Parkinson’s Disease

Presentation 

  • 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)
  • Speech changes (hypophonia), hand-writing changes (micrographia), bradykinesia
  • 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 pt does not respond, it is important to consider a Parkinson’s Disease mimicker. Leave as Parkinson’s plus.

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)
      • Associated with apraxia and aphasia
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