Parkinson's disease is a common neurodegenerative disorder that can cause significant disability and decreased quality of life. The cardinal physical signs of the disease are distal resting tremor, rigidity, bradykinesia, and asymmetric onset. Levodopa is the primary treatment for Parkinson's disease; however, its long-term use is limited by motor complications and drug-induced dyskinesia. Dopamine agonists are options for initial treatment and have been shown to delay the onset of motor complications. However, dopamine agonists are inferior to levodopa in controlling motor symptoms. After levodopa-related motor complications develop in advanced Parkinson's disease, it is beneficial to initiate adjuvant therapy with dopamine agonists, catechol O-methyltransferase inhibitors, or monoamine oxidase-B inhibitors. Deep brain stimulation of the subthalamic nucleus has been shown to ameliorate symptoms in patients with advanced disease. Depression, dementia, and psychosis are common psychiatric problems associated with Parkinson's disease. Psychosis is usually drug induced and can be managed initially by reducing antiparkinsonian medications. The judicious use of psychoactive agents may be necessary. Consultation with a subspecialist is often required.
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Patient Handout by the authors of the above article: Parkinson's Disease: What You Should Know

Parkinson's disease is a progressive degenerative disorder of the central nervous system. The hallmark physical signs are tremor, rigidity and bradykinesia. Idiopathic Parkinson's disease is caused by the progressive loss of dopaminergic neurons in the substantia nigra and nigrostriatal pathway of the midbrain. Secondary parkinsonism may be caused by certain drugs (e.g., metoclopramide and haloperidol) or by cerebrovascular disease (e.g., multiple lacunar strokes). The disease can usually be diagnosed based on the history and physical findings. Dopamine replacement is still considered the most efficacious treatment for Parkinson's disease, but dopamine agonists, formerly prescribed only as adjunctive therapy, are emerging as useful initial therapy. Other pharmacologic treatments include drugs that inhibit dopamine-metabolizing enzymes (monoamine oxidase-B and catechol O-methyltransferase). Injections of botulinum toxin can be helpful in patients with associated dystonia or blepharospasm. Surgery may be indicated for certain patients or when symptoms do not respond to medical therapy. Additional adjunctive therapies include physical therapy, nutritional counseling and techniques to help patients manage emotional and cognitive changes related to the disease.
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Patient Handout by the above authors: Parkinson’s Disease

Levodopa remains the cornerstone for managing Parkinson's disease. Physician's preference usually determines the dopamine agonist chosen for the early phases of treatment. The concept of neuro-protection, however, remains unproven. A better understanding of the cause of the disease and treatment-related complications could make managing Parkinson's disease more rewarding.

Valid for credit through March 28,2009.

Target Audience: This activity is intended for neurologists, primary care practitioners, nurses, pharmacists, and other healthcare providers who manage patients with Parkinson's disease.

Upon completion of this activity, participants will be able to: Explain the rationale for early treatment of Parkinson's disease, including the potential for disease modification or neuroprotection; Describe the efficacy, safety, and tolerability of different treatment options that may be used in early disease; Design a treatment regimen for a patient with early disease based on available treatment guidelines.

Idiopathic Parkinson's disease (PD) is a progressive, neurodegenerative illness with no known cure. Hallmark motor features of the disease include resting tremor, rigidity, bradykinesia, and gait disturbance.1 Nonmotor symptoms such as depression and dementia are common, particularly in later stages of the disease, and can be as debilitating as the motor symptoms.2 The average PD patient is 64.2 years old at symptom onset and 65.5 years old when diagnosed. Initiation of pharmacologic treatment is often delayed until symptoms are profoundly impacting the patient's quality of life and/or producing significant disability.

Currently available treatments for PD are those that provide symptomatic benefit, and none have been proven to alter the underlying progression of the disease or provide neuroprotective benefits The available treatments include levodopa (with carbidopa), catechol-O-methyltransferase inhibitors (which improve levodopa bioavailability), dopamine agonists (DAs), monoamine oxidase-B inhibitors, amantadine, and anticholinergics.

Parkinson's disease can leave your patient immobile, unable to effectively communicate, and with little hope. But it doesnʼt have to be that way! Learn all about its signs and symptoms, treatment options, and what you can do to help your patients live with this potentially disabling disease.

Parkinson's disease (PD) is one of the most common neurodegenerative diseases affecting approximately 1% of the population above the age of 65 years. There are approximately 1 million people affected by PD in the United States. The average age of onset of PD is the early 60s; however, about 10% of the patients will have onset of the symptoms in their 40s; this is referred to as young-onset PD. The incidence of PD varies in different races; the lowest is in Asian and African blacks and highest among whites. There is a slight predominance among men vs women with a ratio of 3:2.

Parkinson's disease (PD) is a neurodegenerative disorder second only to Alzheimer's disease in prevalence. The disease was first described in the early 19th century by James Parkinson who called it the "shaking palsy." PD is associated with three primary characteristics: resting tremor, bradykinesia (or akinesia), and ridgidity. A fourth characteristic, postural reflex impairment, usually presents only as the disease progresses.

Patients with PD have a life expectancy shorter than the general population. The disease strikes men more often than women, and is typically thought of as a disease of the elderly. The mean age of onset is 65 years with about 2% of older persons affected. Unfortunately, there is no cure for PD at this time and as the population ages the number of patients with the disease will rise proportionately. Currently, the financial burden associated with PD is high and will continue to grow. A retrospective analysis of health-insurance claims reporting outcomes in 2002 revealed that compared with controls, patients with PD spent an average of two more days in the hospital each year, 43 more days in long-term care facilities, and received 20 more prescriptions per patient. The total estimated cost was $12,000 more for each individual with PD compared with their counterparts, and total disease burden was calculated at $23 billion annually. Direct costs alone are estimated at $11 billion.

Parkinson’s disease (PD) has hit primetime. Media attention soared with the acknowledgement of PD by such famous personalities as actor Michael J. Fox. Reports about PD and its treatment are now featured in lay publications and on television.

PD has been recognized for almost two centuries. The characteristics of “shaking palsy” first described by James Parkinson in 1817 still hold true today. While considerable progress has been made in the recognition and treatment of PD, it currently affects 1.5 million people in North America. The cause is unknown, but many theorize that it is an interaction of genetic and environmental factors.

Because the greatest risk factor is increasing age, the prevalence of PD is expected to rise as the elderly population grows. However, 4% to 6 % of PD cases are young-onset — people under the age of 40. Nurses can expect to encounter patients with PD in settings throughout the health care system and should be aware of the complexities of this chronic, neurodegenerative disorder.

This guideline will assist the interdisciplinary team in the recognition, assessment, treatment and monitoring of LTC facility residents with Parkinson’s disease (PD). Many clinical manifestations of the disease can be treated with a combination of non-pharmacologic and drug therapies. Understanding the full spectrum of the disease, the importance of basic competent primary nursing and medical care, the roles of various disciplines, therapies, and specialties, and the concept of realistic goal-setting for the individual patient are essential to effective treatment of PD.

To define key issues in the diagnosis of Parkinson disease (PD), to define features influencing progression, and to make evidence-based recommendations, 2 clinical questions were identified: 1) Which clinical features and diagnostic modalities distinguish PD from other parkinsonian syndromes? 2) Which clinical features predict rate of disease progression? 1. Early falls, poor response to levodopa, symmetry of motor manifestations, lack of tremor, and early autonomic dysfunction are probably useful in distinguishing other parkinsonian syndromes from Parkinson disease (PD). 2. Levodopa or apomorphine challenge and olfactory testing are probably useful in distinguishing PD from other parkinsonian syndromes. 3. Predictive factors for more rapid motor progression, nursing home placement, and shorter survival time include older age at onset of PD, associated comorbidities, presentation with rigidity and bradykinesia, and decreased dopamine responsiveness. Future research into methods for earlier and more accurate diagnosis of the disease and identification and clarification of predictive factors of rapid disease progression is warranted.

Based on this review, the authors conclude: 1) Selegiline has very mild symptomatic benefit (level A, class II evidence) with no evidence for neuroprotective benefit (level U, class II evidence). 2) For PD patients requiring initiation of symptomatic therapy, either levodopa or a DA can be used (level A, class I and class II evidence). Levodopa provides superior motor benefit but is associated with a higher risk of dyskinesia. 3) No evidence was found that initiating treatment with sustained-release levodopa provides an advantage over immediate-release levodopa (level B, class II evidence).

Screening tools are available for depression and dementia in patients with PD, but more specific validated tools are needed. There are no widely used, validated tools for psychosis screening in Parkinson disease (PD). Clozapine successfully treats psychosis in PD. Cholinesterase inhibitors are effective treatments for dementia in PD, but improvement is modest and motor side effects may occur.

Propranolol and primidone reduce limb tremor (Level A). Alprazolam, atenolol, gabapentin (monotherapy), sotalol, and topiramate are probably effective in reducing limb tremor (Level B). Limited studies suggest that propranolol reduces head tremor (Level B). Clonazepam, clozapine, nadolol, and nimodipine possibly reduce limb tremor (Level C). Botulinum toxin A may reduce hand tremor but is associated with dose-dependent hand weakness (Level C). Botulinum toxin A may reduce head tremor (Level C) and voice tremor (Level C), but breathiness, hoarseness, and swallowing difficulties may occur in the treatment of voice tremor. Chronic deep brain stimulation (DBS) (Level C) and thalamotomy (Level C) are highly efficacious in reducing tremor. Each procedure carries a small risk of major complications. Some adverse events from DBS may resolve with time or with adjustment of stimulator settings. There is insufficient evidence regarding the surgical treatment of head and voice tremor and the use of gamma knife thalamotomy (Level U). Additional prospective, double-blind, placebo-controlled trials are needed to better determine the efficacy and side effects of pharmacologic and surgical treatments of ET.

To make evidence-based treatment recommendations for the medical and surgical treatment of patients with Parkinson disease (PD) with levodopa-induced motor fluctuations and dyskinesia, 5 questions were addressed. 1. Which medications reduce off time? 2. What is the relative efficacy of medications in reducing off time? 3. Which medications reduce dyskinesia? 4. Does deep brain stimulation (DBS) of the subthalamic nucleus (STN), globus pallidus interna (GPi), or ventral intermediate (VIM) nucleus of the thalamus reduce off time, dyskinesia, and antiparkinsonian medication usage and improve motor function? 5. Which factors predict improvement after DBS? 1. Entacapone and rasagiline should be offered to reduce off time (Level A). Pergolide, pramipexole, ropinirole, and tolcapone should be considered to reduce off time (Level B). Apomorphine, cabergoline, and selegiline may be considered to reduce off time (Level C). 2. The available evidence does not establish superiority of one medicine over another in reducing off time (Level B). Sustained release carbidopa/levodopa and bromocriptine may be disregarded to reduce off time (Level C). 3. Amantadine may be considered to reduce dyskinesia (Level C). 4. Deep brain stimulation of the STN may be considered to improve motor function and reduce off time, dyskinesia, and medication usage (Level C). There is insufficient evidence to support or refute the efficacy of DBS of the GPi or VIM nucleus of the thalamus in reducing off time, dyskinesia, or medication usage, or to improve motor function. 5. Preoperative response to levodopa predicts better outcome after DBS of the STN (Level B).

Older people at risk for aspiration include those with stroke, Parkinson’s disease, dementia,reduced level of consciousness, and any severely ill and disabled patients.