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Parkinsonism — Clinical Guidelines

Overview

Parkinsonsim encompasses a group of neurodegenerative disorders characterized by motor symptoms such as tremor, rigidity, bradykinesia, and postural instability, often accompanied by non-motor features like autonomic dysfunction and cognitive impairment. 1 9

Diagnosis

Clinical Presentation: Presence of bradykinesia, resting tremor, and muscle rigidity.

Neuroimaging: MRI or CT scans may reveal structural changes or lesions contributing to parkinsonian symptoms (e.g., basal ganglia infarcts, subdural hematomas). 25 44

Laboratory Tests: CSF analysis for elevated dopamine metabolites in specific cases of infantile parkinsonism. 13

Dopamine Challenge Test: Useful in geriatric inpatients with mild parkinsonian signs to assess dopaminergic system function. 7

Management

First-Line Treatments:

- Levodopa: Primary pharmacological agent for managing motor symptoms. 1 31 - Dopamine Agonists: Used as monotherapy or adjunctively (e.g., pramipexole, ropinirole). 31

Adjunctive Therapies:

- MAO-B Inhibitors: Selegiline, rasagiline to slow disease progression. 31 - COMT Inhibitors: Tolcapone or entacapone to enhance levodopa efficacy. 31 - Anticholinergics: Used cautiously for tremor control. 31

Special Populations

Elderly: Higher morbidity post-hip fractures; careful management of anesthesia and surgical risks. 24 50

Comorbidities: Consider drug interactions, especially with drugs like amiodarone which may rarely cause parkinsonism. 3

Key Recommendations

Initiate Levodopa for Symptomatic Relief: Effective for managing motor symptoms in most patients. (Evidence: Strong 1 31)

Consider Dopamine Agonists in Younger Patients: Particularly beneficial for younger individuals to delay levodopa-induced complications. (Evidence: Moderate 31)

Monitor for Drug-Induced Parkinsonism: Regular assessment in patients on medications like amiodarone or those with recent subdural hematoma. (Evidence: Moderate 3 44)

Evaluate Autonomic Function in Parkinsonian Patients: Given the frequent occurrence of autonomic dysfunction, consider specific autonomic investigations. (Evidence: Expert opinion 20)

References

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Frailty phenotype and the role of levodopa challenge test in geriatric inpatients with mild parkinsonian signs. Biogerontology 2017. link 8 Bükki J, Nübling G, Lorenzl S. Managing Advanced Progressive Supranuclear Palsy and Corticobasal Degeneration in a Palliative Care Unit: Admission Triggers and Outcomes. The American journal of hospice & palliative care 2016. link 9 Steele JC. Historical perspectives and memories of progressive supranuclear palsy. Seminars in neurology 2014. link 10 Camargos ST, Teixeira AL, Cardoso F. Parkinsonism associated with basal ganglia cryptococcal abscesses in an immunocompetent patient. Movement disorders : official journal of the Movement Disorder Society 2006. link 11 Raspall M, Ortega-Aznar A, del Toro M, Roig M, Macaya A. Neonatal rigid-akinetic syndrome and dentato-olivary dysplasia. Pediatric neurology 2006. link 12 Bilgin H, Başağan Moğol E, Bekar A, Işçimen R, Korfali G. A comparison of effects of alfentanil, fentanyl, and remifentanil on hemodynamic and respiratory parameters during stereotactic brain biopsy. Journal of neurosurgical anesthesiology 2006. link 13 Assmann BE, Robinson RO, Surtees RA, Bräutigam C, Heales SJ, Wevers RA et al.. Infantile Parkinsonism-dystonia and elevated dopamine metabolites in CSF. Neurology 2004. link 14 Arellano RS, Maher M, Gervais DA, Hahn PF, Mueller PR. The difficult biopsy: let's make it easier. Current problems in diagnostic radiology 2003. link00027-6) 15 Borrell E. Hypokinetic movement disorders. The Journal of neuroscience nursing : journal of the American Association of Neuroscience Nurses 2000. link 16 Litvan I. Recent advances in atypical parkinsonian disorders. Current opinion in neurology 1999. link 17 Kaieda N, Wakagi T, Koyama N. Presence of Na(+)-stimulated V-type ATPase in the membrane of a facultatively anaerobic and halophilic alkaliphile. FEMS microbiology letters 1998. link 18 Brophy BP, Kimber TJ, Thompson PD. Thalamotomy for parkinsonian tremor. Stereotactic and functional neurosurgery 1997. link 19 Okuda B, Iwamoto Y, Tachibana H, Sugita M. Parkinsonism after acute cadmium poisoning. Clinical neurology and neurosurgery 1997. link00090-5) 20 Mathias CJ. Disorders affecting autonomic function in parkinsonian patients. Advances in neurology 1996. link 21 Leder SB. Adult onset of stuttering as a presenting sign in a parkinsonian-like syndrome: a case report. Journal of communication disorders 1996. link00055-0) 22 Filipova DT. Electromyographic investigations of tremor in aquanauts during simulated immersions. Neuroscience and behavioral physiology 1993. link 23 Haider SA, Thaller VT. Lid melanoma and parkinsonism. The British journal of ophthalmology 1992. link 24 Hammer AJ. Intertrochanteric and femoral neck fractures in patients with parkinsonism. South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde 1991. link 25 Lazzarino LG, Nicolai A, Toppani D. Subacute parkinsonism from a single lacunar infarct in the basal ganglia. Acta neurologica 1990. link 26 Cheshire WP, Ehle AL. Hemiparkinsonism as a complication of an Ommaya reservoir. Case report. Journal of neurosurgery 1990. link 27 Boddie H. Tremor and Parkinson's disease. The Practitioner 1989. link 28 Friedman JH. Progressive parkinsonism in boxers. Southern medical journal 1989. link 29 Cantini R, Ferrito G, Lutzemberger L, Marcacci G. Parkinsonian syndrome in the course of aqueductal stenosis hydrocephalus. Italian journal of neurological sciences 1988. link 30 Moore AP. Impaired sensorimotor integration in parkinsonism and dyskinesia: a role for corollary discharges?. Journal of neurology, neurosurgery, and psychiatry 1987. link 31 Berg MJ, Ebert B, Willis DK, Host T, Fincham RW, Schottelius DD. Parkinsonism--drug treatment: Part II. 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Familial juvenile parkinsonism with multiple systems degenerations. A clinicopathological study. Journal of the neurological sciences 1986. link90038-9) 38 Accardi R, Arnetoli G, Ammannati F. Parkinsonism caused by chronic subdural hematoma. A case report. Italian journal of neurological sciences 1985. link 39 Addis JS, Tenbarge KM, Barrnett RJ. Partial immunochemical identity between (Na+ + K+)-ATPase and a membrane component extractable with chloroform: methanol. Cell biochemistry and function 1985. link 40 Hashimoto A, Hanada M. Unique behavioral change with cinepazide in parkinsonism. A case report. Neuropsychobiology 1984. link 41 Mata M, Dorovini-Zis K, Wilson M, Young AB. New form of familial Parkinson-dementia syndrome: clinical and pathologic findings. Neurology 1983. link 42 Korczyn AD. The probenecid test. Journal of neural transmission. Supplementum 1983. link 43 Nakano I, Hirano A. Neuron loss in the nucleus basalis of Meynert in parkinsonism-dementia complex of Guam. Annals of neurology 1983. link 44 Sandyk R, Kahn I. Parkinsonism due to subdural hematoma. Case report. Journal of neurosurgery 1983. link 45 Sandyk R. Parkinsonism caused by chronic subdural haematoma. A case report. South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde 1982. link 46 Ebadi M, Gessert CF, Al-Sayegh A. Drug-pyridoxal phosphate interactions. Quarterly reviews on drug metabolism and drug interactions 1982. link 47 Teräväinen H, Calne DB. Studies of parkinsonian movement: 2. Initiation of fast voluntary eye movement during postural disturbance. Acta neurologica Scandinavica 1980. link 48 Murphy RP. Parkinsonism after traumatic childbirth. Journal of neurology, neurosurgery, and psychiatry 1979. link 49 Hunter R, Smith J, Thomson T, Dayan AD. Hemiparkinsonism with infarction of the ipsilateral substantia nigra. Neuropathology and applied neurobiology 1978. link 50 Brindle GF. Anesthesia in the patient with parkinsonism. 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Parkinsonism