Huntington's Disease

Huntington's disease is associated with cell loss within the basal ganglia and cortex. It is an autosomal-dominant, progressive neurodegenerative disorder with a distinct phenotype, including chorea and dystonia, incoordination, cognitive decline, and behavioural difficulties.¹ Huntington's disease was first described by George Huntington in 1872. The disease is associated with increases in the length of a CAG (cysteine-adenosine-guanine) triplet repeat present in a gene called 'huntingtin' located on chromosome 4p16.3.²

• The prevalence in most European countries ranges from between 4 and 8 per 100,000 people.³

• Typically, onset of symptoms is in middle-age but the disorder can manifest at any age.¹
• There is often a prodromal phase of mild psychotic and behavioural symptoms which may last for up to ten years before the development of chorea. Early signs may be personality change, self neglect, apathy with clumsiness, fidgets with fleeting facial grimaces.
• Huntington's disease then leads to progressive chorea, rigidity and dementia. It is frequently associated with seizures.
• Dysarthria, dysphagia and abnormal eye movements are common. There may also be other movement disorders, e.g. tics and myoclonus.
• Chorea is initially mild but may be severe and cause uncontrollable limb movements.
• As the disease progresses, chorea is gradually replaced by dystonia and parkinsonian features.
• Behavioural difficulties include apathy or lack of initiative, dysphoria, irritability, agitation or anxiety, poor self-care, poor judgment and inflexibility.¹
• Late features include spasticity, clonus, supranuclear gaze palsy and extensor plantar responses.
• The rate of cognitive decline is very variable. Early changes include behavioural changes and then progresses to impaired intellectual function and memory disturbances.
• Juvenile Huntington's disease (6% of all cases of huntington's disease) is defined as an age of onset of younger than 20 years. It causes parkinsonian features, dystonia, pyramidal tract signs, dementia and epilepsy. Chorea is often mild and may be absent.

• Neuroacanthocytosis
• Tardive dyskinesia
• Other causes of chorea:⁴
  • Hereditary: e.g. Wilson's disease.
  • Sporadic: e.g. drugs, pregnancy, senile chorea, vascular disease, thyrotoxicosis, systemic lupus erythematosus and the lupus anticoagulant syndrome, polycythaemia rubra vera, AIDS and Sydenham's chorea.
• Other causes of dementia.

• MRI and CT scans in moderate-to-severe Huntington's disease show a loss of striatal volume and increased size of the frontal horns of the lateral ventricles, but scans are usually unhelpful for diagnosis of early disorder.¹
• If genetic testing is considered then extensive genetic counseling in a specialist unit is required in view of the implications of an untreatable, familial, progressive, neurodegenerative disease.
• Testing for alternative causes of movement disorders (including SLE, antiphospholipid antibody syndrome, thyroid disease and Wilson disease) and dementia.

• Depression, significant personality change and symptomatic schizophrenia are all common in patients with Huntington's disease.⁵

Current drug therapy has no effect on the progression of disability. Hyperkinesias and psychiatric symptoms may respond well to pharmacotherapy, but neuropsychological deficits and dementia remain untreatable.⁶
• Patients, their families and carers require a great deal of physical and emotional support.
• Chorea: benzodiazepines, valproic acid, dopamine-depleting agents (e.g. reserpine or tetrabenazine) and neuroleptics may be useful.
• Patients with predominant bradykinesia and rigidity may benefit from levodopa or dopamine agonists.
• Depression: needs prompt recognition and treatment with SSRIs or alternative antidepressants. Refractory depression may require ECT treatment.
• Psychosis: antipsychotic medications may be necessary. Newer atypical antipsychotics are preferable in view of their lower incidence of extrapyramidal side effects.
• Neural and stem cell transplantation is a potential future treatment.

• Relentlessly neurodegenerative disorder. The clinical features develop progressively with severe increase in choreic movements and dementia.
• Death is usually from an intercurrent illness, e.g. respiratory tract infection.