Secondary parkinsonism - Clinicals, Diagnosis, and Management

Neurology

Clinicals - History

Fact Explanation
History of long standing hypertension, diabetes, hyperlipidiemia These are risk factors for cerebrovascular events which can cause infarction of the basal ganglia and subsequent secondary parkinsonism History of long standing hypertension, diabetes, hyperlipidiemia
These are risk factors for cerebrovascular events which can cause infarction of the basal ganglia and subsequent secondary parkinsonism
History of episodes of inability to talk, weakness of the body These features usually suggest underlying cause for secondary parkinsonism such as stroke. They may give a history of strokes and transient ischemic attacks. In vascular parkinsonism, tremor is less common. It's also known as lower body parkinsonism with rigidity. Additionally swallowing problems, urinary incontinence can occur. History of episodes of inability to talk, weakness of the body
These features usually suggest underlying cause for secondary parkinsonism such as stroke. They may give a history of strokes and transient ischemic attacks. In vascular parkinsonism, tremor is less common. It's also known as lower body parkinsonism with rigidity. Additionally swallowing problems, urinary incontinence can occur.
History of long standing treatment for psychiatric disease Long term treatment of anti-psychotics/ neuroleptics can cause extensive blockade of the dopamine receptors and produce extrapyramidal side effects such as parkinsonian features and these patients give a history of diseases such as schizophrenia with hallucinations, delusions, or negative symptoms History of long standing treatment for psychiatric disease
Long term treatment of anti-psychotics/ neuroleptics can cause extensive blockade of the dopamine receptors and produce extrapyramidal side effects such as parkinsonian features and these patients give a history of diseases such as schizophrenia with hallucinations, delusions, or negative symptoms
Gait apraxia, urinary incontinence, memory impairment These are features of Normal pressure hydrocephalus which can cause secondary parkinsonism. This is due to involvement of vestibular function. Additionally gait disturbance, urinary incontinence, and dementia or cognitive decline. The gait disturbance, which is commonly the first symptom, and it's called “glued” or “magnetic” gait. Urinary incontinence due to autonomic dysfunction and memory impairment may occur in late stages of parkinsonism as well. Gait apraxia, urinary incontinence, memory impairment
These are features of Normal pressure hydrocephalus which can cause secondary parkinsonism. This is due to involvement of vestibular function. Additionally gait disturbance, urinary incontinence, and dementia or cognitive decline. The gait disturbance, which is commonly the first symptom, and it's called “glued” or “magnetic” gait. Urinary incontinence due to autonomic dysfunction and memory impairment may occur in late stages of parkinsonism as well.
Rest tremor This is a core symptom and it's unilateral, and disappears during activity and sleep and mainly seen in the distal part of an extremity. It is characteristically seen in the hand and is known as pill-rolling tremor. It can also be seen in the lips, chin, jaw and legs however it spares neck/head or voice. The pathophysiology is thought to be due to degeneration of a subgroup of midbrain (A8) neurons, as this area is spared in Parkinson patients not having the tremor. Rest tremor
This is a core symptom and it's unilateral, and disappears during activity and sleep and mainly seen in the distal part of an extremity. It is characteristically seen in the hand and is known as pill-rolling tremor. It can also be seen in the lips, chin, jaw and legs however it spares neck/head or voice. The pathophysiology is thought to be due to degeneration of a subgroup of midbrain (A8) neurons, as this area is spared in Parkinson patients not having the tremor.
Slowness in movements This is a core symptom and usually seen in disorders involving basal ganglia and there are planning, initiating and executing movement are difficult and also there's a problem in performing sequential and simultaneous tasks. Fine motor activities of daily living such as buttoning, using utensils maybe intially impaired but this slowness maybe affected with emotions. Patients are seen to become excited and even do quick movements such as running in an emergency situation. This phenomenon is known as kinesia paradoxica Slowness in movements
This is a core symptom and usually seen in disorders involving basal ganglia and there are planning, initiating and executing movement are difficult and also there's a problem in performing sequential and simultaneous tasks. Fine motor activities of daily living such as buttoning, using utensils maybe intially impaired but this slowness maybe affected with emotions. Patients are seen to become excited and even do quick movements such as running in an emergency situation. This phenomenon is known as kinesia paradoxica
Stiffness, pain and rigidity of muscles There's increased resistance, and it's present throughout the range of passive movement particularly in a limb. when it occurs with tremor in the hand this is known as "cogwheel rigidity". But it can be seen even in proximal muscles such as neck, shoulders, hips. Commonly shoulder stiffness and pain is one of initial features Stiffness, pain and rigidity of muscles
There's increased resistance, and it's present throughout the range of passive movement particularly in a limb. when it occurs with tremor in the hand this is known as "cogwheel rigidity". But it can be seen even in proximal muscles such as neck, shoulders, hips. Commonly shoulder stiffness and pain is one of initial features
Shuffling gait and postural disturbances Abnormal axial postures such as anterocollis, scoliosis may occur due to rigidity of axial muscles and flexed posture is usually a late feature. Gait is abnormal with having small steps and maybe occasionally with freezing Shuffling gait and postural disturbances
Abnormal axial postures such as anterocollis, scoliosis may occur due to rigidity of axial muscles and flexed posture is usually a late feature. Gait is abnormal with having small steps and maybe occasionally with freezing
Freezing or periods of akinesia This is one of the disabling symptoms and commonly seen in men, and commonly affects the legs where there are moments of motor blocks in walking. Freezing or periods of akinesia
This is one of the disabling symptoms and commonly seen in men, and commonly affects the legs where there are moments of motor blocks in walking.
Abnormalities in speech Dysarthria, hypophonia and monotonous soft speech can occur due to bulbar dysfunction and thought to be due to orofacial–laryngeal bradykinesia and rigidity. Sometimes there can be word finding difficulties, known as “tip-of-the-tongue phenomenon Abnormalities in speech
Dysarthria, hypophonia and monotonous soft speech can occur due to bulbar dysfunction and thought to be due to orofacial–laryngeal bradykinesia and rigidity. Sometimes there can be word finding difficulties, known as “tip-of-the-tongue phenomenon
Difficulty in swallowing Dysphagia is due to bulbar dysfunction and could be due to inability to initiate the swallowing reflex or due to prolongation of movements of larynx oesophagus Difficulty in swallowing
Dysphagia is due to bulbar dysfunction and could be due to inability to initiate the swallowing reflex or due to prolongation of movements of larynx oesophagus
Drooling of saliva Because of dysphagia, there will be drooling of saliva Drooling of saliva
Because of dysphagia, there will be drooling of saliva
Difficulty in respiration Muscular rigidity, cervical arthrosis or restricted muscle movement in the neck cause obstructive respiratory disease and chest wall rigidity causes , restrictive pattern. In the late stages pneumonia can occur Difficulty in respiration
Muscular rigidity, cervical arthrosis or restricted muscle movement in the neck cause obstructive respiratory disease and chest wall rigidity causes , restrictive pattern. In the late stages pneumonia can occur
Erectile dysfunction Autonomic dysfunction also occurs and this results in erectile dysfunction Erectile dysfunction
Autonomic dysfunction also occurs and this results in erectile dysfunction
Disturbances in sweating Autonomic dysfunction also occurs and this results in sweating dysfunction Disturbances in sweating
Autonomic dysfunction also occurs and this results in sweating dysfunction
Psychiatric disorders Depression, apathy, anxiety, hallucinations, obsessive–compulsive and impulsive behaviour are commonly seen. Exact mechanism is not fully understood. This is thought to be due to dopamine dysregulation syndrome due to use of dopaminergic drugs such as dopamine agonists Psychiatric disorders
Depression, apathy, anxiety, hallucinations, obsessive–compulsive and impulsive behaviour are commonly seen. Exact mechanism is not fully understood. This is thought to be due to dopamine dysregulation syndrome due to use of dopaminergic drugs such as dopamine agonists
Sleep disturbances Excessive sleepiness is seen and thought to be due to 50% loss of hypocretin (orexin) neurons and maybe attributed to drugs used in treatment as well. A pre-parkinsonian state is recognized with insomnia, increase in violent dreams, talking, yelling in sleep. Sleep disturbances
Excessive sleepiness is seen and thought to be due to 50% loss of hypocretin (orexin) neurons and maybe attributed to drugs used in treatment as well. A pre-parkinsonian state is recognized with insomnia, increase in violent dreams, talking, yelling in sleep.
Olfactory dysfunction, Oral pain, akathisia, genital pain These are pre-parkinsonism features and thought to be due to neuronal loss in the corticomedial amygdala or to decreased dopaminergic neurons in the olfactory bulb. Olfactory dysfunction, Oral pain, akathisia, genital pain
These are pre-parkinsonism features and thought to be due to neuronal loss in the corticomedial amygdala or to decreased dopaminergic neurons in the olfactory bulb.
Disturbances in vision This maybe due to slow visual processing speed leading to decline in visual perception. Alternatively some drugs used in the treatment can also have adverse ocular reactions Disturbances in vision
This maybe due to slow visual processing speed leading to decline in visual perception. Alternatively some drugs used in the treatment can also have adverse ocular reactions

Clinicals - Examination

Fact Explanation
Elevated blood pressure Hypertension is a risk factor for cerebrovascular accidents. But later in the disease postural hypotension can occur due to autonomic involvement. This is a fall in systolic blood pressure of at least 20 mmHg and diastolic blood pressure of at least 10 mmHg on standing or head-up tilt and is due to autonomic dysfunction in parkinsonism Elevated blood pressure
Hypertension is a risk factor for cerebrovascular accidents. But later in the disease postural hypotension can occur due to autonomic involvement. This is a fall in systolic blood pressure of at least 20 mmHg and diastolic blood pressure of at least 10 mmHg on standing or head-up tilt and is due to autonomic dysfunction in parkinsonism
Aphasia, weakness of the face These are features which occur as a result of cerebrovascular accident (CVA). Similarly CVA s can occur in basal ganglia and cause secondary parkinsonism as well Aphasia, weakness of the face
These are features which occur as a result of cerebrovascular accident (CVA). Similarly CVA s can occur in basal ganglia and cause secondary parkinsonism as well
Spasticity of limbs with hyper-reflexia and extensor planter response These are upper motor neuron features of lower limbs which occur as a result of cerebrovascular accident (CVA). Similarly CVA s can occur in basal ganglia and cause secondary parkinsonism as well Spasticity of limbs with hyper-reflexia and extensor planter response
These are upper motor neuron features of lower limbs which occur as a result of cerebrovascular accident (CVA). Similarly CVA s can occur in basal ganglia and cause secondary parkinsonism as well
Rhythmic involuntary movements of tongue, face, and jaw, tics and torticollis These are features of tardive dyskinesia due to long term treatment with dopamine receptor blocking drugs similar to parkinsonian features. Rhythmic involuntary movements of tongue, face, and jaw, tics and torticollis
These are features of tardive dyskinesia due to long term treatment with dopamine receptor blocking drugs similar to parkinsonian features.
neck retraction, tongue protrusion, trismus, and oculogyric crisis These are features of acute dystonic reactions which occur due to dopamine receptor blocking drugs similar to parkinsonian features. Mainly seen in young adults. neck retraction, tongue protrusion, trismus, and oculogyric crisis
These are features of acute dystonic reactions which occur due to dopamine receptor blocking drugs similar to parkinsonian features. Mainly seen in young adults.
Gait apraxia These are features of Normal pressure hydrocephalus which can cause secondary parkinsonism. This is due to involvement of vestibular function. The gait disturbance, which is commonly the first symptom, and it's called “glued” or “magnetic” gait. Gait is abnormal in Parkinson's disease with having small steps and loss of arm swing. Walking is difficult to be initiated and occasionally there are episodes of freezing Gait apraxia
These are features of Normal pressure hydrocephalus which can cause secondary parkinsonism. This is due to involvement of vestibular function. The gait disturbance, which is commonly the first symptom, and it's called “glued” or “magnetic” gait. Gait is abnormal in Parkinson's disease with having small steps and loss of arm swing. Walking is difficult to be initiated and occasionally there are episodes of freezing
Loss of facial expression with reduced blinking rate Bradykinesia of the face causes loss of facial expressions Loss of facial expression with reduced blinking rate
Bradykinesia of the face causes loss of facial expressions
Resting tremor This is a core symptom and it's unilateral, and disappears during activity and sleep and mainly seen in the distal part of an extremity. It is characteristically seen in the hand and is known as pill-rolling tremor. It can also be seen in the lips, chin, jaw and legs however it spares neck/head or voice. The pathophysiology is thought to be due to degeneration of a subgroup of midbrain (A8) neurons, as this area is spared in Parkinson patients not having the tremor. Resting tremor
This is a core symptom and it's unilateral, and disappears during activity and sleep and mainly seen in the distal part of an extremity. It is characteristically seen in the hand and is known as pill-rolling tremor. It can also be seen in the lips, chin, jaw and legs however it spares neck/head or voice. The pathophysiology is thought to be due to degeneration of a subgroup of midbrain (A8) neurons, as this area is spared in Parkinson patients not having the tremor.
Bradykinesia This is a core symptom and usually seen in disorders involving basal ganglia and there are planning, initiating and executing movement are difficult and also there's a problem in performing sequential and simultaneous tasks. Fine motor activities of daily living such as buttoning, using utensils maybe initially impaired but this slowness maybe affected with emotions. Patients are seen to become excited and even do quick movements such as running in an emergency situation. This phenomenon is known as kinesia Bradykinesia
This is a core symptom and usually seen in disorders involving basal ganglia and there are planning, initiating and executing movement are difficult and also there's a problem in performing sequential and simultaneous tasks. Fine motor activities of daily living such as buttoning, using utensils maybe initially impaired but this slowness maybe affected with emotions. Patients are seen to become excited and even do quick movements such as running in an emergency situation. This phenomenon is known as kinesia
Rigidity of muscles with increased resistance to passive movements There's increased resistance mainly objective, and it's present throughout the range of passive movement particularly in a limb. when it occurs with tremor in the hand this is known as "cogwheel rigidity". But it can be seen even in proximal muscles such as neck, shoulders, hips. Commonly shoulder stiffness and pain is one of initial features Rigidity of muscles with increased resistance to passive movements
There's increased resistance mainly objective, and it's present throughout the range of passive movement particularly in a limb. when it occurs with tremor in the hand this is known as "cogwheel rigidity". But it can be seen even in proximal muscles such as neck, shoulders, hips. Commonly shoulder stiffness and pain is one of initial features
Postural and limb deformities Abnormal axial postures such as anterocollis, scoliosis may occur due to rigidity of axial muscles and flexed posture is usually a late feature. Striatal limb deformities can develop in some also dropped head/ bent spine due to extreme neck flexion, extreme flexion of thoracolumbar spine (camptocormia). Sometimes Pisa syndrome due to tilting of the trunk when sitting or standing can occur. Postural and limb deformities
Abnormal axial postures such as anterocollis, scoliosis may occur due to rigidity of axial muscles and flexed posture is usually a late feature. Striatal limb deformities can develop in some also dropped head/ bent spine due to extreme neck flexion, extreme flexion of thoracolumbar spine (camptocormia). Sometimes Pisa syndrome due to tilting of the trunk when sitting or standing can occur.
Glabellar tap In a normal person, light tapping over the glabella produces a reflex blinking of both eyes but in patients with Parkinsonism, eyes continue to blink with tapping. This is not specific for Parkinsonism as it could also result from diffuse (frontal lobe) damage. Glabellar tap
In a normal person, light tapping over the glabella produces a reflex blinking of both eyes but in patients with Parkinsonism, eyes continue to blink with tapping. This is not specific for Parkinsonism as it could also result from diffuse (frontal lobe) damage.
Palmomental reflex This is a primitive reflex and even though this is not sensitive it's more more specific than the glabellar reflex. Palmomental reflex
This is a primitive reflex and even though this is not sensitive it's more more specific than the glabellar reflex.
Mirror movements these are unintentional movements accompany voluntary activity in homologous opposite muscles and mainly seen in early asymmetric Parkinsonism. Mirror movements
these are unintentional movements accompany voluntary activity in homologous opposite muscles and mainly seen in early asymmetric Parkinsonism.
Monotonous, soft speech Dysarthria, hypophonia and monotonous soft speech can occur due to bulbar dysfunction and thought to be due to orofacial–laryngeal bradykinesia and rigidity. Sometimes there can be word finding difficulties, known as “tip-of-the-tongue phenomenon. Sometimes drooling of saliva may be noted in examination due to dysphagia Monotonous, soft speech
Dysarthria, hypophonia and monotonous soft speech can occur due to bulbar dysfunction and thought to be due to orofacial–laryngeal bradykinesia and rigidity. Sometimes there can be word finding difficulties, known as “tip-of-the-tongue phenomenon. Sometimes drooling of saliva may be noted in examination due to dysphagia
Difficulty in breathing Muscular rigidity, cervical arthrosis or restricted muscle movement in the neck cause obstructive respiratory disease and chest wall rigidity causes , restrictive pattern. In the late stages pneumonia can occur Difficulty in breathing
Muscular rigidity, cervical arthrosis or restricted muscle movement in the neck cause obstructive respiratory disease and chest wall rigidity causes , restrictive pattern. In the late stages pneumonia can occur
Reduced visual acuity, Defects in color vision This is thought to be due to lack of dopamine in the retina, abnormal eye movements, or poor blinking. Color vision is blurred. Reduced visual acuity, Defects in color vision
This is thought to be due to lack of dopamine in the retina, abnormal eye movements, or poor blinking. Color vision is blurred.
Defects in saccadic and Smooth Pursuit Eye Movements This is attributed to dopamine deficiency in the basal ganglia Defects in saccadic and Smooth Pursuit Eye Movements
This is attributed to dopamine deficiency in the basal ganglia
Nystagmus Limitation of eye movement can cause nystagmus. Nystagmus
Limitation of eye movement can cause nystagmus.
Large pupils and unequal pupils Large pupil with anisocoria to light adaptation is noted and thought to be due to autonomic imbalance in parasympathetic system. Large pupils and unequal pupils
Large pupil with anisocoria to light adaptation is noted and thought to be due to autonomic imbalance in parasympathetic system.

Investigations - Diagnosis

Fact Explanation
Serum cholesterol It's important to evaluate for serum cholesterol level as atherosclerosis can cause cerebrovascular disease and consequent secondary parkinsonism Serum cholesterol
It's important to evaluate for serum cholesterol level as atherosclerosis can cause cerebrovascular disease and consequent secondary parkinsonism
Fasting blood sugar It's important to evaluate for blood sugar level as diabetes can increase the risk for cerebrovascular disease and consequent secondary parkinsonism Fasting blood sugar
It's important to evaluate for blood sugar level as diabetes can increase the risk for cerebrovascular disease and consequent secondary parkinsonism
Serum cerulopasmin, Serum copper and 24 hour urinary copper In younger patients Wilson's disease needs to be excluded. Serum cerulopasmin, Serum copper and 24 hour urinary copper
In younger patients Wilson's disease needs to be excluded.
Lumbar puncture To exclude normal pressure hydrocephalus as the removal of fluid improves symptoms. It has a traid of ataxia, dementia and urinary incontinence and is recognized as a cause for secondary parkinsonism. This is known as tap test Lumbar puncture
To exclude normal pressure hydrocephalus as the removal of fluid improves symptoms. It has a traid of ataxia, dementia and urinary incontinence and is recognized as a cause for secondary parkinsonism. This is known as tap test
Transcranial ultrasound This is important to exclude secondary parkinsonism Transcranial ultrasound
This is important to exclude secondary parkinsonism
MRI brain To exclude structural brain lesions such as cerebral tumors, cerebral hemorrhages, infarctions, hydrocephalus MRI brain
To exclude structural brain lesions such as cerebral tumors, cerebral hemorrhages, infarctions, hydrocephalus
Positron emission tomography (PET) and single-photon emission computed tomography (SPECT) scanning of the brain This gives an idea of remaining dopaminergic neurons. In PET imaging, there's an increase in F-dopa (fluorodopa) uptake in the contralateral putamen in patient's with Parkinsonism. IPT, TRODAT-1, and FP-CIT tagged with either iodine-123 or technetium-99 are used in the SPECT scanning which is based on the same principle. Positron emission tomography (PET) and single-photon emission computed tomography (SPECT) scanning of the brain
This gives an idea of remaining dopaminergic neurons. In PET imaging, there's an increase in F-dopa (fluorodopa) uptake in the contralateral putamen in patient's with Parkinsonism. IPT, TRODAT-1, and FP-CIT tagged with either iodine-123 or technetium-99 are used in the SPECT scanning which is based on the same principle.
Biopsy and histology This shows degeneration of pigmented dopaminergic neurons in the basal ganglia. Biopsy and histology
This shows degeneration of pigmented dopaminergic neurons in the basal ganglia.
Slit lamp examination This is done to exclude Wilson's disease in which there will be Kayser-Fleisher rings. Slit lamp examination
This is done to exclude Wilson's disease in which there will be Kayser-Fleisher rings.
Electrophysiological studies A surface electromyelogram (EMG) recording can help to detect the frequency and amplitude of a tremor, Multiple system Atrophy patients may have degeneration of Onuf's nucleus which can be detected as polyphasic potentials with a prolonged latency on urethral or anal sphincter EMG Electrophysiological studies
A surface electromyelogram (EMG) recording can help to detect the frequency and amplitude of a tremor, Multiple system Atrophy patients may have degeneration of Onuf's nucleus which can be detected as polyphasic potentials with a prolonged latency on urethral or anal sphincter EMG
Eye movement recordings These can point towards hypometric saccades, supranuclear gaze problems, square wave jerks in atypical parkinsonism Eye movement recordings
These can point towards hypometric saccades, supranuclear gaze problems, square wave jerks in atypical parkinsonism
Valsalva manoeuvre To identify any autonomic dysfunction associated with Parkinsonism Valsalva manoeuvre
To identify any autonomic dysfunction associated with Parkinsonism

Investigations - Management

Fact Explanation
Serum cholesterol It's important to evaluate for serum cholesterol level in the follow up as atherosclerosis is a risk factor for cerebrovascular disease and to prevent further events Serum cholesterol
It's important to evaluate for serum cholesterol level in the follow up as atherosclerosis is a risk factor for cerebrovascular disease and to prevent further events
Fasting blood sugar It's important to evaluate for blood sugar level as diabetes can increase the risk for cerebrovascular disease and to prevent further events Fasting blood sugar
It's important to evaluate for blood sugar level as diabetes can increase the risk for cerebrovascular disease and to prevent further events
Full blood count To detect and correct any anemia prior to surgery Full blood count
To detect and correct any anemia prior to surgery
Coagulation studies To detect and correct any coagulopathy before surgical management Coagulation studies
To detect and correct any coagulopathy before surgical management
Renal function tests- Serum creatinine, Blood urea nitrogen To determine any renal dysfunction prior to anesthesia Renal function tests- Serum creatinine, Blood urea nitrogen
To determine any renal dysfunction prior to anesthesia
Fasting blood sugar It's important to evaluate for blood sugar level as diabetes can increase the risk for cerebrovascular disease and consequent secondary parkinsonism. This is important before anesthesia Fasting blood sugar
It's important to evaluate for blood sugar level as diabetes can increase the risk for cerebrovascular disease and consequent secondary parkinsonism. This is important before anesthesia
MRI brain To exclude secondary causes for Parkinsonism prior to surgery MRI brain
To exclude secondary causes for Parkinsonism prior to surgery
olfactory testing This is easy and quick test. Impairment of olfaction is an early feature of Parkinson's disease and these deficits may precede clinical motor symptoms by years. therefore this can be used to diagnose asymptomatic individuals who have a high risk of developing parkinsonism olfactory testing
This is easy and quick test. Impairment of olfaction is an early feature of Parkinson's disease and these deficits may precede clinical motor symptoms by years. therefore this can be used to diagnose asymptomatic individuals who have a high risk of developing parkinsonism

Management - Supportive

Fact Explanation
Patient education This is a disease which is not curative and only symptomatic improvement is done. Therefore patient education and family education is vital. they should be educated on the etiology, nature, course, prognosis, available treatment options, and importance of follow up. The residencies may need to be modified according to patient's needs, and the dementia which occurs later in the disease needs to addressed. Patients should be educated on that and necessary actions for financial issue, making the last will should be done. Support groups are present for the patient and the family. Caregiver's support is also important. Patient education
This is a disease which is not curative and only symptomatic improvement is done. Therefore patient education and family education is vital. they should be educated on the etiology, nature, course, prognosis, available treatment options, and importance of follow up. The residencies may need to be modified according to patient's needs, and the dementia which occurs later in the disease needs to addressed. Patients should be educated on that and necessary actions for financial issue, making the last will should be done. Support groups are present for the patient and the family. Caregiver's support is also important.
Physiotherapy This is important for improving gait, posture, initiation of movement. walking sticks, wheel chairs maybe needed in the late stages. This is important to prevent falls Physiotherapy
This is important for improving gait, posture, initiation of movement. walking sticks, wheel chairs maybe needed in the late stages. This is important to prevent falls
Occupational therapy This is very important to improve the functional status to carry out activities of daily living. Occupational therapy
This is very important to improve the functional status to carry out activities of daily living.
Speech therapy Speech problems are common in Parkinsonism. To increase vocal intensity a program called Lee Silverman Voice Treatment (LSVT) is used. It improves phonation as well as respiration Speech therapy
Speech problems are common in Parkinsonism. To increase vocal intensity a program called Lee Silverman Voice Treatment (LSVT) is used. It improves phonation as well as respiration
Diet and nutrition A good nutritional support is essential. As the disease is complicated by dysphagia in late stages percutaneous endoscopic gastostomy feeding may be necessary. Diet and nutrition
A good nutritional support is essential. As the disease is complicated by dysphagia in late stages percutaneous endoscopic gastostomy feeding may be necessary.
bladder, bowel care Bladder care are important as these patients show incontinence. Anticholinergics may be useful. Self intermittent catheterization, for urinary incontinence, diapers may be needed in late stages. Constipation can occur due to drugs used in the treatment, therefore increasing fibre intake, laxatives may be needed. bladder, bowel care
Bladder care are important as these patients show incontinence. Anticholinergics may be useful. Self intermittent catheterization, for urinary incontinence, diapers may be needed in late stages. Constipation can occur due to drugs used in the treatment, therefore increasing fibre intake, laxatives may be needed.
Skin care As patients become bed ridden later, it's very important to prevent bed sores. Rolling the patient every 2 hours, air mattresses are necessary. Skin care
As patients become bed ridden later, it's very important to prevent bed sores. Rolling the patient every 2 hours, air mattresses are necessary.
Treatment for psychiatric disorders These patients are likely to develop various psychiatric disorders, therefore anti depressants for depression may be needed. Reduction of the dosage of anti parkinson's drugs maybe necessary to reduce dementia. anxiety, sleep disorders, behavioral symptoms Treatment for psychiatric disorders
These patients are likely to develop various psychiatric disorders, therefore anti depressants for depression may be needed. Reduction of the dosage of anti parkinson's drugs maybe necessary to reduce dementia. anxiety, sleep disorders, behavioral symptoms
Treatment for orthostatic hypotension Education of patients and caregivers is important to avoid rapid changes of position or straining during micturition or defecation, which can trigger orthostatic hypotension Fluid intake should be adequate with salt to ensure adequate hydration. Antihypertensive therapy may need to be discontinued. Fludrocortison, and vasoactive agents, like midodrine may be necessary as well. Treatment for orthostatic hypotension
Education of patients and caregivers is important to avoid rapid changes of position or straining during micturition or defecation, which can trigger orthostatic hypotension Fluid intake should be adequate with salt to ensure adequate hydration. Antihypertensive therapy may need to be discontinued. Fludrocortison, and vasoactive agents, like midodrine may be necessary as well.

Management - Specific

Fact Explanation
Discontinuation of antipsychotics If it's drug induced parkinsonism, neuroleptics/ Antipsychotics may need to be discontinued or dose may need to be reduced Discontinuation of antipsychotics
If it's drug induced parkinsonism, neuroleptics/ Antipsychotics may need to be discontinued or dose may need to be reduced
Neurosurgery If there's a cerebral tumor in the basal ganglia region which causes parkinsonism, these needs surgical removal if possible. Also in Parkinson's disease, Hyperactivity of subthalamic neurons are noted. Therefore surgical procedures such as thalamotomy, Subthalamotomy, Pallidotomy may be helpful in advanced disease. Neurosurgery
If there's a cerebral tumor in the basal ganglia region which causes parkinsonism, these needs surgical removal if possible. Also in Parkinson's disease, Hyperactivity of subthalamic neurons are noted. Therefore surgical procedures such as thalamotomy, Subthalamotomy, Pallidotomy may be helpful in advanced disease.
CSF shunting may be needed in normal pressure hydrocephalus. CSF shunting may be needed in normal pressure hydrocephalus. CSF shunting may be needed in normal pressure hydrocephalus.
CSF shunting may be needed in normal pressure hydrocephalus.
Treatment for cerebrovascular disease involving basal ganglia Treatment for the risk factors for atherosclerotic diseases such as anti-platelet agents, statins and anti-hypertensives are needed to prevent further episodes Treatment for cerebrovascular disease involving basal ganglia
Treatment for the risk factors for atherosclerotic diseases such as anti-platelet agents, statins and anti-hypertensives are needed to prevent further episodes
Treatment for encephalitis Viral encephalitis can cause parkinsonian features. Especially HIV, japanese encephalitis. These needs supportive management as for any encephalitis and appropriate therapy if available. Treatment for encephalitis
Viral encephalitis can cause parkinsonian features. Especially HIV, japanese encephalitis. These needs supportive management as for any encephalitis and appropriate therapy if available.
Treatment for meningitis Cryptococcal meningitis, tubercular and pyogenic meningitis can cause parkinsonian features. Therefore antibiotic treatment, antifungals, anti- TB therapy will be needed. Treatment for meningitis
Cryptococcal meningitis, tubercular and pyogenic meningitis can cause parkinsonian features. Therefore antibiotic treatment, antifungals, anti- TB therapy will be needed.
Pharmacological therapy with Dopamine replacement Levodopa combined with Peripheral dopa De carboxylase inhibitor, is the treatment for early disease. Dopamine agonists are also used in early disease and thought to be having few adverse effects such as motor fluctuations. MAO-B inhibitors, such as selegiline and rasagiline, catechol-O-methyltransferase (COMT) inhibitors such as Entacapone are the other drugs which are used. Selegiline, Rasagiline may have neuroprotective effect as well. Amanatadine is an anti-viral drug that is used. These drugs can be used in combination. However the response to drugs is poor when compared with idiopathic parkinsonism. Pharmacological therapy with Dopamine replacement
Levodopa combined with Peripheral dopa De carboxylase inhibitor, is the treatment for early disease. Dopamine agonists are also used in early disease and thought to be having few adverse effects such as motor fluctuations. MAO-B inhibitors, such as selegiline and rasagiline, catechol-O-methyltransferase (COMT) inhibitors such as Entacapone are the other drugs which are used. Selegiline, Rasagiline may have neuroprotective effect as well. Amanatadine is an anti-viral drug that is used. These drugs can be used in combination. However the response to drugs is poor when compared with idiopathic parkinsonism.
Pharmacological therapy with anticholinergics These are used for the treatment of tremor. Older people are more prone to adverse effects, therefore should be used with caution. Pharmacological therapy with anticholinergics
These are used for the treatment of tremor. Older people are more prone to adverse effects, therefore should be used with caution.
Management of dyskinesia Lower doses of levodopa can be given. For wearing-off, a dopamine agonist or MAO-B inhibitor can be added. Amantadine which is a (NMDA) receptor antagonist is also effective against dyskinesias. Management of dyskinesia
Lower doses of levodopa can be given. For wearing-off, a dopamine agonist or MAO-B inhibitor can be added. Amantadine which is a (NMDA) receptor antagonist is also effective against dyskinesias.
Deep brain stimulation It's a type of stereotactic surgery. Chronic high frequency electrical stimulation it is used to achieve a functional inhibition of the subthalamic neurons. This is effective in advanced Parkinson's disease. Deep brain stimulation
It's a type of stereotactic surgery. Chronic high frequency electrical stimulation it is used to achieve a functional inhibition of the subthalamic neurons. This is effective in advanced Parkinson's disease.

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