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

Evaluation

Management

  • Dopamine agonists
    • Levodopa and Carbidopa (peripheral decarboxylase inhibitor) = gold standard
    • pramipexole (Mirapex)
      ropinirole (Requip)
  • Anticholenergics
  • 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.

Authors:

Ross Donaldson