Parkinsonism: A Review-of-Systems Approach to Diagnosis

ABSTRACT

Atypical parkinsonian disorders may be initially misdiagnosed as Parkinson's disease. The number and complexity of atypical parkinsonisms seem to be increasing. This, along with the lack of diagnostic tests, makes it difficult for the clinician to distinguish between disease types. It then becomes necessary to assess patients in multiple areas through a review-of-systems approach. An approach of this kind can be used for initial diagnosis, monitoring, refinement of diagnosis, and disease management. This article discusses some of the clinical features for a review-of-systems assessment. Using this approach may allow earlier detection of atypical parkinsonisms, leading to better management of symptoms.

KEYWORDS

Parkinson's disease - atypical parkinsonisms - progressive supranuclear palsy - dementia with Lewy bodies - multiple system atrophy - corticobasal degeneration - vascular parkinsonism - medication-induced parkinsonism - normal pressure hydrocephalus

REFERENCES

• 1 Rajput A H, Rozdilsky B, Rajput A. Accuracy of clinical diagnosis in parkinsonism: a prospective study.  Can J Neurol Sci. 1991;  18 275-278
• 2 Hughes A J, Colosimo C, Kleedorfer B, Daniel S E, Lees A J. The dopaminergic response in multiple system atrophy.  J Neurol Neurosurg Psychiatry. 1992;  55 1009-1013
• 3 Hughes A J, Daniel S E, Lees A J. Improved accuracy of clinical diagnosis of Lewy body Parkinson's disease.  Neurology. 2001;  57 1497-1499
• 4 Gelb D J, Oliver E, Gilman S. Diagnostic criteria for Parkinson disease.  Arch Neurol. 1999;  56 33-39
• 5 Wenning G K, Ben-Shlomo Y, Hughes A, Daniel S E, Lees A, Quinn N P. What clinical features are most useful to distinguish definite multiple system atrophy from Parkinson's disease?.  J Neurol Neurosurg Psychiatry. 2000;  68 434-440
• 6 Jankovic J, Rajput A H, McDermott M P, Perl D P. The evolution of diagnosis in early Parkinson disease.  Arch Neurol. 2000;  57 369-372
• 7 Pal P K, Samii A, Calne D B. Cardinal features of early Parkinson's disease. In: Factor SA, Weiner WJ Parkinson's Disease Diagnosis and Clinical Management. Vol. 1. 1st ed. New York; Demos 2002: 41-56
• 8 Watanabe T, Akiguchi I, Yagi H et al.. Proton magnetic resonance spectroscopy and white matter hyperintensities on magnetic resonance imaging in patients with Alzheimer's disease.  Ann NY Acad Sci. 2002;  977 423-429
• 9 Quinn N P. How to diagnose multiple system atrophy.  Mov Disord. 2005;  20(suppl 12) S5-S10
• 10 Greco C M, Berman R F, Martin R M et al.. Neuropathology of fragile X-associated tremor/ataxia syndrome (FXTAS).  Brain. 2006;  129 243-255
• 11 Verghese J, Lipton R B, Dickson D W, Crystal H J. A clinicopathological study of rest tremors in the elderly.  J Am Geriatr Soc. 2004;  52 1781-1783
• 12 Meara J, Bhowmick B K, Hobson P. Accuracy of diagnosis in patients with presumed Parkinson's disease.  Age Ageing. 1999;  28 99-102
• 13 Bower J H, Maraganore D M, McDonnell S K, Rocca W A. Incidence and distribution of parkinsonism in Olmsted County, Minnesota, 1976-1990.  Neurology. 1999;  52 1214-1220
• 14 Colosimo C. Pisa syndrome in a patient with multiple system atrophy.  Mov Disord. 1998;  13 607-609
• 15 Colosimo C, Albanese A, Hughes A J, de Bruin V M, Lees A J. Some specific clinical features differentiate multiple system atrophy (striatonigral variety) from Parkinson's disease.  Arch Neurol. 1995;  52 294-298
• 16 Louis E D, Schupf N, Manly J, Marder K, Tang M X, Mayeux R. Association between mild parkinsonian signs and mild cognitive impairment in a community.  Neurology. 2005;  64 1157-1161
• 17 Wenning G K, Ben Shlomo Y, Magalhaes M, Daniel S E, Quinn N P. Clinical features and natural history of multiple system atrophy: an analysis of 100 cases.  Brain. 1994;  117 835-845
• 18 Clarke C E, Davies P. Systematic review of acute levodopa and apomorphine challenge tests in the diagnosis of idiopathic Parkinson's disease.  J Neurol Neurosurg Psychiatry. 2000;  69 590-594
• 19 Nutt J G, Wooten G F. Clinical practice: diagnosis and initial management of Parkinson's disease.  N Engl J Med. 2005;  353 1021-1027
• 20 Stolze H, Kuhtz-Buschbeck J P, Drucke H, Johnk K, Illert M, Deuschl G. Comparative analysis of the gait disorder of normal pressure hydrocephalus and Parkinson's disease.  J Neurol Neurosurg Psychiatry. 2001;  70 289-297
• 21 Curran T, Lang A E. Parkinsonian syndromes associated with hydrocephalus: case reports, a review of the literature, and pathophysiological hypotheses.  Mov Disord. 1994;  9 508-520
• 22 Hebb A O, Cusimano M D. Idiopathic normal pressure hydrocephalus: a systematic review of diagnosis and outcome.  Neurosurgery. 2001;  49 1166-1184 discussion 1184-1186
• 23 McGirt M J, Woodworth G, Coon A L, Thomas G, Williams M A, Rigamonti D. Diagnosis, treatment, and analysis of long-term outcomes in idiopathic normal-pressure hydrocephalus.  Neurosurgery. 2005;  57 699-705 discussion 699-705
• 24 Demirkiran M, Bozdemir H, Sarica Y. Vascular parkinsonism: a distinct, heterogeneous clinical entity.  Acta Neurol Scand. 2001;  104 63-67
• 25 Bower J H, Dickson D W, Taylor L, Maraganore D M, Rocca W A. Clinical correlates of the pathology underlying parkinsonism: a population perspective.  Mov Disord. 2002;  17 910-916
• 26 Zijlmans J C, Daniel S E, Hughes A J, Revesz T, Lees A J. Clinicopathological investigation of vascular parkinsonism, including clinical criteria for diagnosis.  Mov Disord. 2004;  19 630-640
• 27 Factor S A, Jennings D L, Molho E S, Marek K L. The natural history of the syndrome of primary progressive freezing gait.  Arch Neurol. 2002;  59 1778-1783
• 28 Schneider J A, Li J L, Li Y, Wilson R S, Kordower J H, Bennett D A. Substantia nigra tangles are related to gait impairment in older persons.  Ann Neurol. 2006;  59 166-173
• 29 Giladi N, Herman T, Reider-Groswasser I I, Gurevich T, Hausdorff J M. Clinical characteristics of elderly patients with a cautious gait of unknown origin.  J Neurol. 2005;  252 300-306
• 30 Hohl U, Tiraboschi P, Hansen L A, Thal L J, Corey-Bloom J. Diagnostic accuracy of dementia with Lewy bodies.  Arch Neurol. 2000;  57 347-351
• 31 Boesch S M, Wenning G K, Ransmayr G, Poewe W. Dystonia in multiple system atrophy.  J Neurol Neurosurg Psychiatry. 2002;  72 300-303
• 32 Wenning G K, Geser F, Stampfer-Kountchev M, Tison F. Multiple system atrophy: an update.  Mov Disord. 2003;  18(suppl 6) S34-S42
• 33 Shiba M, Bower J H, Maraganore D M et al.. Anxiety disorders and depressive disorders preceding Parkinson's disease: a case-control study.  Mov Disord. 2000;  15 669-677
• 34 Lange K W, Tucha O, Alders G L et al.. Differentiation of parkinsonian syndromes according to differences in executive functions.  J Neural Transm. 2003;  110 983-995
• 35 Ala T A, Hughes L F, Kyrouac G A, Ghobrial M W, Elble R J. Pentagon copying is more impaired in dementia with Lewy bodies than in Alzheimer's disease.  J Neurol Neurosurg Psychiatry. 2001;  70 483-488
• 36 Aarsland D, Litvan I, Larsen J P. Neuropsychiatric symptoms of patients with progressive supranuclear palsy and Parkinson's disease.  J Neuropsychiatry Clin Neurosci. 2001;  13 42-49
• 37 Burn D J, Lees A J. Progressive supranuclear palsy: where are we now?.  Lancet Neurol. 2002;  1 359-369
• 38 Kuniyoshi S, Riley D E, Zee D S, Reich S G, Whitney C, Leigh R J. Distinguishing progressive supranuclear palsy from other forms of Parkinson's disease: evaluation of new signs.  Ann NY Acad Sci. 2002;  956 484-486
• 39 Boeve B F, Lang A E, Litvan I. Corticobasal degeneration and its relationship to progressive supranuclear palsy and frontotemporal dementia.  Ann Neurol. 2003;  54(suppl 5) S15-S19
• 40 Pharr V, Uttl B, Stark M, Litvan I, Fantie B, Grafman J. Comparison of apraxia in corticobasal degeneration and progressive supranuclear palsy.  Neurology. 2001;  56 957-963
• 41 Quinn N P. Parkinson's disease dyskinesias.  Neurology. 1994;  44 1187 author reply 1187-1188
• 42 Vidailhet M, Rivaud S, Gouider-Khouja N et al.. Eye movements in parkinsonian syndromes.  Ann Neurol. 1994;  35 420-426
• 43 Rivaud-Pechoux S, Vidailhet M, Gallouedec G, Litvan I, Gaymard B, Pierrot-Deseilligny C. Longitudinal ocular motor study in corticobasal degeneration and progressive supranuclear palsy.  Neurology. 2000;  54 1029-1032
• 44 Mosimann U P, Muri R M, Burn D J, Felblinger J, O'Brien J T, McKeith I G. Saccadic eye movement changes in Parkinson's disease dementia and dementia with Lewy bodies.  Brain. 2005;  128 1267-1276
• 45 Scaravilli T, Tolosa E, Ferrer I. Progressive supranuclear palsy and corticobasal degeneration: lumping versus splitting.  Mov Disord. 2005;  20(suppl 12) S21-S28
• 46 Muller A, Reichmann H, Livermore A, Hummel T. Olfactory function in idiopathic Parkinson's disease (IPD): results from cross-sectional studies in IPD patients and long-term follow-up of de-novo IPD patients.  J Neural Transm. 2002;  109 805-811
• 47 Katzenschlager R, Zijlmans J, Evans A, Watt H, Lees A J. Olfactory function distinguishes vascular parkinsonism from Parkinson's disease.  J Neurol Neurosurg Psychiatry. 2004;  75 1749-1752
• 48 Kluin K J, Foster N L, Berent S, Gilman S. Perceptual analysis of speech disorders in progressive supranuclear palsy.  Neurology. 1993;  43 563-566
• 49 Vodusek D B. Sphincter EMG and differential diagnosis of multiple system atrophy.  Mov Disord. 2001;  16 600-607
• 50 Brooks D J. Safety and tolerability of COMT inhibitors.  Neurology. 2004;  62 S39-S46
• 51 Boeve B F, Silber M H, Ferman T J, Lucas J A, Parisi J E. Association of REM sleep behavior disorder and neurodegenerative disease may reflect an underlying synucleinopathy.  Mov Disord. 2001;  16 622-630
• 52 Sakakibara R, Hattori T, Uchiyama T, Yamanishi T. Videourodynamic and sphincter motor unit potential analyses in Parkinson's disease and multiple system atrophy.  J Neurol Neurosurg Psychiatry. 2001;  71 600-606
• 53 Druschky A, Hilz M J, Platsch G et al.. Differentiation of Parkinson's disease and multiple system atrophy in early disease stages by means of I-123-MIBG-SPECT.  J Neurol Sci. 2000;  175 3-12
• 54 Goldstein D S. Dysautonomia in Parkinson's disease: neurocardiological abnormalities.  Lancet Neurol. 2003;  2 669-676
• 55 Gilman S, Low P A, Quinn N et al.. Consensus statement on the diagnosis of multiple system atrophy.  J Neurol Sci. 1999;  163 94-98
• 56 Kitae S, Murata Y, Tachiki N, Okazaki M, Harada T, Nakamura S. Assessment of cardiovascular autonomic dysfunction in multiple system atrophy.  Clin Auton Res. 2001;  11 39-44
• 57 Holmberg B, Kallio M, Johnels B, Elam M. Cardiovascular reflex testing contributes to clinical evaluation and differential diagnosis of parkinsonian syndromes.  Mov Disord. 2001;  16 217-225
• 58 Wenning G K, Scherfler C, Granata R et al.. Time course of symptomatic orthostatic hypotension and urinary incontinence in patients with postmortem confirmed parkinsonian syndromes: a clinicopathological study.  J Neurol Neurosurg Psychiatry. 1999;  67 620-623
• 59 Gelb D J, Oliver E, Gilman S. Diagnostic criteria for Parkinson disease.  Arch Neurol. 1999;  56 33-39
• 60 Steele J C, Richardson J C, Olszewski J. Progressive supranuclear palsy: a heterogeneous degeneration involving the brain stem, basal ganglia and cerebellum with vertical gaze and pseudobulbar palsy, nuchal dystonia and dementia.  Arch Neurol. 1964;  10 333-359
• 61 Litvan I, Agid Y, Calne D et al.. Clinical research criteria for the diagnosis of progressive supranuclear palsy (Steele-Richardson-Olszewski syndrome): report of the NINDS-SPSP international workshop.  Neurology. 1996;  47 1-9
• 62 McKeith I G, Dickson D W, Lowe J et al.. Diagnosis and management of dementia with Lewy bodies: third report of the DLB consortium.  Neurology. 2005;  65 1863-1872