Updated: 10/20/2022

Parkinson Disease

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  • Snapshot
    • A 65-year-old man present with a tremor in his right hand. His tremor is most apparent at rest and improves with movement. His movements are noticeably slower and he has difficulty initiating movement. On physical exam, the patient appears apathetic and has rigidity with passive arm movement. Gait testing is notable for shuffling with a stooped posture.
  • Introduction
    • Definition
      • movement disorder characterized by
        • bradykinesia
        • rigidity
        • postural instability
        • resting tremor
    • Parkinson-plus syndromes
      • multiple system atrophy
        • dysautonomia
          • orthostatic hypotension
          • urinary retention/incontinence
          • early erectile dysfunction
        • parkinsonism
        • sleep disorders (e.g., REM sleep behavior disorder)
        • ataxia
      • progressive supranuclear palsy
        • parkinsonism
        • verticle eye movement abnormalities
      • corticobasal degeneration (CBD)
        • progressive asymmetric movement disorder
          • apraxia is more suggestive of CBD
    • Associated conditions
      • dementia
      • depression
      • sleep disorders
      • psychosis 
  • Pathogenesis
    • Loss of dopaminergic neurons in the substantia nigra leads to dopamine depletion in the striatum
      • this creates an imbalance between dopamine and acetylcholine resulting in improper muscle movement
    • Impaired degradation of α-synuclein can lead to degradation of dopaminergic striatal neurons
  • Presentation
    • Symptoms/physical exam
      • bradykinesia
        • describes a slowness of movement
      • muscle rigidity
        • noticeable resistance to muscle movement by the examiner
      • postural instability
        • feeling of imbalance and having a tendency to fall
          • a late finding in Parkinson disease
          • secondary to loss of centrally-mediated postural reflexes
      • resting tremor
        • "pill rolling" is characteristic when the hand is resting
          • the tremor improves with action
  • Studies
    • Clinical diagnosis
  • Differential
    • Huntington disease
      • differentiating factor
        • choreiform movements
    • Essential tremor
      • differentiating factor
        • tremor is present with movement not at rest
  • Treatment
    • Medical
      • carbidopa-levodopa
        • indication
          • considered first-line treatment for Parkinson disease
            • other dopamine increasing medications can be used
            • treatment is individualized and a first-line medication is different for different patients
    • Operative
      • deep brain stimulation
        • indication
          • typically reserved for advanced Parkinson disease
  • Complications
    • Dementia
    • Sleep disorders
    • Falls

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(M2.NE.15.32) A 59-year-old patient presented to his family physician 8 years ago with initial complaints of increasing generalized stiffness with trouble initiating movement and worsening micrographia. He was started on levodopa after further evaluation led to a suspected diagnosis of Parkinson's disease; however, this therapy ultimately failed to improve the patient's symptoms. Additionally, over the ensuing 8 years since his initial presentation, the patient also developed symptoms including worsening balance, orthostatic hypotension, urinary incontinence, and impotence. The patient's overall condition deteriorated ever since this initial diagnosis with increasing disability from his motor symptoms, and he recently passed away at the age of 67, 8 years after his first presentation to his physician. The family requests an autopsy. Which of the following would be expected on autopsy evaluation of this patient's brain tissue?

QID: 105032

Astrocytosis and caudate atrophy

25%

(8/32)

Glial cytoplasmic inclusions

19%

(6/32)

Round intracellular tau protein aggregates

25%

(8/32)

Beta-amyloid plaques

22%

(7/32)

Periventricular white matter plaques

6%

(2/32)

M 6 E

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