Parkinson’s Case

1. Parkinson’s Case Donald R. Noll DO FACOI edited by Dr. Edward Warren Chair, Geriatrics Carolinas Campus May 2012

2. CC: Worsening of Tremor and Movement HPI: This 67 year old white male has worsening of his Parkinson’s Disease symptoms. Onset was last week, has been getting worse despite faithfully taking his medications. He self adjusted his Sinemet, going from four times a day to six times a day, with only modest improvement. Tremor is bilateral. He also has muscle rigidity, increased frequency of falls, and increased difficulty getting out of a chair and walking. Recently had a EGD, which showed severe, erosive esophagitis. History: Has had idiopathic Parkinson’s Disease for 10 years. PMH: GERD, CHF, HTN, and DJD. Surgical history: Appendectomy. Social History: Former smoker, sailor, truck driver, retired. Family history unremarkable. Medications: Sinemet 25/100 one tab six time a day, quinapril 20 mg daily, furosemide 40 mg daily, esomeprazole 20 mg daily, metaclopramide 10 mg ac an hs ROS: No headache, some increased trouble swallowing, no chest pain, no trouble breathing, prior heartburn symptoms have resolved, no nausea or abdominal pain, some increased tremor, rigidity and bradykinesia, more falls, no skin rash, no focal neurologic deficits History

3. Vitals – BP 145/75, P = 80, R = 18 HENT – head is normocephalic, masklike facies noted, eyes are non-icteric, PERRLA, hearing adequate, neck – stiff as usual Skin – normal turgor and texture Lungs – no rales or rhonchi. Heart – rate regular without murmur Abdomen soft with normal bowel sounds, no masses nor organomegaly Extremities – osteoarthritic changes on the knees, 2+ pitting edema around the ankles Neurologic – no gross focal deficits, but tremor is worse than on prior visits, no dyskinesia, no chorea form movements, + cogwheel rigidity, general muscle rigidity, poor postural balance, masklike facies consistent with Parkinsonism, classic shuffling gait with small steps. Physical

4. Impressions: Worsening of Parkinson’s Disease Symptom probably due to _________________. New recent diagnosis of severe erosive esophagitis HTN – adequate control CHF – stable Plan: Will discontinue ____________ and increase the dose of ___________. Follow up office visit in one week. Medical Decision Making

5. A number of actions can be taken to manage this clinical situation. The physician chose to stop one medication and increase another. Which medication do you think he chose to stop? furosemide quinipril metoclopramide esomeprazole Sinemet 25/100 Question 1

6. Which medication do you think he increased? furosemide quinipril metoclopramide esomeprazole Sinemet25/100 Question 2

7. If you were to start another medication for treating Parkinsonism, which one potentiates the pharmacokinetics of levodopa by reducing its metabolism, but has been associated with diarrhea and liver failure. tolcapone selegiline pramipexole trihexyphenidyl amantidine Question 3

8. Anti-cholinergic Drugs to treat Parkinson’s disease are better at treating which major feature of the disease? While some choices may be partially correct, pick the single best answer. Postural instability Muscle Rigidity Constipation Gait disturbance Tremor Question 4

9. About 80% of persons afflicted with Idiopathic Parkinson’s Disease develop clinically significant cognitive impairment (dementia). Does this typically occur early or late in the disease process? Early Late Both early and late, about equally Question 5

10. If this patient had symptoms of generalized autonomic dysfunction in addition to his Parkinsonism, what condition might he have? LewyBody Disease Huntington’s Disease Postencephalitic Parkinson’s Shy-Drager Syndrome Creutzfeldt-Jakob disease Question 6

11. Would apatient with idiopathic Parkinson’s Disease be likely have LewyBodies in his brain if on autopsy? Yes No Question 7

12. Which patient at autopsy is most likely to have Parkinson’s Disease? Patient A Patient B Question 8 Patient A Patient B

13. Does Idiopathic Parkinson’s Disease classically first present early in the disease as a unilateral or bilateral tremor? Unilateral Bilateral Either, no consistent pattern Question 9

14. Q1 = C: Metoclopramide is well known to antagonize dopamine and cause Parkinsonism. It was added to manage the severe reflux, but its benefits outweigh the side effect of dyskinesia. Better to stop the offending drug, than to increase the Parkinson’s medications. Q2 = D: Since the metoclopramide is being stopped, something should be done to help the reflux esophagitis. The current esomeprazoledose is relatively low, so the dose should be increased to 40 mg daily. He should also not eat nor drink with 2 hours of recumbency, avoid chocolate and caffeine, and elevate the head of his bed with 4” blocks. Close follow-up is important. Q3 = A: The best answer istolcapone, a COMT inhibitor. Be aware of serious side effects. Q4 = E: It is well established that the anti-cholinergic medication treat tremor, which is usually the least debilitating manifestation of Parkinson’s Disease. Q5 = B: Significant cognitive impairment typically occurs late in Parkinson’s Disease: a major way of distinguishing idiopathic Parkinson’s Disease from Lewy Body Dementia. Answer Key

15. Q6 = D: Shy-Drager is not rare, and important to recognize. Q7 = A: Lewy Body Demenita and Parkinson’s Disease sit on two different ends of the same spectrum. They both have LewyBodies. In Lewy Body Dementia they are more diffuse throughout the brain;in Parkinson’s Disease they are restricted to the brain stem area. Q8 = B: The one without pigment, indicated loss of cells in the substantianigra. Q9 = A: The classic presentation of Parkinson’s Disease is tremor in one limb, unilaterally, then gradually becoming bilateral over time as the condition worsens. Bradykinesia is a more universal finding in Parkinson’s. Answer Key