Parkinson's disease

Background

  • Extrapyramidal movement disorder associated with reduced dopaminergic receptors in substantia nigra
  • Most common presentations to the ED[1]:
    • Infectious ~32%
    • Trauma ~28%
    • Cardiovascular ~15%
    • Cerebrovascular ~12%
    • GI ~7%
    • Electrolyte abnormalities 6%

Clinical Features

TRAP mnemonic

  • Tremor (resting)
    • Initially is unilateral tremor of upper extremity, especially finger and thumb ("pill rolling")
    • Dissipates when intentional movement is performed
  • Rigidity (cogwheel)
    • Elicited by causing passive movement of limb through full range of motion
  • Akinesia
    • Slowness of voluntary movement
  • Posture/equilibrium impairment
    • Impaired ability to turn or change direction while walking

Differential Diagnosis

Dementia

Movement Disorders and Other Abnormal Contractions

Evaluation

Management

Initiation of or modifications in medications should be made in conjunction with neurologist

  • Dopamine agonists
    • Levodopa and carbidopa (peripheral decarboxylase inhibitor) = gold standard
    • Pramipexole (Mirapex)
    • Ropinirole (Requip)
  • Anticholinergics
  • Monoamine oxidase inhibitor - blocks DA reuptake
    • Selegiline (Eldepryl)
    • Rasagiline (Azilect)
  • Agents for psychotic symptoms, hallucinations
    • Pimavanserin (Nuplazaid) - serotonin inverse agonist (not anti-dopamine), FDA approved in 2016[2]
    • Avoid antidopaminergic drugs if possible (expect worsening motor symptoms), but commonly used agents:
    • Others:
      • Rivastigmine
      • Citalopram in depressed patients

Disposition

  • Usually treated as outpatient
  • Admit according to presentation

See Also

References

  1. Guneysel O et al. Parkinson’s disease and the frequent reasons for emergency admission. Neuropsychiatr Dis Treat. 2008 Aug; 4(4): 711–714.
  2. FDA approves first drug to treat hallucinations and delusions associated with Parkinson’s disease. April 29, 2016. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm498442.htm.
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