Parkinson's disease: Difference between revisions
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==Background== | ==Background== | ||
*Extrapyramidal movement disorder associated with reduced dopaminergic receptors in substantia nigra | *Extrapyramidal movement disorder associated with reduced dopaminergic receptors in substantia nigra | ||
*Most common presentations to the ED<ref>Guneysel O et al. Parkinson’s disease and the frequent reasons for emergency admission. Neuropsychiatr Dis Treat. 2008 Aug; 4(4): 711–714.</ref>: | |||
**Infectious ~32% | |||
**Trauma ~28% | |||
**Cardiovascular ~15% | |||
**Cerebrovascular ~12% | |||
**GI ~7% | |||
**Electrolyte abnormalities 6% | |||
==Clinical Features== | ==Clinical Features== | ||
===TRAP mnemonic=== | ===TRAP mnemonic=== | ||
*'''T'''remor (resting) | *[[tremor|'''T'''remor]] (resting) | ||
**Initially is unilateral tremor of upper extremity, | **Initially is unilateral tremor of upper extremity, especially finger and thumb ("pill rolling") | ||
**Dissipates when intentional movement is performed | **Dissipates when intentional movement is performed | ||
*'''R'''igidity (cogwheel) | *'''R'''igidity (cogwheel) | ||
| Line 14: | Line 21: | ||
**Impaired ability to turn or change direction while walking | **Impaired ability to turn or change direction while walking | ||
== Differential Diagnosis == | ==Differential Diagnosis== | ||
{{Dementia DDX}} | {{Dementia DDX}} | ||
== | ==Evaluation== | ||
*Consider [[mini mental status exam]] | *Consider [[mini mental status exam]] | ||
== | ==Management== | ||
''Initiation of or modifications in medications should be made in conjunction with neurologist'' | |||
*Dopamine agonists | *Dopamine agonists | ||
**Levodopa | **[[Levodopa]] and [[carbidopa]] (peripheral decarboxylase inhibitor) = gold standard | ||
** | **[[Pramipexole]] (Mirapex) | ||
* | **Ropinirole (Requip) | ||
**Benztropine | *[[Anticholinergics]] | ||
**[[Benztropine]] - caution in acute psychosis | |||
*Monoamine oxidase inhibitor - blocks DA reuptake | *Monoamine oxidase inhibitor - blocks DA reuptake | ||
** | **Selegiline (Eldepryl) | ||
** | **Rasagiline (Azilect) | ||
*Agents for [[psychosis|psychotic symptoms]], [[hallucinations]] | |||
**Pimavanserin (Nuplazaid) - serotonin inverse agonist (not anti-dopamine), FDA approved in 2016<ref>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.</ref> | |||
**Avoid antidopaminergic drugs if possible (expect worsening motor symptoms), but commonly used agents: | |||
***[[Olanzapine]] | |||
***[[Quetiapine]] | |||
**Others: | |||
***Rivastigmine | |||
***[[Citalopram]] in depressed patients | |||
==Disposition== | ==Disposition== | ||
*Usually treated as outpatient | *Usually treated as outpatient | ||
*Admit according to presentation | |||
==See Also== | ==See Also== | ||
| Line 37: | Line 55: | ||
==References== | ==References== | ||
<references/> | |||
[[Category: | [[Category:Neurology]] | ||
Revision as of 04:25, 3 October 2019
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
- Degenerative
- Alzheimer's disease
- Huntington's disease
- Parkinson's disease
- Vascular
- Multiple infarcts
- Hypoperfusion (MI, profound hypotension)
- Subdural hematoma
- SAH
- Infectious
- Meningitis (sequelae of bacterial, fungal, or tubercular)
- Neurosyphilis
- Viral encephalitis (HSV, HIV), Creutzfeldt-Jakob disease
- Inflammatory
- SLE
- Demyelinating disease (e.g. multiple sclerosis)
- Neoplastic
- Primary brain tumor / metastatic disease
- Carcinomatous meningitis
- Paraneoplastic syndromes
- Traumatic
- Toxic
- ETOH
- Meds (anticholinergics, polypharmacy)
- Metabolic
- Psychiatric
- Depression (pseudodementia)
- Hydrocephalic
- Normal pressure hydrocephalus (communicating hydrocephalus)
- Noncommunicating hydrocephalus
Evaluation
- Consider mini mental status exam
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
- Benztropine - caution in acute psychosis
- 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
- ↑ Guneysel O et al. Parkinson’s disease and the frequent reasons for emergency admission. Neuropsychiatr Dis Treat. 2008 Aug; 4(4): 711–714.
- ↑ 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.