Parkinson’s Disease

PATIENT PRESENTATION Social History

Chief Complaint He has a college education. He is married and lives with his
wife of 50 years, and has three children aged 40, 43, and 48.
“My movement has gotten worse and my Parkinson’s medi- He is a retired plumber.
cations do not seem to be as effective anymore.”

History of Present Illness Tobacco/Alcohol/Substance Use

James Park is a 75-year-old, right-handed man who comes in (–) Alcohol, tobacco, or illicit drug use
for a routine follow-up visit at the movement disorders clinic.
The patient is accompanied by his wife. The patient reports Allergies/Intolerances/Adverse Drug Events
that his movements are much worse. He has more difficulty Amantadine (livedo reticularis)
arising out of bed, getting dressed, and feels unsteady while
walking. But he has not fallen. His wife confirms that walking
and performing activities of daily living seem to be more dif-
Medications (Current)
ficult for him. He requires more assistance when arising out Atorvastatin 40 mg po q 24 h
of a chair or the car. He notices that his Parkinson’s medica- Carbidopa/Levodopa 25/100 mg po three times daily
tions improve his movement but this only lasts about 2 hours (0800 – 1400 – 2000)
for each dose of carbidopa/levodopa. This leaves him in an Pramipexole ER 3 mg po q 24 h
“off” state for several hours in between doses. Additionally,
Rasagiline 1 mg po q 24 h
he is very “slow and stiff” upon awakening in the morning.
He also reports feeling very sleepy during the daytime. His Diphenhydramine 25 mg po prn seasonal allergies (recently
wife asks to speak with the neurologist privately and reports takes approximately 1-2 doses per day)
that the patient has developed a gambling habit over that past Doxazosin 8 mg po q 24 h (was increased 8 weeks ago from
6 weeks and seems to be “obsessed” about any form of 4 mg to 8 mg)
gambling but lottery tickets in particular. On weekdays, he HCTZ 12.5 mg po q 24 h
demands that she drive him to the grocery store to purchase
Multivitamin one tablet po q 24 h
lottery tickets and on weekends, he will take a cab to the local
casino and spend the whole day there. They have lost a sub-
stantial portion of their savings from his gambling activity. Review of Systems
Additionally, he seems to be depressed, more forgetful, and (–) Cancer, loss of consciousness, respiratory disease, pain,
is increasingly confused about the date and time. She is very seizures, stroke, or vertigo. Reports depressed mood and
concerned about these new developments. dizziness.

Past Medical History Physical Examination

BPH (8 years)
Genera l
Hyperlipidemia (10 years)
WDWN Caucasian man in no acute distress. Oriented to per-
Hypertension (10 years) son and place but not time. Affect appropriate. Masked facies.
Parkinson’s disease (5 years) Hypophonic, slurred speech, palilalia. Shuffling, unsteady
gait; right foot drags; reduced arm swing bilaterally. No dys-
Family History kinesias or dystonic postures.
He has an older sister; alive and well. His father died of lung
cancer. Mother had Alzheimer’s disease and died of compli- Vita l Signs
cations related to pneumonia. Supine BP 140/76 mm Hg; Standing BP 100/56 mm Hg
1
P 76, RR 16, T 36.4°C
Weight 180 lb. (81.8 kg)
Height 71 in. (180 cm)

HEENT
Cranial nerves
II: Normal visual acuity, visual fields, fundi
III, IV, VI: PERRL, EOMI, (–) nystagmus, (–) gaze palsy
V: Facial sensation intact
VII: Normal facial asymmetry and strength
VIII: Whisper test normal
IX: Uvula midline with “Ah”
XI: Shoulder shrug strength normal
XII: Tongue midline with protrusion

Neck a nd Lymph Nodes

Neck supple; (–) adenopathy

Chest
Clear to auscultation

Ca rdiova scula r
FIGURE 1. Micrographia. (Reprinted with permission from
Deferred Jack J. Chen, PharmD, Loma Linda University Movement
Disorders Center, Loma Linda, CA.)
Abdomen
Deferred
Leg agility: Right = 2, Left = 1
Extremities Arising from a chair = 2
(–) Pedal edema Gait = 2
Pedal pulses are 2+ and equal Freezing of gait = 1
DTRs normal Postural stability = 2
Positive micrographia (Fig. 1) Posture = 3
Global spontaneity of movement (body bradykinesia) = 3
Skin Postural tremor of hands: Right = 0, Left = 0
Warm and dry; (–) rashes or lesions Kinetic tremor of hands: Right = 0, Left = 0
Resting tremor amplitude: RUE = 2; LUE = 1; RLE = 0;
MDS UPDRS Pa rt III (Motor) Exa mina tion (“on”) LLE = 0; lip/jaw = 1
UPDRS Part III (motor) = 36 while “on” (2 months ago) Constancy of rest tremor: 2

Genitourina ry
Toda y’s Ra tings
Deferred
Speech = 2
Facial expression = 3 Recta l
Rigidity: Neck = 2; RUE = 3, LUE = 1; RLE = 1; LLE = 1 Deferred
Finger tapping: Right = 3, Left = 2
Hand movements: Right = 3, Left = 2 Other Rating Scales
Hand pronation – supination: Right = 3, Left = 2 Mini Mental Status Exam (MMSE) = 25/30 (today)
Toe tapping: Right = 1, Left = 1 Mini Mental Status Exam (MMSE) = 28/30 (8 weeks ago)
2
Laboratory Tests 2. Based on the subjective and objective information, what
do you think are this patient’s most significant medical
Conventional Units SI Units problems?
Na 140 mEq/L 140 mmol/L Hint: See pp. 508-509 in PPP
K 3.8 mEq/L 3.8 mmol/L 3. Are any of the patient’s current medications contributing
Cl 101 mEq/L 101 mmol/L to some of the problems? If so, what are they?
CO2/HCO3 23 mEq/L 23 mmol/L Hint: See pp. 511-515 in PPP
BUN 16 mg/dL 5.7 mmol/L 4. What are the treatment goals and treatment options for
this patient?
SCr 1 mg/dL 88.4 μmol/L
Hint: See pp. 510-518 in PPP
Cr Clearance
Glu 98 mg/dL 5.44 mmol/L
Ca 8.8 mg/dL 2.2 mmol/L FOLLOW-UP
Mg Eight weeks later, the patient returns for follow-up. He states
his motor fluctuations have improved with the new regimen.
PO4
His MDS UPDRS Part III (motor) examination (“on”) score is
Hgb 16 g/dL 160g/L 40 and his MMSE is 25. The patient is tolerating the new regi-
Hct 46% 0.46 men. His dizziness and drowsiness have resolved. On exami-
nation, his tremor, rigidity, and bradykinesia are still present,
MCV 92.1 μm 3
92.1 fL
but improved. His wife reports that the gambling behavior
WBC 6.5 × 10 /mm
3 3
6.5 × 109/L has resolved. However, patient still has memory problems
WBC Differential //// and is depressed. The patient confirms that he has lost inter-
est in activities that he previously enjoyed such as oil painting,
Platelets 240 × 103/mm 3 240 × 109/L
going on walks and socializing with family friends.
Albumin 4.1 g/dL 41 g/L Given this new information, identify the treatment goals
Total bilirubin 0.8 mg/dL 13.7 μmol/L and treatment options for this patient and create a care plan
Bilirubin (direct) 0.1 mg/dL 1.4 μmol/L for each problem.
Hint: See p. 515 in PPP
AST 36 IU/L 0.6 μkat/L
ALT 40 IU/L 0.67 μkat/L
Alkaline phosphatase 64 IU/L 1.1 μkat/L
GLOBAL PERSPECTIVE
PD affects individuals worldwide and the signs and
Assessment symptoms are not different for any ethnic or cultural
Seventy-five-old man with moderate-to-advanced stage idio- group. Although there are isolated clusters of PD linked
pathic PD experiencing motor fluctuations including early- to genetic and/or environmental causes, the majority of
morning off time, orthostatic hypotension, daytime sleepiness, PD cases worldwide are not attributable to an identifiable
depressed mood, worsening cognition, and impulse control genetic or environmental element. Epidemiologic studies
disorder. indicate there are differences in both incidence and
prevalence among world regions but these differences
are probably due to factors that may be demographic
Student Work Up (variations in life expectancy across countries) and health
care related (improper diagnosis, variations in access to
Missing Information/Inadequate Data health care), together with methodological differences in
Evaluate: Patient database conducting the epidemiologic studies. Current medications
Drug therapy problems used to treat PD appear to be similar in effect regardless
of ethnicity and currently there is very little evidence to
Care plan (by problem)
indicate that pharmacogenomic variations substantively
affect PD medication response. Therefore, the application
of PD treatment and medication guidelines are considered
TARGETED QUESTIONS universal and not affected by ethnicity. However, when
1. Which signs and symptoms are associated with PD and developing a care plan, it is important to consider the
what is your assessment of the severity of his motor signs patient’s desired outcomes and goals of treatment. As
and symptoms as rated by the neurologist? an example, for some individuals, a mild tremor or mild
Hint: See pp. 508-509 in PPP dyskinesia may not be perceived as sufficiently troublesome

3

and, thus, a low priority therapeutic goal. However, for
other individuals, a mild tremor may have a substantial
negative impact on their quality of life and would rank
symptomatic control as a high priority goal. Overall, the
patient’s and family’s desired goals (which can vary among
cultures) should be incorporated into the care plan to help
guide therapy.
CASE SUMMARY
• This older patient with PD is experiencing motor
fluctuations that are interfering with his quality of life.
Motor fluctuations are common in moderate-to-advanced
PD and occur due to a combination of disease progression
(ongoing neurodegeneration) and the short half-life of
carbidopa/levodopa.
• There are several pharmacotherapy options for
management of motor fluctuations. The care plan should
incorporate the most appropriate option based on the
patient’s medical history and current drug therapy.
• Patients with PD often present with several clinical
problems that are uncovered during a visit. This patient is
experiencing several additional problems that are related
to his PD and/or medications. Once identified, the care
plan should prioritize these problems and incorporate the
appropriate recommendations or interventions.
• These additional problems include nonmotor symptoms
of PD and known side effects of his current PD
medications.
REFERENCES
1. Fox SH, Katzenschlager R, Lim SY, Ravina B, Seppi K,
Coelho M, et al. The Movement Disorder Society Evi-
dence-Based Medicine Review Update: Treatments for
the motor symptoms of Parkinson’s disease. Mov Disord.
2011 Oct;26 Suppl 3:S2-41.
2. Seppi K, Weintraub D, Coelho M, Perez-Lloret S, Fox SH,
Katzenschlager R, et al. The Movement Disorder Society
Evidence-Based Medicine Review Update: Treatments
for the non-motor symptoms of Parkinson’s disease. Mov
Disord. 2011 Oct;26 Suppl 3:S42-80.
3. Refer http://www.movementdisorders.org/MDS-Files1/
PDFs/Rating-Scales/MDS-UPDRSfinal_Update.pdf