AAN GUIDELINES Bundle

Key Points Î Parkinson disease is a progressive neurodegenerative disorder characterized by: > Loss of dopaminergic neurons in the substantia nigra, as well as other dopaminergic and nondopaminergic areas of the brain; > Cardinal motor symptoms of tremor, bradykinesia, and rigidity; > Significant disability and impaired quality of life due to motor complications. Î Parkinson disease is primarily a clinical differential diagnosis from alternative parkinsonian syndromes; e.g., cerebrovascular disease, corticobasal degeneration, dementia with Lewy bodies, multiple system atrophy, progressive supranuclear palsy. Î Features supportive of a diagnosis of Parkinson disease include: > Unilateral onset with persistent asymmetry of motor signs, mostly affecting the side of onset; > Progressive signs/symptoms, with falls occurring later as disease progresses; > Significant loss of smell (differentiates from progressive supranuclear palsy and corticobasal degeneration but not from multiple system atrophy); > Clinical course of ≥10 years with response to levodopa. Î Presumptive diagnosis of Parkinson disease can be confirmed by excellent patient response to levodopa or apomorphine challenge. Î Antiparkinsonian medications are only symptomatic, not neuroprotective. An MAO-B inhibitor can be used as initial treatment for mild symptomatic relief before instituting dopaminergic therapy. Initial dopaminergic therapy is dopamine agonists or levodopa. Dopamine agonists, COMT inhibitors, and MAO-B inhibitors are used as adjunctive therapies to levodopa. Î Long-term treatment with dopaminergic therapies are eventually complicated by: > Off time (periods of return of symptoms when effect of medications wears off ) > Dyskinesia (medication-induced involuntary movements, including chorea and dystonia). Î Deep brain stimulation is a surgical option in appropriate patients to: > Improve motor function; > Reduce motor fluctuations, dyskinesia, and antiparkinsonian medication usage. Î Disease onset at older age and rigidity/hypokinesia as initial symptom can be predictive of: > More rapid rate of motor progression; > Earlier development of cognitive decline and dementia.

• Cover