Parkinsonism

The relationship between DLB and Parkinson’s disease is a very complicated one. And actually, it’s probably best to think of a spectrum of disorders that have a lot of overlapping conditions and problems. So people with Parkinson’s disease can also develop dementia. And it can be quite difficult to explain, what is the difference between a Parkinson’s disease patient who’s got dementia and a patient with dementia with Lewy bodies who’s also got Parkinsonian features. And actually the distinction is a very arbitrary one and it’s this. If you’ve got Parkinson’s disease and you develop dementia, but the onset of your dementia was more than a year after the onset of your motor symptoms, then that’s called Parkinson’s disease with dementia.

If your cognitive symptoms appear first or at the same time as your motor symptoms, then that’s dementia with Lewy bodies. So it’s very arbitrary. There’s nothing special about a year. That’s just a cut off that’s been chosen for diagnostic purposes. But as you can imagine, there’s a huge grey area somewhere in the middle. And actually to get hung up on making absolute hard and fast cutoffs probably isn’t helpful. I think it’s only the last two years that the Parkinson’s has become more of a problem with the shaking, the tremor, the shuffling of the feet has going on for about maybe four years. But it’s only the last couple of years. So probably the Lewy body side of things was worse.

But when he went on to Rivastigmine initially, it did seem to calm things down quite a bit. And it’s so hard to try and remember, because it has been so gradual. It hasn’t been a sharp decline. If you look back at how he was three years ago, probably he was different that he is now. But it’s been so gradual. It seems to be a very slow, slow decline. But it is a decline, there’s no two ways about it. He is definitely declining. Now starting to lose water from–

I think Colin’s more concerned with the Parkinson’s symptoms than anything because I don’t think he realises quite how unable he is to do things. But losing the water, how do you describe that? Weeping. Weeping. Yes. That’s fairly new. It’s got worse. But it has got worse though. We often see this I think. When I first saw him, there wasn’t much in the way of Parkinsonism and this has developed over time. I mean, these are unfortunately progressive diseases. And over time, we do expect the symptoms to progress. As I say, we had a gratifying early response from a cognitive perspective and the cognition has slowly declined over time, and with it an emergence of the Parkinson’s side of things.

And as usual, it’s a difficult balance between the treatment of these two aspects in the knowledge that one may worsen the other. Over time, when the Parkinsonian features become more consistent, people can often resemble more typical Parkinson’s disease. So the sort of Parkinsonism that people with dementia with Lewy body gets are slightly unusual. So often patients presenting with Parkinson’s disease will start off with a unilateral hand tremor. And it’s known from the literature that the people with Parkinson’s disease who get more cognitive impairment, tend to be those who are stiffer and more symmetrical as opposed to more asymmetric and more tremulous. And as Colin’s disease has progressed, he’s developed this quite a lot of stiffness.

And then he’s developing some of the other features that we associate with Parkinson’s disease or the spectrum of diseases in terms of often hypersalivation and some other autonomic features as well.