Parkinson's disease - Clinicals, Diagnosis, and Management

Neurology

Clinicals - History

Fact Explanation
Old age The disease affects approximately 1 percent of persons older than 60 years, and up to 4 percent of those older than 80 years Old age
The disease affects approximately 1 percent of persons older than 60 years, and up to 4 percent of those older than 80 years
Gender - male Epidemiologic studies have found that Parkinson's disease is more prevalent in men than in women Gender - male
Epidemiologic studies have found that Parkinson's disease is more prevalent in men than in women
Family history The autosomal dominant adult-onset type is linked to a site on chromosome 4q, and the gene for autosomal recessive juvenile parkinsonism maps to chromosome 6q Family history
The autosomal dominant adult-onset type is linked to a site on chromosome 4q, and the gene for autosomal recessive juvenile parkinsonism maps to chromosome 6q
Resting tremor , Slow movements , stiffness of the body The hallmark of Parkinson's disease are tremor, rigidity and bradykinesia.
Parkinson's disease, a progressive disorder of the central nervous system (CNS), is caused by the degeneration of dopaminergic neurons in the substantia nigra of the midbrain. These neurons normally project to the striatum, consisting of the caudate and putamen nuclei, whose neurons bear dopamine receptors. This projection of neurons is just one component of the complex network of interconnections among the deep gray-matter structures known as the basal ganglia. Neurochemical or structural pathologic conditions affecting the basal ganglia result in diseases of motor control resulting in motor disorders
Resting tremor , Slow movements , stiffness of the body
The hallmark of Parkinson's disease are tremor, rigidity and bradykinesia.
Parkinson's disease, a progressive disorder of the central nervous system (CNS), is caused by the degeneration of dopaminergic neurons in the substantia nigra of the midbrain. These neurons normally project to the striatum, consisting of the caudate and putamen nuclei, whose neurons bear dopamine receptors. This projection of neurons is just one component of the complex network of interconnections among the deep gray-matter structures known as the basal ganglia. Neurochemical or structural pathologic conditions affecting the basal ganglia result in diseases of motor control resulting in motor disorders
Recent change in hand writing Occurs due to tremor.Handwriting is small and often indecipherable (History of micrographia) Recent change in hand writing
Occurs due to tremor.Handwriting is small and often indecipherable (History of micrographia)
Speech and swallowing difficulties Dysarthria and dysphagia occur frequently in Parkinson’s disease (PD). It is likely related articulatory and phonatory impairment Speech and swallowing difficulties
Dysarthria and dysphagia occur frequently in Parkinson’s disease (PD). It is likely related articulatory and phonatory impairment
Fatigue Fatigue is present in one-third of patients with Parkinson disease at diagnosis, and is associated with severity of illness Fatigue
Fatigue is present in one-third of patients with Parkinson disease at diagnosis, and is associated with severity of illness
Sleep disturbances Studies have found rapid eye movement sleep behavior disorder in patients with Parkinson disease Sleep disturbances
Studies have found rapid eye movement sleep behavior disorder in patients with Parkinson disease
Erectile dysfunction, urinary incontinence, and constipation Autonomic dysfunction is present in most patients late in the disease Erectile dysfunction, urinary incontinence, and constipation
Autonomic dysfunction is present in most patients late in the disease

Clinicals - Examination

Fact Explanation
Resting tremor Observed as patient rests hands in his or her lap; often described as pill-rolling in quality.
Occurs due to motor disturbance caused by the degeneration of dopaminergic neurons in the substantia nigra of the midbrain.
Resting tremor
Observed as patient rests hands in his or her lap; often described as pill-rolling in quality.
Occurs due to motor disturbance caused by the degeneration of dopaminergic neurons in the substantia nigra of the midbrain.
Rigidity The physician feels resistance as he or she places a finger within the patient’s antecubital fossa and repeatedly flexes and extends the patient’s arm at the elbow; resistance can be cogwheel rigidity (catching and releasing) or lead-pipe rigidity (continuously rigid); rigidity must be distinguished from spasticity, which has only increased flexor tone; rigidity also can be tested at wrist supination or pronation Rigidity
The physician feels resistance as he or she places a finger within the patient’s antecubital fossa and repeatedly flexes and extends the patient’s arm at the elbow; resistance can be cogwheel rigidity (catching and releasing) or lead-pipe rigidity (continuously rigid); rigidity must be distinguished from spasticity, which has only increased flexor tone; rigidity also can be tested at wrist supination or pronation
Bradykinesia Difficulty with rapidly and sequentially tapping the fingers of one hand and then the other on a table top; difficulty tapping the heel rapidly; difficulty twiddling or circling the hands rapidly around each other in front of the body; reduced arm swing on affected side during ambulation. Difficulty in rising from a chair Bradykinesia
Difficulty with rapidly and sequentially tapping the fingers of one hand and then the other on a table top; difficulty tapping the heel rapidly; difficulty twiddling or circling the hands rapidly around each other in front of the body; reduced arm swing on affected side during ambulation. Difficulty in rising from a chair
Gait Small, shuffling steps may be observed, with difficulty initiating ambulation; patients may have a festinating gait (involuntary acceleration of gait); heel-to-toe ambulation is impaired; arms often are stationary; posture often is stooped; patients may have difficulty turning and have poor balance Gait
Small, shuffling steps may be observed, with difficulty initiating ambulation; patients may have a festinating gait (involuntary acceleration of gait); heel-to-toe ambulation is impaired; arms often are stationary; posture often is stooped; patients may have difficulty turning and have poor balance
Micrographia Handwriting is small and often indecipherable Micrographia
Handwriting is small and often indecipherable
Orthostatic hypotension Autonomic dysfunction is present in most patients late in the disease Orthostatic hypotension
Autonomic dysfunction is present in most patients late in the disease
Mental state examination Depression and psychosis occur in up to 50 percent of patients who have Parkinson disease.Amitriptyline, desipramine, and nortriptyline improve depression in patients with Parkinson disease Mental state examination
Depression and psychosis occur in up to 50 percent of patients who have Parkinson disease.Amitriptyline, desipramine, and nortriptyline improve depression in patients with Parkinson disease
Postural reflexes Poor postural reflexes. When postural reflexes are inadequate, patients may fall if they are pushed even slightly forward or backward Postural reflexes
Poor postural reflexes. When postural reflexes are inadequate, patients may fall if they are pushed even slightly forward or backward

Investigations - Diagnosis

Fact Explanation
Clinical evidence ( history and examination) The diagnosis of Parkinson disease is clinical, and relies on the presence of the cardinal features of bradykinesia, rigidity, tremor, and postural instability, coupled with gradual symptom progression and a sustained response to therapy with levodopa Clinical evidence ( history and examination)
The diagnosis of Parkinson disease is clinical, and relies on the presence of the cardinal features of bradykinesia, rigidity, tremor, and postural instability, coupled with gradual symptom progression and a sustained response to therapy with levodopa
Magnetic resonance imaging Possibly useful to distinguish Parkinson disease from multisystem atrophy / progressive supranuclear palsy Magnetic resonance imaging
Possibly useful to distinguish Parkinson disease from multisystem atrophy / progressive supranuclear palsy

Investigations - Management

Fact Explanation
Speech assessment Dysarthria can occur later in the disease due to articulatory and phonatory impairment Speech assessment
Dysarthria can occur later in the disease due to articulatory and phonatory impairment
Chest x ray Patients can get aspiration pneumonia caused by aspiration of food due to dysphagia Chest x ray
Patients can get aspiration pneumonia caused by aspiration of food due to dysphagia
Mental state examination Depression and psychosis occur in up to 50 percent of patients who have Parkinson disease.Amitriptyline, desipramine, and nortriptyline improve depression in patients with Parkinson disease Mental state examination
Depression and psychosis occur in up to 50 percent of patients who have Parkinson disease.Amitriptyline, desipramine, and nortriptyline improve depression in patients with Parkinson disease

Management - Supportive

Fact Explanation
Physical,occupational and speech therapy Stretching, strengthening, and balance training may improve gait speed, balance, and participation in activities of daily living.
Specific voice training can effectively treat voice and speech disorders
Physical,occupational and speech therapy
Stretching, strengthening, and balance training may improve gait speed, balance, and participation in activities of daily living.
Specific voice training can effectively treat voice and speech disorders
Diet and nutrition Nutritional interventions (e.g., a high-fiber diet) can help reduce constipation. Dietary amino acids may interfere with levodopa absorption; therefore, protein restriction may be necessary for patients with decreased levodopa response Diet and nutrition
Nutritional interventions (e.g., a high-fiber diet) can help reduce constipation. Dietary amino acids may interfere with levodopa absorption; therefore, protein restriction may be necessary for patients with decreased levodopa response
Management of Cognitive impairment Evaluate for and treat medical problems (e.g., dehydration, metabolic disorders, infection); adjust antiparkinsonian medications; decrease or discontinue anticholinergics, dopamine agonists, amantadine , and selegiline ; consider a cholinesterase inhibitor Management of Cognitive impairment
Evaluate for and treat medical problems (e.g., dehydration, metabolic disorders, infection); adjust antiparkinsonian medications; decrease or discontinue anticholinergics, dopamine agonists, amantadine , and selegiline ; consider a cholinesterase inhibitor
Management of constipation Patients should increase fluid and fiber intake; increase physical activity; discontinue anticholinergics; and use stool softeners, lactulose, mild laxatives, or enemas as needed Management of constipation
Patients should increase fluid and fiber intake; increase physical activity; discontinue anticholinergics; and use stool softeners, lactulose, mild laxatives, or enemas as needed
Management of depression Depression is common in Parkinson’s disease, and has a significant impact on the functional level of those affected
Initiate counseling; consider drug therapy with selective serotonin reuptake inhibitors or tricyclic antidepressants (because of side effect profile, use tricyclic antidepressants with caution)
Management of depression
Depression is common in Parkinson’s disease, and has a significant impact on the functional level of those affected
Initiate counseling; consider drug therapy with selective serotonin reuptake inhibitors or tricyclic antidepressants (because of side effect profile, use tricyclic antidepressants with caution)
Management of dysphagia Perform a swallowing evaluation and refer the patient to a subspecialist; increase “on” time (the period when symptoms are decreased), and encourage patients to eat during this time; patient should eat soft foods; consider gastrostomy Management of dysphagia
Perform a swallowing evaluation and refer the patient to a subspecialist; increase “on” time (the period when symptoms are decreased), and encourage patients to eat during this time; patient should eat soft foods; consider gastrostomy
Management of sleep disturbances Daytime somnolence and sleep attacks; discontinue dopamine agonists.
Nighttime awakenings because of bradykinesia; consider a bedtime dose of long-acting carbidopa/levodopa , adjuvant entacapone , or a dopamine agonist.
Rapid eye movement sleep behavior disorder; decrease or discontinue nighttime use of antiparkinsonian drugs; consider clonazepam
Management of sleep disturbances
Daytime somnolence and sleep attacks; discontinue dopamine agonists.
Nighttime awakenings because of bradykinesia; consider a bedtime dose of long-acting carbidopa/levodopa , adjuvant entacapone , or a dopamine agonist.
Rapid eye movement sleep behavior disorder; decrease or discontinue nighttime use of antiparkinsonian drugs; consider clonazepam

Management - Specific

Fact Explanation
Levodopa Levodopa is the most effective pharmacologic agent for Parkinson’s disease and remains the primary treatment for symptomatic patients. particularly effective at controlling bradykinesia and rigidity.
Levodopa is always combined with carbidopa, because carbidopa prevents peripheral conversion of levodopa to dopamine by blocking dopa decarboxylase. When combined with levodopa, carbidopa increases cerebral levodopa bioavailability and reduces the peripheral adverse effects of dopamine (e.g., nausea, hypotension)
Used in both early stage and late stage treatment
Levodopa
Levodopa is the most effective pharmacologic agent for Parkinson’s disease and remains the primary treatment for symptomatic patients. particularly effective at controlling bradykinesia and rigidity.
Levodopa is always combined with carbidopa, because carbidopa prevents peripheral conversion of levodopa to dopamine by blocking dopa decarboxylase. When combined with levodopa, carbidopa increases cerebral levodopa bioavailability and reduces the peripheral adverse effects of dopamine (e.g., nausea, hypotension)
Used in both early stage and late stage treatment
Dopamine agonists Dopamine agonists directly stimulate dopamine receptors. eg:bromocriptine Studies have demonstrated that dopamine agonists, alone or combined with levodopa, are effective against early Parkinson’s disease.
Used in both early stage and late stage treatment
Dopamine agonists
Dopamine agonists directly stimulate dopamine receptors. eg:bromocriptine Studies have demonstrated that dopamine agonists, alone or combined with levodopa, are effective against early Parkinson’s disease.
Used in both early stage and late stage treatment
Monoamine oxidase inhibitors (MAOIs) MAO-B inhibitors reduced disability, the incidence of motor fluctuations, and the need for levodopa without substantial adverse effects or increased mortality.
Used in both early stage and late stage treatment
Monoamine oxidase inhibitors (MAOIs)
MAO-B inhibitors reduced disability, the incidence of motor fluctuations, and the need for levodopa without substantial adverse effects or increased mortality.
Used in both early stage and late stage treatment
Anticholinergics Useful for the treatment of tremor in patients younger than 60 years without cognitive impairment Anticholinergics
Useful for the treatment of tremor in patients younger than 60 years without cognitive impairment
N-methyl-D-aspartate receptor inhibitor (Amantadine) Treatment of dyskinesias in late disease N-methyl-D-aspartate receptor inhibitor (Amantadine)
Treatment of dyskinesias in late disease
catechol-O-methyl transferase inhibitors (COMT inhibitors) Used in late stage treatments.COMT inhibitors (e.g., entacapone, tolcapone ) decrease the degradation of levodopa and extend its half-life, thus relieving the end-of-dose wearing-off effect and reducing “off” time. catechol-O-methyl transferase inhibitors (COMT inhibitors)
Used in late stage treatments.COMT inhibitors (e.g., entacapone, tolcapone ) decrease the degradation of levodopa and extend its half-life, thus relieving the end-of-dose wearing-off effect and reducing “off” time.
Surgery Factors that predict a good response to surgery for advanced Parkinson disease include good response to levodopa, few comorbidities, absence of cognitive impairment, and absence of (or well-controlled) depression.
Unilateral pallidotomy is an effective symptomatic adjunct to levodopa and can treat motor complications
Surgery
Factors that predict a good response to surgery for advanced Parkinson disease include good response to levodopa, few comorbidities, absence of cognitive impairment, and absence of (or well-controlled) depression.
Unilateral pallidotomy is an effective symptomatic adjunct to levodopa and can treat motor complications

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