Diagnosing Parkinson's - is age a factor

Parkinson's Academy webinar:

How do a Neurologist and Older Person’s Physician assess and manage their patients with Parkinson’s. Does the age of the patient play a factor? If so how does that influence clinical practice? What tools should the clinician have in their tool box? Who else should be involved in the care?

Join Dr Matthew Smith and Associate Professor Emily Henderson as they discuss these issue and more in providing the best care for people living with Parkinson’s.

Summary

While the mean age of Parkinson’s onset is in the 60s, a subset of people develop young-onset (under 40 years) or even juvenile-onset (under 21 years) disease.

Of course, everyone’s life priorities are different, but there are some general age-related factors that can influence how Parkinson’s disease (PD) may impact on a someone’s life. Someone in their 20s or 30s, for example, may be focused on establishing relationships, starting their career, or having children, for example, whereas those in their 70s or 80s may prioritise enjoying retirement or spending time with their family.

“The earlier someone has a diagnosis of PD, the more their life is defined by it,” said Dr Matthew Smith, adding that people diagnosed in their 20s or 30s will have been living with the disease decades by the time they reach older age.

Their outlook, then, may be very different to that of someone who was diagnosed in later life, after they had already had a career and grandchildren, for example.

Differential diagnosis

Other ways in which age can be a factor in PD diagnosis include the wider range of potential differential diagnoses in the under 40s, compared to older patients. Younger people have, for example, an increased likelihood of genetically linked idiopathic PD or other genetic neurological conditions.

Younger people with PD tend to display a broader phenotype, which include a longer period of motor symptoms with intact cognition, fewer falls and less freezing, and a greater incidence of dystonia, dyskinesia, and motor fluctuation. As such, alterative diagnoses may include ataxia, chorea, or neuropsychiatric symptoms/learning difficulties.

All this considered, it means there tends to be a higher acceptance of diagnostic burden in younger people – they tend to be fit and able to attend appointments, and conscious of the potential ramifications of a diagnosis.

“It is really important to take the time to deal with people’s expectations and to be upfront about the uncertainty,” Matthew said, adding that a lack of transparency can affect people’s confidence in their healthcare professionals and the wider healthcare system. Revaluating the phenotype over time is also critical, he said.

His approach to diagnosis includes:

• History and examination: a detailed family, drug, and developmental history, as well as thorough and complete neurological and movement disorder-lined examinations
• Diagnostics: MRI, consider DAT scan, blood test for calcium, copper, and, depending on the patient, consider lactate, white enzymes, and blood film. Genetic testing has a role, “but it is not always straightforward”

Genetics: pitfalls and caveats

Matthew said that he did not take genetic testing lightly, and always makes people go away and think about the pros and cons first.

For some people, it can end the so-called “diagnostic journey”, and access to genetic data is crucial for research and trial eligibility.

“One of the pitfalls, however, is that this is not a simple test: it is not like doing CT to show if there is a stroke in someone’s brain,” Matthew went on. There is a high level of heterogeneity from one person to the next, and many mutations of uncertain significance. Teams need the guidance of a geneticist, he went on, to help “deal with that uncertainty”.

Research and education

In addition, there tends to be a high motivation for research participation and appetite for disease education among younger patients.

“For people diagnosed in their 20s and 30s, we hope very much that there might be a disease modifying drug in their lifetime,” said. “When you are going to be living with this for the next 40 or 50 years, it is defining your life. There’s a real impetus for understanding what is afflicting you.”

Diagnosis in older people

Diagnosis in older people, said Professor Emily Henderson, should always include “life context”, or “what matters most to them”.

“A diagnosis of PD can often precipitate retirement and there is a lot of psychological adjustment that’s needed there.” Rather than starting consultations asking about signs and symptoms, Emily tends to “try to build a picture of who there are”. That involves asking them to describe a typical day and finding out “what confers joy and meaning in life”.

“Every clinical decision and discussion you have can then be framed in that context,” she said. HCPs should also carry out a “forensic inquiry” of comorbidities, particularly those that could have some bearing on PD progression or treatment, such as hypertension.

The key theme of Emily’s advice was support. “It is really important to be upfront about any diagnostic uncertainty, but equally you want to inspire a sense of competence. The therapeutic relationship is increasingly important as the disease progresses. As that happened, medicine is about more than just medicine,” she said.

Just like in younger people, she went on, it was important to continue to revaluate the phenotype, and explain any resulting change in diagnosis or prognosis.

Commonalities

Summing up, Emily said the take home message was to “make no assumptions on how to provide care, based on someone’s age: it is not about the number”. Instead, the key was understanding the persons frailty, biological function, and life context.

For old and young alike, quality of life is of paramount importance, and the community should be working towards a place where all patients are considered for all research and education, she concluded.

Our Parkinson's webinars are available on SoundCloud:
soundcloud.com/neurologyacademy