A 68-year-old female attends the falls clinic.
She had multiple falls over the last six months and she has noticed that she has become much more unsteady
on her feet. Her husband tells you that she has become very restless at night and that he hardly gets any
sleep. Examination reveals bradykinesia and a jerky rest tremor. Her gait is broad based. She scores 28/30 on a mini mental state examination (MMSE). Which of the following is the most likely diagnosis?
A Corticobasal degeneration (CBD)
B Idiopathic Parkinson’s disease
C Multiple system atrophy (MSA) Correct
D Progressive supranuclear palsy (PSP)
E Vascular parkinsonism
Multiple system atrophy (MSA) is a progressive neurodegenerative disease. The above patient fulfils the
criteria for a parkinsonian syndrome (and probably has rapid eye movement sleep disorder), but there are a
number of red flags alluding to a Parkinson’s plus syndrome:
- The patient has multiple falls early in the disease
- She has cerebellar signs - broad based (ataxic) gait
- She has a ‘jerky’ tremor.
Option A is incorrect. Corticobasal degeneration presents with parkinsonism, but also cognitive impairment
(MMSE here is normal). CBD presents with apraxia and this is responsible for the gait disturbance - it does not
present with cerebellar signs as it affects the cerebral cortex and basal ganglia.
Option B is incorrect because idiopathic Parkinson’s disease does not present with early falls or early postural
instability. This feature usually presents late in the course of the disease. It also does not present with
cerebellar signs.
Option D is incorrect because PSP does present with early falls (usually backwards) but does not present with
cerebellar signs.
Option E is incorrect because the gait in vascular parkinsonism is usually shuffly with short step length and not
ataxic. Rest tremor is absent in vascular parkinsonism, but postural tremor may occur