Diagnosing Atypical Parkinsonian Disorders (Podcast)

Parkinson’s disease is the most common form of parkinsonism, typically diagnosed through a combination of physical exam, medical history and symptoms. Atypical parkinsonian disorders, however, often follow more aggressive courses and can be more challenging to diagnose.

“Whenever somebody follows a trajectory that looks different from Parkinson's disease, we call it atypical parkinsonism,” says Junaid Siddiqui, MD, a movement disorders specialist in Cleveland Clinic’s Center for Neuro-Restoration. “That would include earlier memory problems, earlier balance difficulties or falls, or significantly dysautonomia.”

In the latest episode of Cleveland Clinic’s Neuro Pathways podcast, Dr. Siddiqui discusses the complexities of diagnosing and managing atypical parkinsonism. These disorders tend not to respond to levodopa (commonly prescribed for Parkinson’s disease) or show only short-lived, mild response.

Dr. Siddiqui describes primary symptoms of the following parkinsonian disorders:

• Progressive supranuclear palsy (PSP)
• Multiple system atrophy (MSA)
• Corticobasal syndrome (CBD)
• Dementia with Lewy bodies (DLB)

He also discusses an algorithm he developed with other movement disorder experts working with the CurePSP group to help general neurologists with patients they believe might have atypical parkinsonism.

To hear the 24-minute episode, click on the podcast player above. Or read on for a short, edited excerpt. Check out more Neuro Pathways episodes at clevelandclinic.org/neuropodcast or wherever you get your podcasts.

This activity has been approved for AMA PRA Category 1 Credit™ and ANCC contact hours. After listening to the podcast, you can claim your credit here.

Excerpt from the podcast

Podcast host Glen Stevens, DO, PhD: So (let’s say) I'm getting a little bit older, I get a little mild tremor. I've kind of slowed down in my movements. I think I might have Parkinson's, I come and see you. How good are you at diagnosing Parkinson's disease?

Dr. Siddiqui: We have gotten good in picking up parkinsonism, especially in the movement disorder world. So that's how we start (parkinsonism). Whenever somebody comes in with a tremor, the first thing we notice is whether the tremor is symmetric or asymmetric, is it at rest or does it come out with use of hands? The handwriting size, has it become larger or smaller? Then we ask questions about a sense of smell or REM sleep behavior disorder and constipation. So we enquire about both non-motor symptoms and motor symptoms. We try to make a trajectory of when the symptoms started, how long it has been since the symptoms have begun and how severe they are. That gives us an idea of how aggressive the underlying condition is. Then we talk about the possibilities. If somebody has an asymmetric tremor at rest with micrographia, hyposmia, if they have REM sleep behavior disorder, constipation, and they've had these symptoms for the last four or five years, it is more likely to be Parkinson's disease rather than atypical parkinsonian disorder.

Dr. Stevens: How good are we at picking up the atypical disorders? Is it more difficult? Are there any ancillary tests that we can use? Does imaging help?

Dr. Siddiqui: Obtaining a good history is the most important thing that we can do. If you can get a history, the patient is trying to tell you what they have. So history gives us 80% or more of a diagnosis. So if somebody comes in with parkinsonism and they have falls before three years of disease onset, they have memory problems within a year of disease onset, they have severe dysautonomia … we already know that they have an atypical parkinsonian disorder. All we need to figure out if this is α-synucleinopathy or is it tauopathy? So α-synucleinopathies would be MSA or DLB. And tauopathies would be PSP and CBD.