Course:PostgradFamilyPractice/ExamPrep/99 Priority Topics/Parkinsonism

Parkinsonism - Key Features

1 In patients with suspected Parkinson’s disease, accurately distinguish idiopathic Parkinson’s disease from atypical Parkinson’s disease (e.g., disease at a young age, drug-related disease), as treatment differs.

2 In the care of all patients with Parkinson’s disease, involve other health care professionals to enhance the patient’s functional status.

3 In an elderly patient with a deterioration in functional status, look for and recognize Parkinson’s disease when it is present, as it is a potentially reversible contribution to the deterioration.

4 In a patient with a tremor, do an appropriate physical examination (e.g., observation, use of techniques to enhance the tremor) to distinguish the resting tremor of parkinsonism from other (e.g., essential) tremors.

5 As part of the management of patients with Parkinson’s disease, identify anticipated side effects of medications, especially those with which you are unfamiliar.

6 As part of the ongoing follow-up care of patients with Parkinson’s disease:
- Assess functional status.
- Monitor them for medication side effects.
- Look for other problems (e.g., depression, dementia, falls, constipation), as they are more common

Presentation
• TRAP - any 2 of Tremor, Rigidity, Akinesia/bradykinesia, Postural instability
• Parkinsonʼs Disease

• Clinical Diagnosis

• Cardinal S&S: Distal Resting Tremor (3-6Hz, pill-rolling); Rigidity; Bradykinesia; Asymmetrical onset

• Additional S&S: Difficulty turning over in bed, opening jars, rising from a chair; Poor heel-to-toe gait; Shuffling gait; Loss of balance; Micrographia; Loss of olfaction

• Therapeutic Challenge: adequate response to levodopa trial

Differential Diagnosis
• Symptoms Suggesting Alternate Diagnosis: Lack of Levodopa response, hallucinations, prominent/early dementia, early postural instability, severe & early autonomic dysfunction, upward gaze paralysis, involuntary mvmts (other than tremor)

Investigations
• Physical Examination of Tremor
• Resting Tremor - seen w hand resting in lap
• Need to distinguish from Kinetic Tremor (occurs w mvmts) & Postural Tremor (limb is held against gravity)
• LOOK: Observe (1) Hands in lap/arms at sides, (2) Extend arms to do finger-to-nose test, (3) Perform tasks (drink from glass, write/draw)

• Classify: Involved body part (arms, head), When tremor present (rest, intention), Frequency (fast/slow), Amplitude (fine/coarse)

• (4) Stand & Walk - difficulty initiating mvmt, dec arm swing, shuffling gate

• FEEL/MOVE: Rigidty & Bradykinesia - flex/ext arms, cog wheeling?

• CT or MRI - if diagnosis of idiopathic PD is uncertain and other diagnoses are being considered

Management
• Goal: maximize ptnt autonomy & QOL; Initiate therapy at onset of functional impairment
• United Parkinsonʼs Disease Rating Scale (UPDRS) - standardized assessment tool; Measures (1) mental effects, (2) ADL limitations, (3) motor impairment, (4) treatment/disease complications (see below).
• Assessing Functional Status

Study Guide

Parkinsonism

Resources

American Family Physician Tremor www.aafp.org/afp/2003/1015/p1545.html
American Family Physician Parkinsonʼs Disease: Diagnosis & Treatment www.aafp.org/afp/2006/1215/p2046.html
Unified Parkinsonʼs Disease Rating Scale (UPDRS)