Epidemiology |
Onset between 45 and 65 years of age Approximately equal sex and ethnic distribution Risk factors for development of dementia include increased age, greater severity of neurologic symptoms, and presence of APOE e2 allele | ||
Cardinal features of parkinsonian syndrome |
4-6 Hz resting tremor Rigidity Bradykinesia Postural instability | ||
Clinical features |
Motor General | ||
Unilateral onset Persistent asymmetry affecting side of onset most Excellent initial response (70%-100%) to levodopa | |||
Bradykinesia | |||
Masked facies Decreased blinking Hypophonic speech Prolonged response latency Slowed festinating gait with decreased arm swing Micrographia | |||
Rigidity | |||
Trunk & limb muscles Cogwheeling | |||
Tremor | |||
Resting Typically, pill-rolling | |||
Cognitive | |||
Characterized by dementia of the subcortical type (please refer to Chapter 31) Antiparkinsonian medications frequently exacerbate cognitive impairment Treatment of comorbid mood disorders may improve cognition | |||
Psychiatric Mood | |||
˜50% depression Prominent features include anxiety and increased suicidality | |||
Anxiety | |||
Typically Generalized Anxiety Disorder Panic disorder, obsessive compulsive disorders, and discrete phobias have also been observed Psychosis Characterized by visual hallucinations, delusions, confusion Fluctuates during day, worse in evening Often associated with longstanding parkinsonian illness, high doses of antiparkinson medications, and dementia | |||
Sleep disturbances | |||
Increased time to sleep onset with multiple awakenings Vivid, disconcerting dreams | |||
Diagnosis |
Clinical diagnosis strongly suggested by history and physical exam Central nervous system imaging, particularly MRI, is indicated in the presence of remarkably unilateral neurologic findings to rule out mass lesion or in the event of atypical neurologic findings MRI shows reductions in the size of substantia nigra in advanced cases of Parkinson disease | ||
Management |
General considerations | ||
Coordinate care with neurologists and other specialists including physical therapy, dietician, social workers Psychoeducation for patient, family, caregivers Assessment of functional limitations, including activities of daily living, gait disturbance, fall risk Attention to caregiver burden Hallucinations and delusions typically occur at night and are the chief reason families place patients in nursing homes | |||
Treatment of movement disorder | |||
Therapy often entails slowing the progression of the disease with neuroprotective agents (e.g., selegiline) followed by symptomatic treatment with agents such as dopamine agonists and anticholinergics Neuroprotective agents such as selegiline can slow the progression of the disorder and thus defer the need for dopaminergic therapy Despite levodopa therapy, parkinsonian motor symptoms reemerge after 5-10 years For patients unable to tolerate levodopa, amantadine and dopamine receptor agonists are useful adjuncts in the therapy of Parkinson disease Surgical procedures include stereotactic ventral pallidotomy, deep brain stimulation, or transplantation | |||
Treatment of comorbid psychiatric symptoms | |||
When possible, simplify/optimize medication regimens Rule out underlying metabolic and infectious causes for perceptual and mood disturbances Psychotic symptoms are common adverse effects of antiparkinsonism medications Consider discontinuation of antiparkinsonism medications in the following order: anticholinergics > amantadine > selegiline > dopaminergic agents Persistent psychotic symptoms warrant use of antipsychotic agents Clozapine and quetiapine at low doses are preferred agents due to decreased inherent risk of extrapyramidal symptoms Mood and anxiety symptoms may respond to dopaminergic agent dose reductions Rule out parkinsonian drug-associated psychiatric symptoms | |||
Visual hallucinations, typically characterized by human or animal figures, usually at night Persecutory delusions Elevated mood Anxiety Increased sexual interest Management includes discontinuation of anticholinergic medications, dosage adjustment of antiparkinsonian medications, and/or addition of neuroleptic agents for persistent psychotic symptoms (consider Clozaril or Seroquel to minimize extrapyramidal symptoms) |

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