Differing demographics of vascular parkinsonism and idiopathic parkinson s disease
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Differing Demographics of Vascular Parkinsonism and Idiopathic Parkinson’s Disease. Karthik Sarma MD Resident PGY4 Shreyansh Shah MD and William Ondo MD Dept of Neurology. 14 th April, 2011. 63rd AAN Annual Meeting, Hawaii, 2011. Disclosures. Anand K Sarma, MD Shreyansh D Shah, MD

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Differing Demographics of Vascular Parkinsonism and Idiopathic Parkinson’s Disease

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Differing demographics of vascular parkinsonism and idiopathic parkinson s disease

Differing Demographics of Vascular Parkinsonism and Idiopathic Parkinson’s Disease

Karthik Sarma MD

Resident PGY4

Shreyansh Shah MD and William Ondo MD

Dept of Neurology

14th April, 2011

63rd AAN Annual Meeting, Hawaii, 2011.


Disclosures

Disclosures

  • Anand K Sarma, MD

  • Shreyansh D Shah, MD

  • William G Ondo, MD

No disclosures

No disclosures

W. Ondo: Grant Support: Ipsen, Acadia, Bayer, Takeda, Allergan, PSG, HSG, IMPAX

Speaking / Consulting fees: GSK, Allergan, Novartis, Ipsen, TEVA, UCB Pharma, Merz, Lundbeck


Vascular parkinsonism

Vascular Parkinsonism

  • Critchley introduced the term in 1929

  • Initially used to describe clinical presentations consisting of…

    • rigidity

    • short-stepping gait

    • fixed facies

    • pyramidal, pseudobulbar signs and cerebellar signs

    • dementia and urinary incontinence

  • Variously referred to as Lower Body Parkinsonism, Arteriosclerotic Pseudo-Parkinsonism, etc.


Features of vp

Features of VP

  • Clinical

    • Typically older age of onset

    • Shorter duration of symptoms at presentation

    • Symmetric gait difficulties

    • No rest tremor

  • Imaging

    • Typically chronic small vessel ischemic changes

  • Pathology

    • Absence of Lewy body pathology


Imaging

Imaging

Source: BCM imaging database


Diagnosing vp

Diagnosing VP

  • No consensus diagnostic criteria available

  • Diagnostic problem in the community especially when non-neurologists and non-movement disorders experts involved in making the diagnosis of Parkinsonian symptoms

  • Several criteria proposed including:

    • Vascular Rating Scale by Winikates and Jankovic

    • Loeb and Gandolfo’s modification of Hachinski score

    • Zijlmans et al criteria for VP


Epidemiology of idiopathic pd

Epidemiology of idiopathic PD

  • Age of the patient considered as one of the most important risk factors for development of PD

    AGE α RISK of PD

  • Studies have revealed that both Incidence and Prevalence increase with age


Prevalence studies

Prevalence studies


Incidence of pd

Incidence of PD

Age- and sex-specific average annual incidence rates (per 100,000 person-years) of parkinsonism and its types: Olmsted County, MN, 1976–1990*

Incidence and distribution of parkinsonism in Olmsted County, Minnesota, 1976-1990.

Bower JH, Maraganore DM, McDonnell SK, Rocca WA.

Neurology. 1999 Apr 12;52(6):1214-20.


Question

Question…

Does the misdiagnosis of VP as PD increase the age of onset of PD in epidemiologic studies?


Hypothesis

Hypothesis

VP misdiagnosed as PD would cause the average age at symptom onset of PD to increase, altering the age related distribution of PD and hence the epidemiology of PD.

The incidence of PD in the population follows a bell shaped (normal) distribution about a median age of 60 years.


Study methods

Study Methods

  • Queried the PDCMDC database for the last 100 consecutive active patients with a diagnosis of VP and PD each.

  • Collected demographic information including age at symptom onset, risk factors, clinical and radiological features.

  • Examined entire database for diagnoses ratio.

  • Calculated how VP would alter epidemiology of PD if labeled as PD.


Results

Results

  • No. of VP charts examined: 108

  • Diagnosis changed after initial assignment: 10

  • Total No. of VP considered for analysis: 98

  • The difference of the mean age at symptom onset between VP with and without overt stroke was not significantly different, p = 0.34


Results continued

Results continued

*- using Mann Whitney U test


Early clinical features comparison

Early Clinical Features: Comparison

* Chi Square test


Prominent clinical features at presentation

Prominent Clinical Features at Presentation

%

Patients

Clinical features


Risk factors comparison

Risk Factors: Comparison

* Chi Square test


Differing demographics of vascular parkinsonism and idiopathic parkinson s disease

Risk Factors: Comparison

* Chi Square test


Risk factors

Risk Factors

% Patients

Vascular Risk Factors


Imaging characteristics

Imaging Characteristics

% Patients


Age wise distribution of onset of symptoms

Age wise distribution of Onset of Symptoms

% Patients

Age Groups in years

Age Groups in years


Caveats of extrapolating the results to predict age of onset for pd

Caveats of extrapolating the results to predict age of onset for “PD”…

  • Sample of 200 patients may not be a representative sample of the database

  • Patient sample and database may not be representative of the population

  • Obvious recruitment bias at a Parkinson’s Disease center

  • Relative occurrence of VP and PD in the population are not similar to database


But if we did extrapolate

But if we did extrapolate…

Does VP misdiagnosed as PD increase the average age at onset of PD?


Differing demographics of vascular parkinsonism and idiopathic parkinson s disease

Mean Age at Onset for PD would increase from:

57.81 to 59.36

[ 73.59 * 805 / 7742 ] + [ 57.81 * 6937 / 7742 ]

= 59.36

Proportional weighting based on relative occurrence


Value of study

Value of study

  • Provides a possible explanation for variability in epidemiology trials of age of onset for PD and more commonly, falsely elevated ages

  • Encouraged future studies such as the ongoing sorting of our entire database

  • Demands a population based incidence study differentiating VP and PD

  • Importance of differentiating the two in the community given disparate pathophysiology, progression, response to treatment, prognosis and importantly, person making the diagnosis.


Acknowledgements

Acknowledgements

I would like to thank my friend and colleague, Yogeshwar V Kalkonde for his valuable input and help.


Differing demographics of vascular parkinsonism and idiopathic parkinson s disease

Questions?

View of Waikiki sunset from my room.

Karthik Sarma; 9th April, 2011.

Thank you!


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