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Parkinsons Disease

Epidemiology: Mean onset 55 years
Pathology: Loss of pigmented neurons in substantia nigra. About 80% must be depleted before symptoms occur.

Clinical

History

Fatigue, tremor (pill-rolling), ↓mobility, problems walking, falling
Late features: Mask-like facies, monotonous tone, oblinking, dysarthria, dysphagia, micrographia, ↓ADLs, autonomic dysfuntion (↑sweating)
ΔΔ for tremor: Benign essential (intention, bilateral, FH, better w alcohol), cerebellar (intention, faster as approach target)

Examination:

TRAP = Tremor, Rigidity, Akinesia, Posture
Tremor:  pill rolling, occurs at rest, unilateral at first
Rigidity: cogwheel
Akinesia: initiating movement, turning, festinant gait = fast small steps, no arm swinging
Posture: stooped

Treatment

POSSET, psychiatric (association with dementia and depression), SALT (when swallowing fails)
Drugs: Enhance dopamine transmission

Levodopa

Indicated for those over 65+ starting when independence compromised. Often withheld in the early stages because prolonged use it becomes less effective. Given with a peripheral decarboxylase inhibitor (carbidopa/benserazide) to ↓GI side effects.
Side effects:

Other Drugs

MAOIs (e.g. selegeline): early PD
Catechol-O-Methyl Transferase (COMT) inhibitors (e.g. entacapone): inhibit COMT in periphery thus increasing the bioavailability of L-DOPA by facilitating its transmission across the blood-brain barrier
Dopamine agonists (e.g. bromocriptine, apomorphine): first line for the under 65s. Side effects: same as L-DOPA.

Natural history

Relatively normal life span, many die of old age. Postural instability is an omnious sign.

Parkinsonism

Parkinsons can be idiopathic (Parkinson's Disease) or associated with other disorders:
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