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How Do They Diagnose Parkinson’s Disease

How Is Parkinsons Diagnosed

How do you diagnose Parkinson’s disease? (Sheila Eichenseer, MD)

Doctors use your medical history and physical examination to diagnose Parkinson’s disease . No blood test, brain scan or other test can be used to make a definitive diagnosis of PD.

Researchers believe that in most people, Parkinson’s is caused by a combination of environmental and genetic factors. Certain environmental exposures, such as pesticides and head injury, are associated with an increased risk of PD. Still, most people have no clear exposure that doctors can point to as a straightforward cause. The same goes for genetics. Certain genetic mutations are linked to an increased risk of PD. But in the vast majority of people, Parkinsons is not directly related to a single genetic mutation. Learning more about the genetics of Parkinsons is one of our best chances to understand more about the disease and discover how to slow or stop its progression.

Aging is the greatest risk factor for Parkinsons, and the average age at diagnosis is 60. Still, some people get PD at 40 or younger.

Men are diagnosed with Parkinsons at a higher rate than women and whites more than other races. Researchers are studying these disparities to understand more about the disease and health care access and to improve inclusivity across care and research.

Aging is the greatest risk factor for Parkinsons, and the average age at diagnosis is 60. Still, some people get PD at 40 or younger.

The Michael J. Fox Foundation has made finding a test for Parkinsons disease one of our top priorities.

Further Testing In Parkinson’s

In other situations, where perhaps the diagnosis is not as clear, younger individuals are affected, or there are atypical symptoms such as tremor affecting both hands or perhaps no tremor at all, further testing may help. For example, imaging can play a role in differentiating between essential tremor and Parkinsons. It can also be important to confirm what is initially a clinical diagnosis of Parkinsons prior to an invasive treatment procedure such as surgical DBS

How It All Fits Together

Diagnosing Parkinsons disease can be tricky. The process relies heavily on your doctors judgment. In addition, the causes and risk factors of Parkinsons are not entirely clear yet, which contributes to the difficulty in diagnosing this condition.

However, there have been efforts to try and detect this disease earlier. For instance, clinicians have started focusing more on prodromal symptoms, which are early symptoms that appear before movement-related difficulties begin.

These symptoms include:

  • Loss of smell, which can sometimes occur years before other symptoms
  • Chronic constipation, without any other explanation
  • Rapid eye movement behavior disorder, which causes sleep disturbances

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The Diagnostic Criteria Used Today

In 2015, a Movement Disorder Society task force proposed a set of criteria that became known as the Movement Disorder Society United Parkinsons Disease Rating Scale , which includes non-motor symptoms in its criteria.9

The new criteria requires you to have slowness of movement, plus either a rest tremor or rigidity. It also requires that you do not meet any criteria in a list called absolute exclusion criteria. This list of symptoms indicates you most likely do not have PD or that you may have an atypical parkinsonism disorders that resemble Parkinsons disease but are ultimately different. If you meet any of those requirements, PD is ruled out. For example, one absolute exclusion criteria is if you are taking a drug that is known to cause Parkinsons-like side effects.

Next, you must meet at least two of the following four criteria:

  • Dramatic improvement of motor symptoms when you take the gold-standard Parkinsons medication called levodopa
  • The presence of dyskinesia as a result of taking levodopa dyskinesia is a possible side effect of levodopa among people with PD
  • Rest tremor, meaning your tremor occurs when the body part is at rest
  • Loss of smell, or if you have a test called MIBG scintigraphy and it indicates that you have autonomic dysfunction, which is when your autonomic nervous system doesnt work correctly, leading to issues with things like heart rate and blood pressure.

If Its Not Parkinsons Disease What Could It Be

Parkinsons Disease: Symptoms, Diagnosis and Treatment ...

Here are some possibilities:

Side effects of medication: Certain drugs used for mental illnesses like psychosis or major depression can bring on symptoms like the ones caused by Parkinsonâs disease. Anti-nausea drugs can, too, but they typically happen on both sides of your body at the same time. They usually go away a few weeks after you stop taking the medication.

Essential tremor: This is a common movement disorder that causes shaking, most often in your hands or arms. Itâs more noticeable when youâre using them, like when you eat or write. Tremors caused by Parkinsonâs disease usually happen when youâre not moving.

Progressive supranuclear palsy: People with this rare disease can have problems with balance, which may cause them to fall a lot. They donât tend to have tremors, but they do have blurry vision and issues with eye movement. These symptoms usually get worse faster than with Parkinson’s disease.

Normal pressure hydrocephalus : This happens when a certain kind of fluid builds up in your brain and causes pressure. People with NPH usually have trouble walking, a loss of bladder control, and dementia.

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How Is Alzheimer’s Disease Diagnosed

Doctors use several methods and tools to help determine whether a person who is having memory problems has possible Alzheimers dementia , probable Alzheimers dementia , or some other problem.

To diagnose Alzheimers, doctors may:

  • Ask the person and a family member or friend questions about overall health, use of prescription and over-the-counter medicines, diet, past medical problems, ability to carry out daily activities, and changes in behavior and personality
  • Conduct tests of memory, problem solving, attention, counting, and language
  • Carry out standard medical tests, such as blood and urine tests, to identify other possible causes of the problem
  • Perform brain scans, such as computed tomography , magnetic resonance imaging , or positron emission tomography , to rule out other possible causes for symptoms

These tests may be repeated to give doctors information about how the persons memory and other cognitive functions are changing over time. They can also help diagnose other causes of memory problems, such as stroke, tumor, Parkinsons disease, sleep disturbances, side effects of medication, an infection, mild cognitive impairment, or a non-Alzheimers dementia, including vascular dementia. Some of these conditions may be treatable and possibly reversible.

People with memory problems should return to the doctor every 6 to 12 months.

A Decade Of Unnecessary Parkinsons Drugs Is Likely To Have Remodelled My Brain

A key issue is that I no longer have a convenient label for my symptoms. I had pre-existing joint and gastro issues that have worsened immeasurably during the past decade. My ability to concentrate, to function, to move, to be all worsened beyond comprehension. I have been told that nearly a decade of unnecessary Parkinsons drugs is likely to have remodelled my brain, through its innate neuroplasticity, so that it now considers the symptomatic side effects of those drugs normal for me. Just as hitting a tennis ball every day for 10 years will build up your ball-hitting skills, so the brain can be driven by drugs and their side effects into behaviours that it then reconfigures and learns as normal.

Writhing and contorting

Actually weaning myself off Stalevo a Parkinsons medication used to increase dopamine levels in the brain which I was taking eight times a day, was pretty terrifying. I was initially advised to drop one daily dose per week. By the second week I was writhing and contorting involuntarily not something I had ever done before. I was then asked to drop one daily dose per month. I took my last Stalevo dose on 25 October 2015.

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Patients With A Previous Diagnosis Of Parkinson’s Disease

The diagnosis of probable Parkinson’s disease was confirmed in 109 of the 131 patients with this diagnosis , including three in whom atypical features were found but were insufficient to invalidate the diagnosis of Parkinson’s disease . Two additional patients were found to have possible Parkinson’s disease. However, in 20 of the 131 patients the diagnosis of Parkinson’s disease was unequivocally rejected . The alternative diagnoses were non-parkinsonian tremor in four patients , vascular parkinsonism in six , progressive supranuclear palsy in four , and multiple system atrophy in three . Two patients received a diagnosis of idiopathic torsion dystonia, and one of dementia without parkinsonism. When only those patients who had seen a specialist at some point in the past were considered, the diagnosis was changed from Parkinson’s disease to a different diagnosis in 11%.

Patients with an initial diagnosis of Parkinson’s disease

What Tests Might I Have

How does a physician arrive at a Parkinson’s disease diagnosis?

Your doctor may want to start by testing your blood or doing a brain scan to rule out other conditions.

People who have Parkinsonâs disease donât make enough of a brain chemical called dopamine, which helps you move. If those first tests donât show a reason for your symptoms, your doctor may ask you to try a medication called carbidopa-levodopa, which your brain can turn into dopamine. If your symptoms get much better after you start the drug, your doctor probably will tell you that you have Parkinsonâs disease.

If the medication doesnât work for you and thereâs no other explanation for your issues, your doctor might suggest an imaging test called a DaTscan. This uses a small amount of a radioactive drug and a special scanner, called a single photon emission computed tomography scanner, to see how much dopamine is in your brain. This test can’t tell you for sure that you have Parkinson’s disease, but it can give your doctor more information to work with.

It can take a long time for some people to get a diagnosis. You may need to see your neurologist regularly so they can keep an eye on your symptoms and eventually figure out whatâs behind them.

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What Are The Symptoms Of Parkinson’s Disease

The main symptoms of Parkinson’s disease are:

  • tremor or shaking, often when resting or tired. It usually begins in one arm or hand
  • muscle rigidity or stiffness, which can limit movement and may be painful
  • slowing of movement, which may lead to periods of freezing and small shuffling steps
  • stooped posture and balance problems

The symptoms of Parkinson’s disease vary from person to person as well as over time. Some people also experience:

  • loss of unconscious movements, such as blinking and smiling
  • difficulties with handwriting
  • drop in blood pressure leading to dizziness
  • difficulty swallowing
  • sweating

Many of the symptoms of Parkinson’s disease could be caused by other conditions. For example, stooped posture could be caused by osteoporosis. But if you are worried by your symptoms, it is a good idea to see your doctor.

Conditions That May Be Mistaken For Parkinsons Disease

There are a few conditions that may be confused with Parkinsons disease. These conditions can cause similar symptoms, and because there is no definitive test that proves you have Parkinsons disease or any of these similar conditions. As you might imagine, this can make it challenging at times for doctors to figure out which condition you have. A few of the most common conditions that might look like Parkinsons are:

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Other Challenges Of Diagnosing Parkinsons Disease

Parkinsons disease progresses slowly, often with non-motor symptoms appearing months or years before motor symptoms. This can make it challenging for doctors to diagnose you in the early stages, especially since the diagnostic criteria is based mostly on motor symptoms. You may have to wait until your symptoms progress for you and your doctor to confirm your diagnosis.14

Age and gender can be another issue. Since Parkinsons is associated more with older men, doctors may not think their younger or female patients have Parkinsons.5 On the other hand, since the disease is associated with aging, your symptoms may be blamed on getting older.

Remember that movement disorder specialists are extremely knowledgeable about Parkinsons disease and can help put the pieces together where other more generalized doctors may not. Never hesitate to fight for the care you deserve.

Related: Heres whats important to remember if you were just diagnosed with Parkinsons disease.

What Medications Are Used To Treat Parkinsons Disease

(PDF) The Challenge and Opportunity to Diagnose Parkinson ...

Medications are the main treatment method for patients with Parkinsons disease. Your doctor will work closely with you to develop a treatment plan best suited for you based on the severity of your disease at the time of diagnosis, side effects of the drug class and success or failure of symptom control of the medications you try.

Medications combat Parkinsons disease by:

  • Helping nerve cells in the brain make dopamine.
  • Mimicking the effects of dopamine in the brain.
  • Blocking an enzyme that breaks down dopamine in the brain.
  • Reducing some specific symptoms of Parkinsons disease.

Levodopa: Levodopa is a main treatment for the slowness of movement, tremor, and stiffness symptoms of Parkinsons disease. Nerve cells use levodopa to make dopamine, which replenishes the low amount found in the brain of persons with Parkinsons disease. Levodopa is usually taken with carbidopa to allow more levodopa to reach the brain and to prevent or reduce the nausea and vomiting, low blood pressure and other side effects of levodopa. Sinemet® is available in an immediate release formula and a long-acting, controlled release formula. Rytary® is a newer version of levodopa/carbidopa that is a longer-acting capsule. The newest addition is Inbrija®, which is inhaled levodopa. It is used by people already taking regular carbidopa/levodopa for when they have off episodes .

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Sensitivity Specificity And Predictive Value Of A Previous Diagnosis Of Parkinson’s Disease

Of 126 patients with a pre-existing clinical diagnosis of probable and possible Parkinson’s disease in the overall sample , 111 were confirmed as having Parkinson’s disease, resulting in a sensitivity of 88.1% similarly, it was confirmed that 54 of 74 patients did not have Parkinson’s disease, resulting in a specificity of 73.0% . The positive and negative predictive values of a previous clinical diagnosis of Parkinson’s disease were 84.7% and 78.3% . In other words, in 85% of patients with a previous diagnosis of Parkinson’s disease this diagnosis was confirmed, and 78% of patients with a diagnosis other than Parkinson’s disease did not have the disease .

When this was broken down by a specialist or other doctor diagnosis, the diagnostic validity was as follows. Neurologists and geriatricians had a sensitivity and specificity of 93.5% and 64.5% , respectively, compared with 73.5% and 79.1% for non-specialists. The positive predictive values were greater for specialists than for other doctors , but the negative predictive values were equivalent v non-specialist 79.1% ).

What Is Essential Tremor And How Is It Different To A Parkinsons Tremor

A tremor is a rhythmical, involuntary movement that affects a part of the body, such as the hand.

Essential tremor is the most common type of tremor. Its most noticeable when your hands are doing something and it usually affects both the right and left sides of the body equally. Essential tremors often lessen when your body is resting.

Unlike an essential tremor, a Parkinsons tremor is most obvious when the affected body part is resting and tends to be less noticeable with movement. It usually starts on one side of the body and may progress to the other side as Parkinsons develops.

The time it takes to get a diagnosis can vary from person to person. Some people may receive a diagnosis of Parkinsons quite quickly, but for others it may be a long process. This can be due to a number of things, including your medical history, your age and what symptoms you have.

Your specialist may wish to rule out other causes of your symptoms first and see how you respond to treatment. This may take some time, and, as already mentioned, there is currently no definitive test for Parkinsons.

How you respond to treatment may help your specialist make a diagnosis. Keeping a diary or record of your symptoms will give the specialist more information to guide their decision.

Because the symptoms of Parkinsons are sometimes similar to other forms of parkinsonism, people can sometimes be misdiagnosed.

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What Tests Diagnose Parkinson’s Disease

There currently are no tests that can definitively diagnose Parkinsons Disease. A diagnosis is based on the clinical findings of your physician in combination with your report on the symptoms you are experiencing.

In situations where an older person presents with the typical features of Parkinsons and they are responsive to dopamine replacement therapy, there is unlikely to be any benefit to further investigation or imaging.

What Happens If A Doctor Thinks It’s Alzheimer’s Disease

Diagnosing Parkinson’s Disease by Dr. Steve McGee (Stanford Skills Symposium)

If a primary care doctor suspects mild cognitive impairment or possible Alzheimers, he or she may refer the patient to a specialist who can provide a detailed diagnosis or further assessment. Specialists include:

  • Geriatricians, who manage health care in older adults and know how the body changes as it ages and whether symptoms indicate a serious problem
  • Geriatric psychiatrists, who specialize in the mental and emotional problems of older adults and can assess memory and thinking problems
  • Neurologists, who specialize in abnormalities of the brain and central nervous system and can conduct and review brain scans
  • Neuropsychologists, who can conduct tests of memory and thinking

Memory clinics and centers, including Alzheimers Disease Research Centers, offer teams of specialists who work together to diagnose the problem. Tests often are done at the clinic or center, which can speed up diagnosis.

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