AAN GUIDELINES Bundle

Î Bradykinesia + at least 1 of following: > Muscular rigidity > 4–6 Hz unilateral resting tremor > Postural instability/gait instability (not due to primary visual, vestibular, cerebellar, or proprioceptive dysfunction) Î Depression > Screening: Beck Depression Inventory, Hamilton Depression Rating Scale, Montgomery Asberg Depression Rating Scale > Treatment: consider amitriptyline Î Psychosis Î Treatment: consider clozapine, quetiapine Î Dementia > Screening: Cambridge Cognitive Examination, Mini-Mental State Î Examination > Treatment: consider donepezil, rivastigmine Î Physical/exercise therapy (may improve motor function level, but benefits not sustained when therapy discontinued) Î Speech therapy (may improve speech volume in complications from dysarthria) Adjuncts to pharmacotherapy Management of Depression, Psychosis, and Dementia [see Table 1 ] Î Cerebrovascular disease Î Corticobasal degeneration Î Dementia with Lewy bodies Î Multiple system atrophy Î Progressive supranuclear palsy Differential diagnoses Î Tremor as initial presentation [more benign course/longer response to dopaminergic therapy] Î Older age (57–78 yr) at onset [more rapid motor decline, earlier cognitive decline and dementia] Î Rigidity/hypokinesia as presenting signs [more rapid motor decline, earlier cognitive decline and dementia] Î Associated comorbidities [faster motor decline] Î Male sex [faster motor decline] Features predicting rates of progression of Parkinson disease Î Consider deep brain stimulation of subthalamic nucleus to: > Improve motor function > Reduce motor fluctuations, dyskinesia, and antiparkinsonian medication usage Î Candidate patients: > Levodopa-responsive, non-demented, and neuropsychiatrically intact > Intractable motor fluctuations, dyskinesia, or tremor Surgical option for Parkinson disease [see Table 2] Î Unilateral onset Î Persistent asymmetry of motor signs, mostly affecting side of onset Î Progressive signs/symptoms Î Falls occurring later as disease progresses Î Clinical course of ≥10 yr Î Significant loss of smell (hyposmia/anosmia) Î Excellent response to levodopa and apomorphine challenges Î Severe levodopa induced chorea Î Response to levodopa ≥10 yr Features supporting diagnosis of Parkinson disease [ ≥3 of following for presumptive diagnosis]: Î Tremor associated with voluntary movements or postures, absent at rest Î Symmetry of motor signs at onset Î Falls at presentation or early in disease progress Î Strokes, with stepwise progression of parkinsonian features Î Repeated head injuries Î Encephalitis Î Neuroleptic treatment at onset of symptoms Î > 1 affected relatives Î Sustained remissions Î Early severe autonomic involvement Î Early severe dementia with disturbances of memory, language, and praxis Î Babinski sign Î Cerebellar signs Î Cerebral tumor or communicating hydrocephalus on CT Î Supranuclear gaze palsy Î Negative response to large doses of levodopa (malabsorption excluded) Î MPTP exposure (neurotoxin accidentally produced in illicit manufacture of MPPP, a street analog of opioid meperidine) Features excluding diagnosis of Parkinson disease Î Consider an MAO-B inhibitor as initial treatment for mild symptomatic relief before instituting dopaminergic therapy Î Dopaminergic therapy: > Dopamine agonists: > Fewer motor complications (e.g., wearing off, dyskinesias, on-off motor f luctuations) > More frequent adverse events (e.g., hallucinations, somnolence, edema) > Levodopa > Better improvement of motor disability > No difference in rate of motor complications between immediate- and sustained-release formulations Î Adjunctive therapy: > MAO-B Inhibitors > COMT Inhibitors > Dopamine Agonists Symptomatic therapy for Parkinson disease [see Table 3]

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