Parkinson resident survival guide

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Parkinson Resident Survival Guide Microchapters

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Fahimeh Shojaei, M.D., Moises Romo, M.D.

Synonyms and keywords:Parkinson's disease management, Parkinson's disease workup, Parkinson's disease approach, approach to Parkinson's disease, Parkinson's disease treatment


Parkinson's disease is a degenerative movement disorder of the central nervous system. It is characterized by motor symptoms such as bradykinesia, rigidity, and tremor, but also cognitive and comunicative symptoms such as facial masking and dysarthria. These primary symptoms are the results of decreased stimulation of the motor cortex by the basal ganglia, normally caused by the insufficient formation and action of dopamine. Diagnosis is mainly clinical, it may be supported by MRI findings and dopamine transporter single-photon emission computed tomography (DaT SPECT), but definitive diagnosis is made by autopsy. The mainstay of therapy for motor symptoms of Parkinson disease are: Levodopa, dopamine agonists, monoamine oxidase (MAO) B inhibitors, anticholinergic agents, amantadine, catechol-O-methyl transferase (COMT) inhibitors, estrogen and other drugs such as Exenatide, uric acid, isradipine, nilotinib and GDNF infusion. Other therapies will depend on comorbidities.


Life Threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.

Common Causes


Shown below is an algorithm summarizing the diagnosis of Parkinson's disease according to the American Academy of Neurology guidelines:[1]


Prodromal period
Possible early symptoms of Parkinson disease

Rapid eye movement sleep behavior disorder
Autonomic symptoms (eg, constipation, orthostatic hypotension)

Family history

• First-degree relative with Parkinson disease

• Known Parkinson disease gene mutation in family
Physical examination
Findings must include

• Rigidity and/or tremor
Findings may include
• Hypophonia
• Micrographia
• Decreased arm swing

• Short step length
Patient medical history
Symptoms may include

Gait changes
• Soft voice
• Decreased facial expression

Depression and/or anxiety
Other factors
Dopamine transporter single-proton emission computed tomography imaging findings
Genetic data
Evaluation consistent with Parkinson disease
Assessment of features potentially indicative of atypical parkinsonism

• Rapid progression
• Early and recurrent falls
• Severe early dysphonia or dysarthria
• Severe early autonomic failure

Cerebellar findings (eg, dysmetria)
All features present?
Evaluate for patient response to levodopa
Consider diagnosis of atypical parkinsonism
Confirmation of Parkinson disease diagnosis



Shown below is an algorithm summarizing the treatment of Parkinson's disease according to the American Academy of Neurology guidelines:[1]

Parkinson disease motor symptoms
Bradykinesia with or without rigidity
Initial medical therapy
Tremor and/or bradykinesia options

Levodopa preparations
Dopamine agonists
Monoamine oxidase-B

Tremor only

Anticholinergic agents

(eg, trihexyphenidyl)
Subsequent medical therapy
Increasing doses and add-on therapies for “wearing off”

Levodopa preparations
• Istradefylline
Dopamine agonists
Monoamine oxidase B inhibitors
Catechol-O-methyltransferase inhibitors

(primarily for dyskinesia)
Advanced therapy
Tremor and/or bradykinesia options
Tremor only
Levodopa carbidopa

enteral suspension infusion
• Unilateral or bilateral

deep brain stimulation
• Unilateral focused

ultrasound thalamotomy
• Unilateral or bilateral deep brain stimulation






  1. 1.0 1.1 1.2 1.3 1.4 Marino, Bianca L.B.; de Souza, Lucilene R.; Sousa, Kessia P.A.; Ferreira, Jaderson V.; Padilha, Elias C.; da Silva, Carlos H.T.P.; Taft, Carlton A.; Hage-Melim, Lorane I.S. (2020). "Parkinson's Disease: A Review from Pathophysiology to Treatment". Mini-Reviews in Medicinal Chemistry. 20 (9): 754–767. doi:10.2174/1389557519666191104110908. ISSN 1389-5575.
  2. Fox, Susan H.; Katzenschlager, Regina; Lim, Shen-Yang; Barton, Brandon; de Bie, Rob M. A.; Seppi, Klaus; Coelho, Miguel; Sampaio, Cristina (2018). "International Parkinson and movement disorder society evidence-based medicine review: Update on treatments for the motor symptoms of Parkinson's disease". Movement Disorders. 33 (8): 1248–1266. doi:10.1002/mds.27372. ISSN 0885-3185.
  3. 3.0 3.1 3.2 3.3 Seppi, Klaus; Ray Chaudhuri, K.; Coelho, Miguel; Fox, Susan H.; Katzenschlager, Regina; Perez Lloret, Santiago; Weintraub, Daniel; Sampaio, Cristina; Chahine, Lana; Hametner, Eva‐Maria; Heim, Beatrice; Lim, Shen‐Yang; Poewe, Werner; Djamshidian‐Tehrani, Atbin (2019). "Update on treatments for nonmotor symptoms of Parkinson's disease—an evidence‐based medicine review". Movement Disorders. 34 (2): 180–198. doi:10.1002/mds.27602. ISSN 0885-3185.
  4. Suchowersky, O.; Reich, S.; Perlmutter, J.; Zesiewicz, T.; Gronseth, G.; Weiner, W. J. (2006). "Practice Parameter: Diagnosis and prognosis of new onset Parkinson disease (an evidence-based review)". Neurology. 66 (7): 968–975. doi:10.1212/01.wnl.0000215437.80053.d0. ISSN 0028-3878.
  5. Albanese, Alberto; Bonuccelli, Ubaldo; Brefel, Christine; Chaudhuri, K. Ray; Colosimo, Carlo; Eichhorn, Tobias; Melamed, Eldad; Pollak, Pierre; Van Laar, Teus; Zappia, Mario (2001). "Consensus statement on the role of acute dopaminergic challenge in Parkinson's disease". Movement Disorders. 16 (2): 197–201. doi:10.1002/mds.1069. ISSN 0885-3185.
  6. Hughes AJ (1999). "Apomorphine test in the assessment of parkinsonian patients: a meta-analysis". Adv Neurol. 80: 363–8. PMID 10410742.