the action tremor, myoclonus, and REM sleep behavior disorder. They are very stiff, very rigid and so we could give baclofen, if they are very much of spasms and they have these facial spasms and so on, then we could use botulinum toxin injection. They are also frequently depressed, anxious and in pseudobulbar palsy, they have emotional incontinence or lack of emotional control, they could cry and laugh inappropriately, then we could use SSRI’s. So, those are the main things that we could do. For th dementia part for PSP, donepezil may help a little bit too. Next slide. The Next slide is a table that I showed the clinical differentiation of Parkinsonian Disorder. I don’t have time to go over that, but please keep it as a reference that that is how we see a higher frequency of occurrence of the clinical symptoms and the one that is less than zero is just a dash there. Next slide. Okay, now I would like to go to vascular parkinsonism very quickly for the next few minutes with the other things. It is an acute or sub-acute onset with stepwise. Just like a person prone to having strokes presents its risk factors for cerebrovascular disease, two or more basal ganglia infarcts by MRI scan or widespread subcortical white matter lesions evident on neuroimaging MRI scan. They typically don’t have rest tremor. They have a lot of postural instability and gait disorder and again, they don’t respond to levodopa treatment. So, if we get an MRI scan, we suspect PSP, is it MSA or is it vascular Parkinsonism, then when we take a look at the MRI scan, they have some strokes, small strokes and the basil ganglia or a lot of vascular changes with the white matter, then the features together, then we think that they vascular Parkinsonism. Next slide. The treatment then would be to control stroke risk factors. Keep a person active. Stretching exercises, physical therapy, assistive devices and then safe-proof the living environment. Just treat them as a stroke patient. But, very much exercise, stretching and so on. Next slide. Normal pressure hydrocephalus, the Next slide is a condition we see relatively commonly. It is a syndrome that has a triad of gait disturbance, urinary incontinence and a dementing process and we can see that from either a CT scan or a MRI scan there’s enlargement of the ventricle that is proportionate to cortical atrophy and a small vessel that keep changes. And it is confirmed by trial release of large volume cerebral spinal fluid by a lumbar puncture. We drain off about 1/3 to 50 cc’s, then we check their cognitive function and also their gait. Like within a few hours to see if there is some improvement and the treatment if we think it is appropriate, it is tricky because a lot of older folks have enlarged ventricles, but it is just due to their atrophy of the brain. It is not due to a normal pressure hydrocephalus. Next slide. So, there are specific features. But the correction is by surgical corrections. Putting in a shunt. It could be very beneficial. One thing that I want to mention is that the good prognosis for these people is the presence of a full triad, all three of them. The gait disturbance, the incontinence and early dementia and short duration of symptoms. You know, it’s not going on for many years, just maybe the last year they started having symptoms. If the dementia is mild, it also when you take a look at the brain scan, the cerebral atrophy is kind of mild also, then there’s a good prognosis and people can benefit from the shunt. Of course, putting in the shunt has complications and it is very important for these people to be diagnosed and evaluated appropriately. There’s another separate topic, I don’t have time, if people are interested, you should look up a little bit on that. Next slide. Lastly, the drug induced Parkinsonism, they look like they are Parkinsonism, but they are due to exposure to a dopamine-receptor blocking agent and these agents include antipsychotics, either the traditional ones, haloperidol and meliorates and Thorazine and so on. And also some of the atypical antipsychotics, like reserpine and benzodiazepines. Quetiapine though is relatively safe with people with Parkinson’s Disease, without aggravating their condition. Anti-emetics, like encompazine or fanega or these long-term use of that can also cause Parkinsonian features. Also, metoclopramide, a lot of times we don’t think about it that we use a lot of for people who have digestive problems and these have been reported in the literature and we see that it is not that uncommonly in clinical settings too to have Parkinsonian features. So, these are, of course, to stop these drugs as a treatment. And also, now a days, we actually have a couple of drugs that we would use for the MODERATOR IS UNINTELLIGBLE, Parkinsonism, tetrabenazine is now available on the market, which is FDA approved for the involuntarily movements for people with Huntingdon’s Disease, but it is very good treatment actually for any MODERATOR IS UNINTELLIGBLE, so including MODERATOR IS UNINTELLIGBLE or dyskinesia and so on. And then some benzodiazepines sometimes when you want to keep a person calm. So, just the last word, atypical Parkinsonian disorders, the differential diagnosis of atypical Parkinson’s Disorder is difficult because they are very much abundant, overlapping features of many of these disorders. So clinicians should be familiar with the less common, but distinct features of these disorders as I mentioned. And have a high index of suspicion in order to tackle these diagnostic challenges. Particularly in the early stages of the disease. Unfortunately, there’s no reliable diagnostic markets for any of these diseases, including the Parkinson’s Disease, so these are all clinical diagnosis and you have to see enough patients and know the features in order to make the diagnosis. Next slide. I have in the last slide some resources for patients and also for clinicians if you want to get more information about these conditions. Okay, thank you very much. Thank you Dr. Lai and I think we have about five minutes if people have questions for Dr. Lai, this is your opportunity to ask them. Anybody have any questions? I know it’s a lot of information, so if you can’t, maybe you can save a copy of the slides just for reference there. I have a question. Yes sir. In my few clinical cases I have seen with postal pontil cerebral atrophy, the people seem to have lived quite a long time, far longer than the usual, than the life expectancy you have listed in your slide. Do you have any views of longevity in the different sub-types of MSA? Yes, all of these conditions, they are neurodegenerative conditions. So, I just can give you a mean survival. There are individuals that can survive longer. That’s always th case. We see differences in Parkinson’s, differences in Alzheimer’s and so on. So, individual cases, we shouldn’t really be from the onset be too pessimistic and just tell them we really don’t know now a days, also, we know the conditions, we can treat symptomatically, a lot more, a lot better and I think their survival could be longer than what I indicated. Thank you. I have a question, Dr. Lai. I have a patient he has a 30 some year history of tremor, it’s a bilateral tremor, maybe minimal bradykinesia and he is able to ambulate fairly well, but he doesn’t just want to ?? levodopa, but this has been going on for 30 some years. Does he have a rest tremor or an action tremor? He has mostly rest tremor. Okay, so there are two main types of Parkinson’s Disease. One is tremor dominant Parkinson’s Disease and the other one is the PIGD, the postural instability gait disorder. If people with the tremor onset and usually in a younger age and they are responsive to levodopa treatment, usually have a better prognosis, they are slower in progression and also they could laugh or go on for a much longer time without getting into real disability. You know, that’s actually a favorable combination of conditions for this person. So, you can tell the patient for the next 5 1- 10 years, we still don’t think that there is, so long as they keep active, make sure that they don’t get deconditioned, they could still do very well. I think we have time for one more question. Okay, if we don’t have any other questions, again, we thank you all for being on the call and it will be repeated at 2:00 Central time, 3:00 Eastern time today. And we will let you know in plenty of time about the July 9th program. It will also be the same format. Again, Dr. Lai, we thank you very much. Okay, thank you. Bye. [ END OF CONFERENCE.] PADRECC National Vants Audio Conference Atypical Parkinsonian Disorders Eugene C. Lai, M.D. Ph.D. May 14, 2009 Page 1