Parkinson's disease: Difference between revisions
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== Treatment == | == Treatment == | ||
*Dopamine agonists | *Dopamine agonists | ||
**Levodopa | **Levodopa and Carbidopa (peripheral decarboxylase inhibitor) = gold standard | ||
**pramipexole (Mirapex)<br>ropinirole (Requip) | **pramipexole (Mirapex)<br>ropinirole (Requip) | ||
*Anticholenergics | *Anticholenergics | ||
**Benztropine | **Benztropine - caution in acute psychosis | ||
*Monoamine oxidase inhibitor - blocks DA reuptake | *Monoamine oxidase inhibitor - blocks DA reuptake | ||
**selegiline (Eldepryl) | **selegiline (Eldepryl) | ||
**rasagiline (Azilect) | **rasagiline (Azilect) | ||
*Agents for psychotic symptoms, hallucinations | |||
**Rivastigmine | |||
**Citalopram in depressed patients | |||
**Avoid antidopaminergic drugs if possible, but frequently used atypical antipsychotics include: | |||
**Olanzapine | |||
**Quetiapine | |||
**Expect worsening motor symptoms | |||
**Pimavanserin (Nuplazaid) - serotonin inverse agonist (not anti-dopamine), FDA approved in 2016 | |||
==Disposition== | ==Disposition== | ||
Revision as of 18:15, 2 May 2016
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, esp 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
Diagnosis
- Consider mini mental status exam
Treatment
- Dopamine agonists
- Levodopa and Carbidopa (peripheral decarboxylase inhibitor) = gold standard
- pramipexole (Mirapex)
ropinirole (Requip)
- Anticholenergics
- Benztropine - caution in acute psychosis
- Monoamine oxidase inhibitor - blocks DA reuptake
- selegiline (Eldepryl)
- rasagiline (Azilect)
- Agents for psychotic symptoms, hallucinations
- Rivastigmine
- Citalopram in depressed patients
- Avoid antidopaminergic drugs if possible, but frequently used atypical antipsychotics include:
- Olanzapine
- Quetiapine
- Expect worsening motor symptoms
- Pimavanserin (Nuplazaid) - serotonin inverse agonist (not anti-dopamine), FDA approved in 2016
Disposition
- Usually treated as outpatient
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.