Parkinson’s Disease¶
Clinical Presentation¶
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Resting tremor is typically a very early symptom, often worse on one side
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Cogwheel rigidity; can be confused for paratonia, which is seen in demented or encephalopathic patients who have involuntary variable resistance movements during passive ROM assessment
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Speech changes (low volume), hand-writing changes (slow small movements)
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Gait changes
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Festination – slow start with movements that gradually build up speed
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En bloc turning – taking multiple steps to turn around
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Anosmia and REM behavior sleep disorders are very common
Evaluation¶
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Clinical diagnosis; there are some supportive imaging studies like DaTscan that looks for activity of substantia nigra (usually not necessary)
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Clinical response to dopamine replacement is so typical that if a patient does not respond, it is important to consider a Parkinson plus syndrome (see below)
Management¶
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Dopamine replacement – carbidopa/levodopa; dosed at regular intervals several times a day. These generally do not need to be held on admission.
- If pt is altered, can hold anticholinergics, MAO-B inhibitors or COMT inhibitors
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Dopamine agonists – can cause confusion, hallucinations, dyskinesias
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MAO-B inhibitors (MAOIs): can cause confusion, hallucinations, insomnia and dyskinesias
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COMT inhibitors – can cause confusion, hallucinations, insomnia, and dyskinesias
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Anticholinergics – useful for tremor when there is not much bradykinesia or gait disturbances. In older pts cognitive changes are a bigger concern along with hallucinations
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PD medications are rarely titrated in the hospital because acute medical illness makes PD symptoms worse and everything will need to be re-adjusted as an outpatient
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Be cautious with PRN anti-emetics in patients with PD. Many work via dopamine antagonism. Zofran is generally the safest option.
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Similarly, many antipsychotics have dopamine antagonism. Safest option is seroquel
Parkinson Plus Syndromes¶
Evaluation¶
- Consider if atypical features such as bilateral symmetric onset, early cognitive/personality changes, cerebellar findings, or prominent autonomic dysfunction early
Types¶
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Progressive Supranuclear Palsy
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PD symptoms with early falls and minimal tremor
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Vertical eye movement abnormalities
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Multisystem Atrophy
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Profound orthostatic hypotension without any increase in HR
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Three types:
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MSA-A – autonomic features prominent (previously Shy-Drager Syndrome)
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MSA-P – prominent atypical Parkinsonism features
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MSA-C – prominent cerebellar dysfunction
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Lewy Body Dementia
- Parkinsonism with prominent early cognitive impairment and hallucinations