History

Fact Explanation
Old age [1] The disease affects approximately 1 percent of persons older than 60 years, and up to 4 percent of those older than 80 years [1]
Gender - male [2] Epidemiologic studies have found that Parkinson's disease is more prevalent in men than in women [2]
Family history [2] The autosomal dominant adult-onset type is linked to a site on chromosome 4q, and the gene for autosomal recessive juvenile parkinsonism maps to chromosome 6q [2]
Resting tremor[5] , Slow movements [6], stiffness of the body [1] The hallmark of Parkinson's disease are tremor, rigidity and bradykinesia. Parkinson's disease, a progressive disorder of the central nervous system (CNS), is caused by the degeneration of dopaminergic neurons in the substantia nigra of the midbrain. These neurons normally project to the striatum, consisting of the caudate and putamen nuclei, whose neurons bear dopamine receptors. This projection of neurons is just one component of the complex network of interconnections among the deep gray-matter structures known as the basal ganglia. Neurochemical or structural pathologic conditions affecting the basal ganglia result in diseases of motor control resulting in motor disorders [2]
Recent change in hand writing [1] Occurs due to tremor.Handwriting is small and often indecipherable (History of micrographia) [3]
Speech and swallowing difficulties [4] Dysarthria and dysphagia occur frequently in Parkinson’s disease (PD). It is likely related articulatory and phonatory impairment [4]
Fatigue [1] Fatigue is present in one-third of patients with Parkinson disease at diagnosis, and is associated with severity of illness [1]
Sleep disturbances [1] Studies have found rapid eye movement sleep behavior disorder in patients with Parkinson disease [1]
Erectile dysfunction, urinary incontinence, and constipation [1] Autonomic dysfunction is present in most patients late in the disease [1]
References
  1. GAZEWOOD JD, RICHARDS DR, CLEBAK K. Parkinson disease: an update. Am Fam Physician [online] 2013 Feb 15, 87(4):267-73 [viewed 17 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23418798
  2. YOUNG R. Update on Parkinson's disease. Am Fam Physician [online] 1999 Apr 15, 59(8):2155-67, 2169-70 [viewed 17 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10221302
  3. RAO SS, HOFMANN LA, SHAKIL A. Parkinson's disease: diagnosis and treatment. Am Fam Physician [online] 2006 Dec 15, 74(12):2046-54 [viewed 17 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17186710
  4. TJADEN K. Speech and Swallowing in Parkinson's Disease Top Geriatr Rehabil [online] 2008, 24(2):115-126 [viewed 17 August 2014] Available from: doi:10.1097/01.TGR.0000318899.87690.44
  5. DAI D, WANG Y, ZHOU X, TAO J, JIANG D, ZHOU H, JIANG Y, PAN G, RU P, JI H, LI J, ZHANG Y, YIN H, XU M, DUAN S. Meta-analyses of seven GIGYF2 polymorphisms with Parkinson's disease. Biomed Rep [online] 2014 Nov, 2(6):886-892 [viewed 08 October 2014] Available from: doi:10.3892/br.2014.324
  6. ALTUğ F, ACAR F, ACAR G, CAVLAK U. The effects of brain stimulation of subthalamic nucleus surgery on gait and balance performance in Parkinson disease. A pilot study. Arch Med Sci [online] 2014 Aug 29, 10(4):733-8 [viewed 08 October 2014] Available from: doi:10.5114/aoms.2012.31371

Examination

Fact Explanation
Resting tremor [1] Observed as patient rests hands in his or her lap; often described as pill-rolling in quality. Occurs due to motor disturbance caused by the degeneration of dopaminergic neurons in the substantia nigra of the midbrain. [1]
Rigidity [1] The physician feels resistance as he or she places a finger within the patient’s antecubital fossa and repeatedly flexes and extends the patient’s arm at the elbow; resistance can be cogwheel rigidity (catching and releasing) or lead-pipe rigidity (continuously rigid); rigidity must be distinguished from spasticity, which has only increased flexor tone; rigidity also can be tested at wrist supination or pronation [1]
Bradykinesia [1] Difficulty with rapidly and sequentially tapping the fingers of one hand and then the other on a table top; difficulty tapping the heel rapidly; difficulty twiddling or circling the hands rapidly around each other in front of the body; reduced arm swing on affected side during ambulation. Difficulty in rising from a chair [1]
Gait [1] Small, shuffling steps may be observed, with difficulty initiating ambulation; patients may have a festinating gait (involuntary acceleration of gait); heel-to-toe ambulation is impaired; arms often are stationary; posture often is stooped; patients may have difficulty turning and have poor balance [1]
Micrographia [1] Handwriting is small and often indecipherable [1]
Orthostatic hypotension [2] Autonomic dysfunction is present in most patients late in the disease [2]
Mental state examination [1] Depression and psychosis occur in up to 50 percent of patients who have Parkinson disease.Amitriptyline, desipramine, and nortriptyline improve depression in patients with Parkinson disease [1]
Postural reflexes [1] Poor postural reflexes. When postural reflexes are inadequate, patients may fall if they are pushed even slightly forward or backward [1]
References
  1. GAZEWOOD JD, RICHARDS DR, CLEBAK K. Parkinson disease: an update. Am Fam Physician [online] 2013 Feb 15, 87(4):267-73 [viewed 17 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23418798
  2. RAO SS, HOFMANN LA, SHAKIL A. Parkinson's disease: diagnosis and treatment. Am Fam Physician [online] 2006 Dec 15, 74(12):2046-54 [viewed 17 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17186710

Differential Diagnoses

Fact Explanation
Essential tremor [1] Symmetric postural tremor; worsens with movement; affects distal extremities, head, and voice; family history common; improves with alcohol, beta blockers [1]
Vascular parkinsonism [1] Clinical features similar to Parkinson disease; may have focal neurologic findings; stepwise progression with poor response to carbidopa/levodopa; presence of basal ganglia and/or thalamic infarcts on computed tomography or magnetic resonance imaging [1]
Drug induced parkinsonism [1] Clinical features similar to Parkinson disease; drug history and drug withdrawal evaluation can confirm diagnosis; antiemetics and psychotropic drugs most common causative agents [1]
Dementia with Lewy bodies [1] Onset of motor symptoms accompanied by dementia and visual hallucinations; patients have marked fluctuations in attention and cognition; poor response to carbidopa/levodopa [1]
Atypical parkinsonism (includes progressive supranuclear palsy and multisystem atrophy) [1] Clinical features similar to Parkinson disease, but with other signs early in the disease process: prominent gait and speech impairment, prominent postural instability, and axial rigidity greater than extremity rigidity; absence of resting tremor and prominent autonomic dysfunction; poor response to carbidopa/levodopa [1]
References
  1. GAZEWOOD JD, RICHARDS DR, CLEBAK K. Parkinson disease: an update. Am Fam Physician [online] 2013 Feb 15, 87(4):267-73 [viewed 17 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23418798

Investigations - for Diagnosis

Fact Explanation
Clinical evidence ( history and examination) [1] The diagnosis of Parkinson disease is clinical, and relies on the presence of the cardinal features of bradykinesia, rigidity, tremor, and postural instability, coupled with gradual symptom progression and a sustained response to therapy with levodopa [1]
Magnetic resonance imaging [2] Possibly useful to distinguish Parkinson disease from multisystem atrophy / progressive supranuclear palsy [1]
References
  1. GAZEWOOD JD, RICHARDS DR, CLEBAK K. Parkinson disease: an update. Am Fam Physician [online] 2013 Feb 15, 87(4):267-73 [viewed 18 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23418798
  2. WEI L, ZHANG J, LONG Z, WU GR, HU X, ZHANG Y, WANG J. Reduced topological efficiency in cortical-Basal Ganglia motor network of Parkinson's disease: a resting state FMRI study. PLoS One [online] 2014, 9(10):e108124 [viewed 08 October 2014] Available from: doi:10.1371/journal.pone.0108124

Investigations - Fitness for Management

Fact Explanation
Chest x ray [1] Patients can get aspiration pneumonia caused by aspiration of food due to dysphagia [1]
References
  1. GAZEWOOD JD, RICHARDS DR, CLEBAK K. Parkinson disease: an update. Am Fam Physician [online] 2013 Feb 15, 87(4):267-73 [viewed 18 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23418798

Investigations - Followup

Fact Explanation
Speech assessment [1] Dysarthria can occur later in the disease due to articulatory and phonatory impairment [1]
References
  1. GAZEWOOD JD, RICHARDS DR, CLEBAK K. Parkinson disease: an update. Am Fam Physician [online] 2013 Feb 15, 87(4):267-73 [viewed 18 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23418798

Investigations - Screening/Staging

Fact Explanation
Mental state examination [1] Depression and psychosis occur in up to 50 percent of patients who have Parkinson disease.Amitriptyline, desipramine, and nortriptyline improve depression in patients with Parkinson disease [1]
References
  1. GAZEWOOD JD, RICHARDS DR, CLEBAK K. Parkinson disease: an update. Am Fam Physician [online] 2013 Feb 15, 87(4):267-73 [viewed 18 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23418798

Management - General Measures

Fact Explanation
Physical,occupational and speech therapy [3] Stretching, strengthening, and balance training may improve gait speed, balance, and participation in activities of daily living. Specific voice training can effectively treat voice and speech disorders [2]
Diet and nutrition [1] Nutritional interventions (e.g., a high-fiber diet) can help reduce constipation. Dietary amino acids may interfere with levodopa absorption; therefore, protein restriction may be necessary for patients with decreased levodopa response [2]
Management of Cognitive impairment [1] Evaluate for and treat medical problems (e.g., dehydration, metabolic disorders, infection); adjust antiparkinsonian medications; decrease or discontinue anticholinergics, dopamine agonists, amantadine , and selegiline ; consider a cholinesterase inhibitor [1]
Management of constipation [1] Patients should increase fluid and fiber intake; increase physical activity; discontinue anticholinergics; and use stool softeners, lactulose, mild laxatives, or enemas as needed [1]
Management of depression [1] Depression is common in Parkinson’s disease, and has a significant impact on the functional level of those affected [4] Initiate counseling; consider drug therapy with selective serotonin reuptake inhibitors or tricyclic antidepressants (because of side effect profile, use tricyclic antidepressants with caution) [1]
Management of dysphagia [1] Perform a swallowing evaluation and refer the patient to a subspecialist; increase “on” time (the period when symptoms are decreased), and encourage patients to eat during this time; patient should eat soft foods; consider gastrostomy [1]
Management of sleep disturbances [1] Daytime somnolence and sleep attacks; discontinue dopamine agonists. Nighttime awakenings because of bradykinesia; consider a bedtime dose of long-acting carbidopa/levodopa , adjuvant entacapone , or a dopamine agonist. Rapid eye movement sleep behavior disorder; decrease or discontinue nighttime use of antiparkinsonian drugs; consider clonazepam [1]
References
  1. RAO SS, HOFMANN LA, SHAKIL A. Parkinson's disease: diagnosis and treatment. Am Fam Physician [online] 2006 Dec 15, 74(12):2046-54 [viewed 17 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17186710
  2. GAZEWOOD JD, RICHARDS DR, CLEBAK K. Parkinson disease: an update. Am Fam Physician [online] 2013 Feb 15, 87(4):267-73 [viewed 17 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23418798
  3. CHOLEWA J, GORZKOWSKA A, SZEPELAWY M, NAWROCKA A, CHOLEWA J. Influence of functional movement rehabilitation on quality of life in people with Parkinson's disease. J Phys Ther Sci [online] 2014 Sep, 26(9):1329-31 [viewed 08 October 2014] Available from: doi:10.1589/jpts.26.1329
  4. KETHARANATHAN T, HANWELLA R, WEERASUNDERA R, DE SILVA VA. Major depressive disorder in Parkinson¿s disease: a cross-sectional study from Sri Lanka. BMC Psychiatry [online] 2014 Sep 30, 14(1):278 [viewed 08 October 2014] Available from: doi:10.1186/s12888-014-0278-8

Management - Specific Treatments

Fact Explanation
Levodopa [1] Levodopa is the most effective pharmacologic agent for Parkinson’s disease and remains the primary treatment for symptomatic patients. particularly effective at controlling bradykinesia and rigidity. Levodopa is always combined with carbidopa, because carbidopa prevents peripheral conversion of levodopa to dopamine by blocking dopa decarboxylase. When combined with levodopa, carbidopa increases cerebral levodopa bioavailability and reduces the peripheral adverse effects of dopamine (e.g., nausea, hypotension) Used in both early stage and late stage treatment [1]
Dopamine agonists [1] Dopamine agonists directly stimulate dopamine receptors. eg:bromocriptine Studies have demonstrated that dopamine agonists, alone or combined with levodopa, are effective against early Parkinson’s disease. Used in both early stage and late stage treatment [1]
Monoamine oxidase inhibitors (MAOIs) [1] MAO-B inhibitors reduced disability, the incidence of motor fluctuations, and the need for levodopa without substantial adverse effects or increased mortality. Used in both early stage and late stage treatment [1]
Anticholinergics [2] Useful for the treatment of tremor in patients younger than 60 years without cognitive impairment [2]
N-methyl-D-aspartate receptor inhibitor (Amantadine) [2] Treatment of dyskinesias in late disease [2]
catechol-O-methyl transferase inhibitors (COMT inhibitors) [1] Used in late stage treatments.COMT inhibitors (e.g., entacapone, tolcapone ) decrease the degradation of levodopa and extend its half-life, thus relieving the end-of-dose wearing-off effect and reducing “off” time. [1]
Surgery [1] Factors that predict a good response to surgery for advanced Parkinson disease include good response to levodopa, few comorbidities, absence of cognitive impairment, and absence of (or well-controlled) depression. Unilateral pallidotomy is an effective symptomatic adjunct to levodopa and can treat motor complications [2]
References
  1. RAO SS, HOFMANN LA, SHAKIL A. Parkinson's disease: diagnosis and treatment. Am Fam Physician [online] 2006 Dec 15, 74(12):2046-54 [viewed 17 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17186710
  2. GAZEWOOD JD, RICHARDS DR, CLEBAK K. Parkinson disease: an update. Am Fam Physician [online] 2013 Feb 15, 87(4):267-73 [viewed 17 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23418798