Internal Medicine

0521779407-17 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:18

1138 Parkinson’s Disease and Parkinsonism

■Drug-induced parkinsonism (esp dopamine receptor antagonists)

excluded by history

■Infectious & postinfectious causes excluded by history

■Toxic exposures (MPTP, pesticides) excluded by history

management

■Depends on cause & type of symptoms

➣For PD, treatment is symptomatic

specific therapy

■Tremor

➣Amantadine

➣Benztropine or trihexyphenidyl

■Bradykinesia

➣Dopamine agonists

Bromocriptine

Pergolide

Pramipexole

Ropinirole

Apomorphine (IM) for rescue of disabling akinesia

➣L-dopa/carbidopa may also be used

➣COMT inhibitors

Extend half-life of L-dopa in moderate/advanced PD

Entacapone: w/ each dose of L-dopa

Tolcapone (monitor liver enzymes)

➣L-dopa/carbidopa/entacapone combination

■Drug-induced confusion, paranoia, hallucinations

➣Quetiapine

➣Clozapine (requires routine complete blood counts)

follow-up

■Depends on cause & severity of symptoms

complications and prognosis

■PD is a chronic progressive disorder

■Clinical course is variable

■40% develop depression that responds to treatment (TCAs, SSRIs,

etc.)

■30% develop dementia

■Most die of aspiration pneumonia