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Parkinson’s Disease

Presentation

  • Resting tremor is typically a very early symptom, often worse on one side

  • 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

  • Speech changes (low volume), hand-writing changes (slow small movements)

  • Gait changes

    • Festination – slow start with movements that gradually build up speed

    • En bloc turning – taking multiple steps to turn around

  • Anosmia and REM behavior sleep disorders are very common

Evaluation

  • Clinical diagnosis; there are some supportive imaging studies like DaTscan that looks for activity of substantia nigra (usually not necessary)

  • 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

  • Continue home Parkinson’s medications the way they take at home. Abrupt discontinuation can cause severe withdrawal.

  • Dopamine replacement: Carbidopa/levodopa; dosed at regular intervals several times a day. Generally does not need to be held during admission.

    • If pt is altered, can hold anticholinergics, MAO-B inhibitors, or COMT inhibitors

  • Dopamine agonists: can cause confusion, hallucinations, dyskinesias

  • MAO-B inhibitors (MAOIs): can cause confusion, hallucinations, insomnia and dyskinesias

  • COMT inhibitors: can cause confusion, hallucinations, insomnia, and dyskinesias

  • 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

  • Parkinson’s Disease medications are rarely titrated in the hospital because acute medical illness worsens Parkinsonian symptoms. Everything will need to be re-adjusted outpt

  • Be cautious with PRN anti-emetics in pts with PD. Many work via dopamine antagonism. Zofran is generally the safest option

  • Similarly, many antipsychotics have dopamine antagonism. Safest option is quetiapine.

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

  • Progressive Supranuclear Palsy

    • PD symptoms with early falls and minimal tremor

    • Vertical eye movement abnormalities

  • Multisystem Atrophy

    • Profound orthostatic hypotension without any increase in HR

    • Three types:

      • MSA-A – autonomic features prominent (previously Shy-Drager Syndrome)

      • MSA-P – prominent atypical Parkinsonism features

      • MSA-C – prominent cerebellar dysfunction

  • Lewy Body Dementia

    • Parkinsonism with prominent early cognitive impairment and hallucinations

  • Corticobasal degeneration

    • Alien limb phenomenon (affected limb doesn’t belong to them) o Associated with apraxia and aphasia