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parkinsonism

A neurologic disorder usually resulting from dopamine deficiency as a result of degenerative, vascular or inflammatory changes in the basal ganglia. It is characterized a resting tremor, muscular rigidity, bradykinesia, a droopy posture & mask-like facies. It may occur as a side effect of antipsychotic medications or as a feature of several neurodegenerative disorders. Etiology: 1) idiopathic Parkinson's disease (most common etiology) 2) multiple system atrophy a) striatonigral degeneration b) sporadic olivopontocerebellar atrophy c) Shy-Drager syndrome d) amyotrophy parkinsonism 3) progressive supranuclear palsy 4) corticobasal ganglionic degeneration 5) diffuse Lewy body disease 6) vascular parkinsonism 7) hereditary disorders a) Wilson's disease b) Huntington's disease c) juvenile paralysis agitans d) L-dopa responsive dystonia e) Hallervorden-Spatz disease (pantothenate kinase-2 deficiency) f) Dentatorubral-pallidoluysian atrophy g) Machado-Joseph-Azorean disease (SCA 3) h) Fahr's disease i) Leigh's disease j) spinocerebellar ataxias k) fragile X tremor/ataxia syndrome l) familial amyotrophy-dementia-parkinsonism 8) other neurodegenerative disorders sometimes associated with parkinsonism a) Alzheimer's disease b) Pick's disease (frontotemporal dementia) c) Creutzfeldt-Jakob disease (Prion disease) d) Neuro-acanthocytosis (chorein mutation) e) neuro-metabolic disorders 9) secondary parkinsonism a) head trauma (dementia pugilistica {professional boxing}) b) post-anoxia c) normal pressure hydrocephalus (NPH) d) metabolic disorders 1] hypoparathyroidism 2] hypothyroidism, rare, resolves with treatment 3] paraneoplastic syndrome e) hepatocerebral degeneration f) basal ganglia calcification (rare) g) post-viral encephalitis (encephalitis lethargica) h) brain tumors (rare) j) toxins 1] carbon tetrachloride 2] carbon monoxide 3] carbon disulfide 4] cyanide 5] manganese 6] methanol 7] MPTP i) pharmacologic agents: (drug-induced parkinsonism) 1] antipsychotics: a] haloperidol (Haldol) b] fluphenazine (Prolixin) c] aripiprazole* (NEJM) [9] 2] antiemetics a] prochlorperazine (Compazine) b] metoclopramide (Reglan) 3] reserpine 4] alpha-methyldopa (rare) 5] lithium carbonate (rare) * change to lamotrigine (NEJM) [9] Clinical manifestations: - bradykinesia [5] - rigidity - resting tremor - postural instability - freezing gait - stooped posture - masked facies - hypophonia [5] - cognitive impairment may be an early sign of impending parkinsonism [8] * Red flags for atypical forms of parkinsonism [5] - dysautonomia - orthostatic hypotension, urinary incontinence, sweating dysfunction - abnormal eye movements - supranuclear gaze palsy - early cognitive impairment, early onset dementia - visual hallucinations (not provoked by medications) - early postural instability & falls (within 1st year) - gait ataxia +/- cerebellar signs (dysmetria, nystagmus) - symmetric or markedly asymmetric involvement - rapid onset & stepwise deterioration -> vascular parkinsonism - lack of response to sinemet (most important red flag) [5] Complications: - weight loss in Parkinson's disease is associated with dementia, dependency & mortality [7]

Interactions

disease interactions

Related

Lewy body dementia

Specific

drug-induced parkinsonism parkinson plus syndrome Parkinson's disease (paralysis agitans, PD) post-encephalitic parkinsonism vascular parkinsonism

General

movement disorder sign/symptom syndrome

Figures/Diagrams

Figures/diagrams/slides/tables related to parkinsonism

References

  1. Stedman's Medical Dictionary 26th ed, Williams & Wilkins, Baltimore, 1995
  2. Lang & Lazano NEJM 339(15):1044-53 1998
  3. Bronstein J, In: Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 29-Oct 2, 2004
  4. Abdo WF, Borm GF, Munneke M, Verbeek MM, Esselink RA, Bloem BR. Ten steps to identify atypical parkinsonism. J Neurol Neurosurg Psychiatry. 2006 Dec;77(12):1367-9. Epub 2006 Jul 17. PMID: 16847047 - Burn DJ. Ten steps to identify atypical parkinsonism. J Neurol Neurosurg Psychiatry. 2006 Dec;77(12):1299. No abstract available. PMID: 17110742
  5. Medical Knowledge Self Assessment Program (MKSAP) 17, American College of Physicians, Philadelphia 2015
  6. Aerts MB, Esselink RA, Post B, van de Warrenburg BP, Bloem BR. Improving the diagnostic accuracy in parkinsonism: a three- pronged approach. Pract Neurol. 2012 Apr;12(2):77-87 PMID: 22450452
  7. Cumming K, Macleod AD, Myint PK, Counsell CE. Early weight loss in parkinsonism predicts poor outcomes: Evidence from an incident cohort study. Neurology 2017 Nov 28; 89:2254 PMID: 29079685 Free PMC Article
  8. Darweesh SKL, Wolters FJ, Postuma RB et al. Association between poor cognitive functioning and risk of incident parkinsonism: The Rotterdam Study. JAMA Neurol 2017 Dec 1; 74:1431 PMID: 28973176
  9. NEJM Knowledge+