Parkinson's disease: Difference between revisions
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==Background== | ==Background== | ||
*Extrapyramidal movement disorder | *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=== | |||
* | *[[tremor|'''T'''remor]] (resting) | ||
**Initially is unilateral tremor of upper extremity, especially finger and thumb ("pill rolling") | |||
**Dissipates when intentional movement is performed | |||
* | *'''R'''igidity (cogwheel) | ||
**Elicited by causing passive movement of limb through full range of motion | |||
* | *'''A'''kinesia | ||
**Slowness of voluntary movement | |||
* | *'''P'''osture/equilibrium impairment | ||
**Impaired ability to turn or change direction while walking | |||
== | ==Differential Diagnosis== | ||
{{Dementia DDX}} | |||
{{Movement disorder DDX}} | |||
==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 [[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== | ||
*Usually treated as outpatient | |||
*Admit according to presentation | |||
[[Category: | ==See Also== | ||
*[[Dementia]] | |||
==References== | |||
<references/> | |||
[[Category:Neurology]] | |||
Latest revision as of 13:45, 14 November 2020
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
Movement Disorders and Other Abnormal Contractions
- Chorea
- Neuroleptic malignant syndrome
- Serotonin syndrome
- Hypocalcemia
- Strychnine toxicity
- Acute tetanus
- Parkinson's disease
- Mono amine oxidase inhibitor toxicity
- Phencyclidine toxicity
- Anti-NMDA receptor encephalitis
- Huntington disease
- Wilson's disease
- CVA
- Schizophrenia
- Psychotic agitation
- Dementia
- Lewy body dementia
- Vascular dementia
- Frontotemporal dementia
- Dystonic reaction
- Extrapyramidal reaction
- Torticollis
- Idiopathic movement disorder
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.