Introduction
Parkinson’s Plus disorders, or atypical Parkinsonism, are conditions which involve the degeneration of the basal ganglia, which is the movement center of the brain. Parkinson’s and Parkinson’s Plus will both include a loss of cells in the basal ganglia, leading to a lack of dopamine. Dopamine is required by the brain in order to bring about normal and properly coordinated movements. This lack of dopamine causes the symptoms of Parkinson’s that are generally included in Parkinson’s Plus, such as tremors, postural instability (balance difficulty), rigidity and slowness of movement (bradykinesia).
To clarify further: although the Parkinson’s Plus diseases typically have some aspects of these symptoms resulting from dopamine loss, Parkinson’s Plus is not merely another name for Parkinson’s Disease. Parkinson’s Plus disorders are diseases which include the Parkinson’s Disease symptoms plus additional serious conditions. As the brain atrophies, the symptoms will also worsen and affect speech, swallowing, balance, walking, tremors, eye movements, bodily functions, stiffness and facial expression, to name a few of the issues that are more prevalent. Cognition (the thinking process) is affected, and is one of the least noticed, but most severe aspects of Parkinson's Plus.
Parkinson’s Plus Conditions versus Idiopathic Parkinson’s Disease
Patients with Parkinson-plus syndromes typically have a worse prognosis than those with Parkinson disease (PD), and Parkinson Plus disorders respond poorly to the standard anti-Parkinson’s treatments. Although the medications used may be similar to those used to treat Parkinson’s, Parkinson’s Plus disorders may not respond as well to medications. An inadequate response to treatment in a patient with parkinsonian symptoms may indicate that a Parkinson’s Plus disorder is developing, and searching for the signs and symptoms of degeneration in other nervous systems or brain structures is important. However, as in Idiopathic (regular) Parkinson’s Disease, there is no assurance that MRI results will show enough evidence to confirm a diagnosis.
Parkinson’s Plus disorders often progress more rapidly than Parkinson’s disease. There is no cure for these conditions, so treatment focuses on managing symptoms.
Diagnosing Parkinson’s Plus
Parkinson’s Plus Conditions include the following diseases (listed below). It is often difficult for Doctor’s to diagnose the Parkinson’s Plus condition to the point of determining which of the following diseases it is, specifically. Like Parkinson’s Disease, identifying specific bio-markers (signs and symptoms that are key indicators) is difficult and the diagnosis of these diseases is primarily a clinical process of observation. In some cases, the diagnosis is confirmed after death when the brain is then studied and it becomes possible to differentiate. Some patients will even develop symptoms of more than one of these subtypes, thus forming what would be a hybrid condition (two or more diseases combined). The part or parts of the brain affected with cell loss or shrinkage, will determine which of the symptoms are manifested, thus the diagnosis is based on the symptoms that are emphasized in each condition.
The term “Levodopa” refers to the most important and common medication used to treat hallmark symptoms, and it is usually most effective in cases of Idiopathic Parkinson’s Disease, and only moderately helpful in the case of Parkinson’s Plus. This distinction about the effectiveness of Levodopa is one of the most important differences between Idiopathic Parkinson’s when compared to Parkinson’s Plus.
Multiple Systems Atrophy
Multiple system atrophy (MSA) is a rare degenerative condition. In MSA, more widespread neurological damage occurs than with Idiopathic Parkinson’s Disease. This includes damage to the autonomic nervous system – the part of the nervous system that controls involuntary functions.
MSA involves a number of areas of the brain. Different MSA subtypes have different names, depending on which area of the brain is most affected. They include the following.
(MSA) Shy Drager Syndrome
Multiple Systems Atrophy (Shy Drager) may appear to be a more typical case of PD in the first few years of disease onset, but as it progresses extreme drops in blood pressure upon rising from a chair (accompanied by dizziness), difficulty with bowel and bladder control, exaggerated pulse rate fluctuations and sexual impotence are hallmarks that will differentiate it from Parkinson’s Disease. Johnny Cash was thought to have Parkinson’s Disease initially, and eventually it progressed into a case of MSA.
Striato-Nigral Degeneration (MSA-P)
This subtype is difficult in the initial years to distinguish from Parkinson’s Disease, thus the “P” is added to the abbreviation, MSA-P. Tremors, balance issues, rigidity, speech and swallowing are all eventually affected. It will be distinguished from Idiopathic Parkinson’s Disease by its faster onset and poor response to Levodopa therapy. The autonomic issues will also become progressively worse as the disease progresses.
Olivoponto Cerebellar Atrophy (MSA-C)
This one is similar to PD, but in addition to balance, ataxia (including walking/gait issues) and speech are affected more severely. The “C” in the abbreviation MSA-C signifies that this disease emphasizes atrophy in the cerebellum. The cerebellum is the area of the brain responsible for balance and coordination. Difficulty with the overall coordination of bodily movements is the striking difference between this and the other MSA subtypes. The prominent features are unsteady/staggering walk with slurred speech.
Progressive Supranuclear Palsy (PSP)
PSP often resembles Parkinson's disease. Changes in the protein tau lead to neural degeneration. These changes lead to an aggregation of fibrillar polymers, known as taupathies. Its unique features include early development of a severe loss of balance, unsteady walking and frequent falls. People with PSP also may develop blurred vision and impaired eyesight, especially the inability to look up or down. This lack of eye movement causes difficulty for the patient to see where he or she is going, and interferes with reading and eating. Other symptoms include a gradual but significant impairment in speech and swallowing. Apathy, depression and a reduced ability to think are common among patients with PSP.
No medication has been found to treat this disorder. As with the other Parkinson’s Plus conditions, PD drugs such as Levodopa and dopamine agonists are sometimes mildly beneficial and worth attempting as treatments. Currently, medical interventions are aimed at reducing the impact of specific symptoms, such as: balance, eating and swallowing.
Corticobasal Degeneration (CBD)
CBD is a movement disorder that usually starts after age 60. Like Progressive Supranuclear Palsy, it is a taupathy (see above in first paragraph of PSP explanation). First, symptoms often appear on one side of the body and spread to the other side. They include stiffness, rigidity, slowness, tremor, jerky movements and loss of sensation. Later, patients can develop problems with walking and maintaining balance, dementia, memory loss and “alien limb” phenomenon (a condition in which a limb appears to move on its own).
Depression and other emotional changes also can develop.
Levodopa treatment is rarely successful. Other medicines may help manage specific symptoms.
Dementia with Lewy bodies (DLB)
Lewy bodies are abnormal protein deposits found in brain cells. In Parkinson’s disease, Lewy bodies form in only one area of the brain, the Basal Ganglia (where dopamine cells are lost, reducing the dopamine needed for normal movement). In DLB, these deposits are found in other important areas of the brain, as well.
Symptoms of DLB are similar to Parkinson’s and Alzheimer’s diseases, with an overwhelming emphasis on dementia characteristics. In addition, patients can have repeated visual hallucinations, and experience varying levels of alertness and mental ability. Depression, apathy, anxiety and delusional thoughts also are common. Some patients develop a sleep disorder years before developing DLB that causes them to violently and loudly act out their dreams.
Treatment with Levodopa and Alzheimer’s medications may be beneficial.
Other Diseases Sometimes Categorized as Parkinson’s Plus
Some medical references will include Alzheimer’s Disease in this category, as A.D. can begin with what appear to be P.D.-like tremors and other typical PD issues. Lou Gehrig’s Disease (ALS) is mentioned in the category of Parkinson’s Plus in a number of medical references, as well.
Additional Services
In addition to medical treatments, support groups, counseling, and education for patients and caregivers are likely to help improve the patient’s quality of life. Physical, occupational and speech therapy will assist the patient in coping with the illness.
Notes/Questions:
This document was written by Dr. Daniel R. Brooks and may only be used by permission