Brain, Vol. 123, No. 12, 2569-2571,
December 2000
© 2000 Oxford University Press
Book reviews |
PARKINSON'S DISEASE AND PARKINSONISM IN THE ELDERLY.
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Department of Neurology, University Medical Center St, Nijmegen, The Netherlands
The title Parkinson's Disease and Parkinsonism in the Elderly binds the authors to a discussion of diagnostic and therapeutic problems of parkinsonism in particular in relation to old age. I therefore considered whether problems typically related to old age were covered by the book and found that this certainly was the case: the second chapter covers the differential diagnosis with vascular parkinsonism, normal pressure hydrocephalus, essential tremor and senile gait; Chapter 9 extensively discusses drug therapy of Parkinson's disease in the elderly, and throughout the book, special reference is made to problems related to old age. The list of contributors includes an even balance of specialists in geriatric medicine, neurology and rehabilitation in the broadest sense. The book can be divided into two parts: eight chapters discuss matters of diagnosis and drug therapy; these are followed by a second part with six chapters on social needs and rehabilitation. I therefore conclude that this book is written for those practically involved in care of the elderly with parkinsonism.
The first chapter, by Meara, offers a glossary of terms. Parkinsonism is defined as a clinical syndrome of akinesia accompanied by rigidity and often tremor. I would have preferred the term `bradykinesia' (slowness of movement) rather than `akinesia' (loss of movement), because bradykinesia is thought by many to be the hallmark of the hypokinetic-rigid syndrome. A pill-rolling tremor is, however, believed to be `almost pathognomic' (Chapter 1) or `very strongly suggests' (Chapter 2) Parkinson's disease, but unfortunately the authors do not provide a reference to substantiate this. Denny Brown (The Basal Ganglia, 1962) argued that the movement of the thumb against the finger is very typical of Parkinson's disease, but in those days neurologists were not yet aware of a number of parkinsonian syndromes which we now differentiate from Parkinson's disease. More recently a review of 100 cases of MSA showed pill-rolling tremor in 9% (Brain 1994; 117: 835–45). Hence, I would suggest omitting the term pathognomic in subsequent editions. Unfortunately, neurology is not that easy that one can jump to diagnosis from a single symptom alone.
Rodnitzky deals with the diagnosis of parkinsonism in the elderly in Chapter 2. The clinical features suggesting Parkinson's disease are discussed, but ample attention is also paid to atypical features like early dementia, falls and autonomic dysfunction suggesting diagnoses other than Parkinson's disease. As far as the diagnosis Parkinson's disease is concerned, the author mentions the existence of diagnostic guidelines and rightly remarks that guidelines are not infallible. However, because most readers of the book will not be experts in the field, this chapter would have been of even more practical value if the author had given a simple scheme with the exact practical diagnostic rules they use themselves, or had provided a copy of one of the well known guidelines. Of course no scheme is infallible, but doctors in doubt can be reassured that their diagnosis is in accordance with expert standards, and, hence, beyond criticism, although the diagnosis may not be absolutely certain. A minor point of criticism: the authors make the categorical statement `the urethral sphincter is invariably denervated in MSA patients with incontinence' without providing a reference for this important diagnostic point, but they do not mention anal sphincter EMG and, unfortunately, more recent studies indicating that similar EMG findings can be found in Parkinson's disease could not be discussed. There is only one point in this well-written chapter that I can hardly accept without further evidence or appropriate reference: `a severe and unilateral rest tremor could result from lesions of the contralateral cerebellar outflow pathways'. I know about PET studies showing cerebellar overactivity in Parkinson's disease resting tremor, but such overactivity can reflect compensatory rather than causative cerebellar activity and these studies do not justify this statement. The chapter ends with an accurate description of neuroimaging, but unfortunately IBZM- and CIT-SPECT are not mentioned, although they are more widely and readily available than PET facilities. But maybe this is not the case in all countries?
Chapter 3 (`Parkinson's disease and parkinsonism in the elderly', by Meara and Bhowmick) seems to resemble or duplicate Chapter 2 to a certain extent, but it contains lots of practical guidelines on all facets of parkinsonism and related problems frequently seen in these patients. To my surprise the authors seem to leave open the possibility that idiopathic Parkinson's disease can be diagnosed in clinically typical patients without Lewy bodies. They refer to Rajput (Ann Neurol 1989; 25: 602–6), but most experts will probably agree that Rajput described parkin gene-related autosomal recessive parkinsonism. The diagnosis of Parkinson's disease is a matter of definition, of course, but I think that most experts reserve the diagnosis idiopathic Parkinson's disease for a parkinsonian syndrome pathologically characterized by Lewy body formation. This chapter recommends the use of clinical diagnostic criteria and rating scales, but the readers have to go to the library to select an appropriate scale themselves. I am afraid that many readers will just buy this book to see what the experts advise, because they lack the expertise themselves. I doubt whether I would treat elderly patients with late onset Parkinson's disease `with maximally tolerated doses of levodopa to obtain best control of symptoms'. Many neurologists prescribe doses just high enough to obtain a level of motor performance that is acceptable to the patient and family, which is often lower than that providing maximal benefit. The advice in Chapter 9 is also more in line with this. On the other hand, I'm very pleased to see that in drug-resistant parkinsonism a minimum daily dose of 600 mg levodopa should be reached and that even higher doses are required in some patients, for most of my second opinion patients thought to be drug resistant are simply underdosed. The sections on depression, autonomic symptoms and cognitive symptoms are very well written, with practical therapeutic advices. However, when one reads that `urodynamic studies are rarely useful in directing treatment' I would contend that they could be important in the case of retention. To my reassurance, Chapter 7 also advises cystometric evaluation of urinary symptoms by an urologist. In a new edition, the use of Viagra in cases of sexual dysfunction should be discussed. It is useful in a substantial number of my patients.
In Chapter 4 Hubble provides an excellent description of theoretical and clinical aspects of drug-induced parkinsonism. In the Department of Psychiatry, I have seen many cases of drug induced parkinsonism and quite a number of them show akathisia: they cannot stand still and continue to march on the spot. This phenomenon is not, however, mentioned in the table of differential diagnostic clues. In the part on pathogenesis of neuroleptic induced parkinsonism, I looked for the author's opinion about inhibition of complex I by neuroleptics, which could explain persisting parkinsonism after withdrawal of neuroleptics, but this finding is not discussed either. Nevertheless, Chapter 4 can be strongly recommended to those who are not familiar with the problem of drug-induced parkinsonism.
Chapter 5 gives an excellent up-to-date overview of essential tremor by Pahwa and Koller, which could, however, have been published in any book on movement disorders. In contrast to the other chapters, it is not primarily written from the point of view of medical problems in the elderly.
In Chapter 6, Liston and Tallis deal with gait apraxia and multi-infarct states. The reader soon becomes confused because so many descriptive terms are used by different authors, e.g. ataxia of gait, gait apraxia, frontal ataxia, frontal disequilibrium, subcortical dysequilibrium, cautious gait, ignition apraxia, lower body parkinsonism, etc., whereas many readers probably cannot imagine exactly which kind of phenomenology is meant by the respective authors. Unfortunately, Bruns, van Bogaert, Critchley, Pierre-Marie and other influential authors did not publish videotapes in those days, for obvious reasons, but this would have provided clarity. I appreciated this chapter very much because the authors try to explain these high-level gait disorders in relation to the conceptual framework of the medial and lateral premotor systems and the role of internal and external cues on motor behaviour. Insiders may well have quite a lot of remarks about the authors' theory. For example, I question why a distinction is made between visual and auditory cues in Table 6.2, because I think that both types of cue can be equally effective on the same motor phenomena. But the great advantage of this chapter lies in the fact that it can function as an eye opener for many readers who are not familiar with these typical neurophysiologically explicable features of human behaviour, which they might previously have considered to be psychogenic. Maybe the ideas resulting from this chapter could be more easily translated to clinical practice if the authors had discussed a little bit more about the practical function of cues: do they hint about what to do, how to do it, or when?
Meara and Hobson present an appropriate discussion of the epidemiology of Parkinson's disease and parkinsonism in Chapter 7. Chapter 9 offers background information and practical advice on drug therapy in elderly patients with Parkinson's disease. Zesiewicz and Hauser have done a very good job: they not only deal with all available antiparkinsonian drugs, but also treatment strategies. For example, the authors advise starting with dopamine agonists under 65 years of age, with levodopa over 70 years of age, and to make an individual judgement between 65 and 70 years of age. In other parts of the book I got the impression that geriatrics can fairly easily prescribe dopamine agonists even in very old patients, but this chapter is in agreement with most guidelines on this subject. It must be mentioned, however, that a very recent report shows that agonists are tolerated well by 46% of patients aged 80 years and older (Mov Disord 2000; 15: 664–8). Zesiewicz and Hauser also focus on the treatment of secondary symptoms, including sleep abnormalities, depression, autonomic dysfunction, etc. In this chapter, orthostatic hypotension is defined as a drop of 30 mmHg in systolic pressure or 20 mm in mean blood pressure, which is somewhat different from the definitions in other chapters (i.e. 20 mg drop systolic, 10 mg drop diastolic blood pressure on standing). Excessive sweating, which may be very troublesome in some patients, is not mentioned. Apart from these minor points, if patients are treated following the rules in this chapter, they will be treated well.
Chapters 8 and 10–14 deal with rehabilitation, nursing, physiotherapy, occupational therapy, and speech and language therapy. In our University Hospital, we provide nursing, speech therapy, physiotherapy and ergotherapy with special expertise in parkinsonian patients. I can clearly state that the overall patient care has been very much improved thanks to the efforts of these co-workers. If neurologists or geriatricians are not fully aware of the advantages of these disciplines, these chapters will readily elucidate how the life of patients can be improved with non-drug strategies.
The disadvantages accompanying multi-authored texts are also found in this book: topics are repeated in multiple chapters, and opinions and advice may differ between the respective authors. On certain occasions I thought that I could perceive that some of the authors are not neurologists with special training in extrapiramidal movement disorders, for example because of rather unexpected references to classical findings or theories. For example, if `the proper execution of automatic learned motor plans' is discussed, I would refer to Marsden's readily accessible Wartenberg Lecture (Neurology 1982; 32: 514–39), or a similarly influential article, rather than to a review in a book not written by one of the key authors on this subject.
However, these minor shortcomings are not detrimental to the great practical value of this book for all those involved in clinical diagnosis and therapy in the broadest sense in elderly patients with parkinsonism.
Notes
Edited by Jolyon Meara and William C. Koller. 2000. Cambridge, UK: Cambridge University Press. Price £29.95. ISBN 0-521-62884-9.
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