24.1 Clinical History – Main Complaint

A 72-year-old woman was seen with her husband at the movement disorder clinic. She was referred by her attending neurologist who has been following her for 9 years for Parkinson’s disease (PD). Her symptoms had begun 10 years ago, with a left arm tremor that progressively worsened to affect the left side of her body and her right arm. The tremor was accompanied by generalized slowness of movement and stiffness. She was put on l-3,4-dihydroxyphenylalanine (L-DOPA) 8 years ago with a good initial response. Doses were progressively increased over the years. When seen at the clinic, she was taking L-DOPA/carbidopa (referred to as L-DOPA) 100/25 mg 1.5 pills every 3 hours from 6:00 a.m. to midnight, a total of 10.5 pills daily. Sometimes, she had to take an extra pill at night because of difficulty turning over in bed. She believed the effect of the antiparkinsonian medication was not lasting more than 2.5 hours and felt uncomfortable, with tremor resurgence, about 30 min before taking the next L-DOPA dose. Approximately 1 hour after L-DOPA intake, she would present fidgetiness and mild abnormal movements that were not bothersome but that were noticed by her husband and children. She had a few accidental falls. She sometimes experienced dizziness upon standing up rapidly. Approximately 1 year ago, she began experiencing visual hallucinations (VHs) that were, at times, frightening and prevented the neurologist from increasing L-DOPA doses. Most of the times, the VHs consisted of bugs, but on a few occasions they encompassed faces of unknown people. She had to be put on quetiapine 25 mg a.m. and 50 mg at bedtime to alleviate these VHs. Her husband was also concerned that she had become more forgetful in the past year. She was more apathetic and was not interested in going out anymore. At times, she was going through episodes of confusion. She was also experiencing episodes of daytime sleepiness and would have to nap for at least 1 hour every afternoon.

24.2 General History

The patient was a right-handed retired nurse. She was living with her husband in an apartment. The couple had two children, both of whom were in their 40s and in good health. She quit smoking 35 years ago. She drank one glass of wine per week. She had never used recreational drugs. Her past medical history was significant for hypothyroidism and hypertension, for which she was taking L-thyroxin and an angiotensin-converting enzyme inhibitor.

24.3 Family History

The patient’s family history was negative for neurological and psychiatric disorders. Her mother died at 93 years from a myocardial infarction, while her father died at 92 from a pulmonary embolism. She had one brother, who was 70 and suffered from diabetes mellitus type 2 and hypertension.

24.4 General Examination

The patient was seen in the afternoon. She had taken three doses of L-DOPA (1.5 pills of 100/25 mg L-DOPA/carbidopa), the last one an hour ago. She was seen while in the “on” state.

Blood pressure when lying flat was 120/75, pulse 70/min. Standing blood pressure, 5 minutes later, was 115/50, pulse 74/min.

General neurological examination revealed saccadic smooth pursuits with mild upward gaze limitation. Blinking rate was reduced. There was mild hypomimia. Speech was soft and monotonous. Cranial nerves were otherwise unremarkable. There were no square-wave jerks. Deep tendon reflexes were normal and symmetrical. Plantar response was flexor bilaterally. Muscle strength was normal. Vibration and light touch were normal. There was no cerebellar anomaly.

The patient exhibited mild left arm and leg tremor at rest. Tremor was reemerging upon maintaining a posture for a few seconds. There was no kinetic tremor. There was mild bradykinesia that affected both the upper and lower limbs but was more pronounced on the left side. Muscle tone was increased in the neck and the four extremities, slightly more on the left than on the right side. Mild choreic dyskinesia affecting both lower extremities was seen when the patient was concentrating. Gait was slow, with reduced left arm swing, but there was no shuffling. Turns were decomposed. Pull test showed a loss of postural reflexes.

Montreal Cognitive Assessment (MoCA) score was 17/30. Attention and concentration were relatively preserved, as the patient performed well at the tapping, serial subtraction, and digit span tasks. Language was mildly impaired; she confounded the rhinoceros with a hippopotamus. Repetition was intact. She was oriented to time and place. Executive functions were also impaired, as she could not complete the trail-making test, could not name more than seven words starting with the letter “F,” and had difficulty with the verbal abstraction task. She was unable to recall the five words without cue. She had visuospatial impairment, as she could not successfully copy a cube and draw a clock.

She did not report any hallucinations during the questionnaire or the physical examination.