Resting tremor is typically a very early symptom, often worse on one side.
Cogwheel rigidity: can be confused for paratonia (seen in demented or encephalopathic pts who have involuntary variable resistance during passive ROM).
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 pt does not respond, it is important to consider a Parkinson’s Disease mimicker such as Parkinson’s plus disorders.
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. Should not be held during admission. If patients are required to be N.P.O, for more than 1-2 days please page neurology for guidance to avoid dopamine withdrawal.
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. Medications can be re-adjusted outpatient.
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/falls 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: prominent autonomic features.
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 (pt feels like affected limb doesn’t belong to them).
