Case Studies
Case 7: Slowing up in a 60-year-old man
A 62-year-old man presents with a six-month history of slowing up, with a change in handwriting. His GP thinks he looks depressed and treats him with an SSRI with no benefit. You are asked to see him to suggest another antidepressant. He has a previous medical history of Méničre’s disease and has been on an anti-sickness tablet, metoclopramide for this. His mother developed Alzheimer’s disease in her 80’s.
Show/Hide Caption
A DaT scan showing loss of dopamine transporter signal, more in the putamen than can date in Parkinson’s disease.
Your Answer:
Correct answer: The most likely diagnosis in this patient is some form of parkinsonian syndrome. This may have been provoked by the use of anti-emetic medication, some of which block the dopamine receptors and this includes metoclopramide. Thus it is important in this patient to find out whether his symptoms came on with the treatment for his Méničre’s disease. If one suspects Parkinson’s disease then it is useful to find out whether: he has developed arrest tremor; a change in his handwriting such that it has become smaller; a voice that has become quieter, and whether he has noticed that he doesn’t swing his arms and walks with a slight dragging of one leg and has slowed up in general.
Your Answer:
Correct answer: Given that one suspects this man has Parkinson’s disease one would look for an absence of facial expression, so called hypomimia, and a quiet voice hypophonia. His eye movements may reveal some hypometric saccades. In the limbs he may have increased tone of a cogwheel nature with a resting tremor and bradykinesia. On walking he may have a stooped gait with an absence of arm swing with a degree of shuffling and some problems turning with some postural instability.
Your Answer:
Correct answer: The family history is almost certainly irrelevant given that a significant number of people who develop Alzheimer’s disease in their ninth decade. The previous medical history is only relevant insomuch as the patient may have been put on a dopamine blocking anti emetic which has provoked their parkinsonian syndrome.
Your Answer:
Correct answer: The investigation of Parkinson’s disease often relies on the ruling out of other conditions. The vast majority of people rely on history and clinical examination for the diagnosis. There is dopamine imaging now available and one can do this to see whether there is dopamine deficiency within the striatum. The easiest way to do this is through a DaT scan in Nuclear Medicine departments. The management would involve the extent to which the patient is incapacitated by their symptoms. In the first instance one would stop the anti-emetic and review the patient. If they still have symptoms and require treatment, then traditionally one would use dopamine replacement therapy in the form of dopamine agonists or levodopa.