Review
Neurology Series Editor, William J. Mullally, MD
Parkinson's Disease and Parkinsonism

https://doi.org/10.1016/j.amjmed.2019.03.001Get rights and content

Abstract

Parkinson's disease is a progressive neurodegenerative disease characterized by tremor and bradykinesia and is a common neurologic ailment. Male sex and advancing age are independent risk factors and, as the population ages, is taking an increasing toll on productivity and medical resources. There are a number of other extrapyramidal conditions that can make the diagnosis challenging. Unlike other neurodegenerative diseases, idiopathic Parkinson's disease has effective treatments that mitigate symptoms. Medications can improve day-to-day function and, in cases where medication does not give a sustained benefit or has significant side effects, treatments like deep brain stimulation result in improved quality of life.

Section snippets

Clinical Significance

  • Parkinson's disease is the second most common neurodegenerative disorder with only Alzheimer's disease being more prevalent.

  • It is defined primarily by its motor symptoms including tremor, bradykinesia and akinesia but may demonstrate a number of non-motor symptoms such as cognitive decline, depression, anxiety, sleep disturbance and dysautonomia.

  • Treatment of the motor symptoms is accomplished primarily by dopaminergic medications or, more recently, with deep brain stimulation.

Clinical Presentation

Parkinson's disease is manifested by motor and nonmotor symptoms. The classic findings of Parkinson's disease are motor symptoms. These were described in the paper by Hoehn and Yahr6 in 1967 looking at 183 Parkinson's patients. They include resting tremor, bradykinesia, postural instability, and rigidity. Parkinson's disease frequently presents with tremor, usually unilateral. The tremor is typically seen in one extremity initially (sometimes involving only one finger or the thumb). The tremor

Pathology

The pathological hallmark of Parkinson's disease is depigmentation of the substantia nigra and locus coeruleus with neuronal loss in the pars compacta of the substantia nigra. Both apoptosis and autophagy are involved in the process.25 Neuronal loss is also seen in the basal nucleus of Meynert and the dorsal motor nucleus of the vagus nerve. In affected areas, Lewy bodies, which are eosinophilic cytoplasmic inclusion bodies containing alpha synuclein, are noted. The primary cause of Parkinson's

Pharmacologic Treatment

The decision of when to treat a patient with Parkinson's disease is made in collaboration with the patient. When symptoms affect the quality of life (the ability to work or socialize), treatment is started. There is no compelling evidence that starting treatment early has any impact on the progression of the disease, and no treatment confers neuroprotection. The decision to treat is based on the impact of symptoms.

Levodopa was the first effective medication for Parkinson's disease and is still

Functional Neurosurgical Treatment

Before levodopa became the primary treatment for Parkinson's disease (in the early 1960s), some patients received lesions to the thalamus pioneered by Cooper and others.30., 31. Surgical treatment of Parkinson's disease was largely abandoned until the limitations of dopaminergic therapy became apparent. These included motor fluctuations, dyskinesias, hallucinations, and intractable tremor.

There was a resurgence of stereotactic ablative surgery to the thalamus, subthalamic nucleus, and globus

Lewy Body Disease

Lewy body disease is akin to classic Parkinson's disease, clinically and pathologically. Pathologically, in addition to Lewy bodies being found in the striatum, there is widespread involvement of Lewy bodies in cortical neurons, with a relative paucity of the neurofibrillary tangles and amyloid plaques associated with Alzheimer disease.36., 37. The diagnosis is clinical and consists of the appearance of parkinsonian symptoms, dementia, hallucinations and delusions, frequently fluctuating with

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    Funding: None.

    Conflicts of interest: None.

    Authorship: MTH was the sole author of the manuscript.

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