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We know that this patient has postural hypotension, and therefore lying and standing blood pressure measurements would prove this to be true. However, there are many causes for postural hypotension in the elderly, and therefore this would not prove a Parkinson's plus syndrome
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Lying and standing blood pressure measurement
QuestionChoice
Parkinson's disease is closely linked to Lewy Body Dementia, and therefore in all patients with Parkinson's disease, it is important to assess cognitive function. However, this would not account for the recurrent falls and would not be likely to aid further diagnosis here.
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Abbreviated Mental Test (AMT)
QuestionChoice
This history is not suggestive of syncopal episodes as a cause for his falls. Whilst an ECG should always be performed in patients with recurrent falls to look for arrhythmias; a stand-alone ECG is unlikely to pick up a cause for falls. 24 hour Halter monitoring is more sensitive and would be a reasonable investigation if there were concerns about a cardiac cause for his falls
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12 lead ECG
QuestionChoice
The two main differential diagnoses in this scenario are Progressive Supranuclear Palsy (PSP) and Multiple system atrophy (MSA). This patient likely has a Parkinson's plus syndrome as he has symptoms of autonomic instability (urinary incontinence, postural hypotension and recurrent chest infections, which raises a concern about poor swallow), and the co-benyldopa does not seem to have had much effect. It's important to test for vertical gaze palsy to help you narrow down your differential diagnosis. 
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Testing vertical gaze
QuestionChoice
Infection is a common cause of falls in the elderly. Common sources are urine and chest; however, there is nothing in the history suggestive of infection; therefore, whilst this is always worth checking, it is unlikely to provide a diagnosis here
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Urinalysis
QuestionComment
Sweet lord, are you telling me I was supposed to infer poor swallow from recurrent chest infections? 
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George
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# Summary

Parkinsonism refers to a group of neurological conditions that share the core motor features of Parkinson’s disease—bradykinesia, rigidity, resting tremor, and postural instability. While Parkinson’s disease is the most common cause of parkinsonism, several other important neurodegenerative conditions can present with a similar signs and symptoms. These conditions are collectively known as **Parkinson-plus syndromes**. These include **progressive supranuclear palsy (PSP)**, **multiple system atrophy (MSA)**, **Lewy body dementia (LBD)**, and **corticobasal degeneration (CBD)**. 

## Progressive Supranuclear Palsy (PSP)

- Also known as **Steele-Richardson-Olszewski syndrome**
- Early postural instability and frequent falls.
- **Impairment of vertical gaze** (particularly downgaze).
- Stiff, broad-based gait.
- Parkinsonism (bradykinesia, rigidity).
- An MRI of the brain may show a **hummingbird sign**, a characteristic shape of midbrain atrophy seen in PSP.



## Multiple System Atrophy (MSA)

- Presents with parkinsonism and early **autonomic dysfunction**. 
- It is divided into two types based on the predominant symptoms:
	1. **MSA-P** (Parkinsonian type): Similar to Parkinson's disease but with early autonomic issues.
	2. **MSA-C** (Cerebellar type, also known as Shy-Drager syndrome): Presents with **cerebellar ataxia**, alongside parkinsonism. Early signs include **postural hypotension**, **urinary incontinence**, and **erectile dysfunction** (an early prominent feature in men).
- Generally exhibits poor response to levodopa therapy


## Lewy Body Dementia (LBD)

- Characterised by **dementia and parkinsonism**, often occurring within one year of each other. 
- The hypothesised pathophysiology involves the early death of dopaminergic neurons in the **cerebrum**, which then extends to the basal ganglia, leading to motor symptoms.
-  Unlike Alzheimer’s, LBD affects **attention and executive function** early on, with less involvement of memory (hippocampus). 
-  **Visual hallucinations** are a prominent feature and tend to occur early in the disease.

## Corticobasal Degeneration (CBD)

### Key Clinical Features:
- Unilateral parkinsonism, typically affecting one limb.
- **Alien limb phenomenon**.(patients feel that their limbs move involuntarily outside of their control
- **Cortical sensory loss** (patients cannot recognise objects by touch despite normal sensory input).
- **Apraxia** (difficulty with purposeful movement despite intact motor function).


## Other Conditions Mimicking Parkinsonism

### Vascular Parkinsonism

- Often affects the **lower limbs** and is seen in patients with a history of **vascular disease** (e.g., strokes). 
- Patients develop gait issues with rigidity and bradykinesia predominantly in the lower extremities.

### Dementia Pugilistica

- Also known as **chronic traumatic encephalopathy** (CTE), this condition arises from **repetitive head trauma**, commonly seen in **boxers**. 
- It presents with parkinsonism and cognitive decline.

### Drug-Induced Parkinsonism

- Caused by medications such as **antipsychotics** (e.g., haloperidol, risperidone), **metoclopramide**, and **prochlorperazine**.
- Onset is typically **rapid** and **bilateral**.
- Management involves stopping the offending drug and, in some cases, using **procyclidine** to manage symptoms.
- Can lead to **neuroleptic malignant syndrome** (a life-threatening condition characterized by fever, rigidity, and altered mental status).

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In Parkinson's Plus Syndromes, vertical gaze testing reveals difficulty with downward gaze, impaired saccades, and smooth pursuit
A 74-year-old male is referred to the falls clinic after he suffers three mechanical falls at home within two months. He has a past medical history that includes postural hypotension, urinary incontinence, recurrent chest infections and six months ago was diagnosed with Parkinson's disease. He currently takes, co-benyldopa and has just finished a course of amoxicillin. On examination, you note that he has hypomimia, rigidity and bradykinesia with a very mild tremor.

You suspect a Parkinson's Plus Syndrome. Which of the following would you perform next?
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