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)
Features excluding diagnosis of Parkinson disease
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
s) lease
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)
Differential diagnoses
Î Cerebrovascular disease Î Corticobasal degeneration Î Dementia with Lewy bodies Î Multiple system atrophy Î Progressive supranuclear palsy
Adjuncts to pharmacotherapy
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)
Management of Depression, Psychosis, and Dementia [see Table 1]
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
