Question

L.C. is a 78-year-old Caucasian man with a 4-year history of Parkinson’s disease (PD). He is a retired engineer, is married, and lives with his wife in a small farming community. He has 4 adult children who live close by. He is taking carbidopa-levodopa, pergolide, and amantadine. L.C. reports that overall he is doing “about the same” as he was at his last clinic visit 6 months ago. He reports that his tremor is about the same, his gait is perhaps a little more unsteady, and his fatigue is slightly more noticeable. L.C. is also concerned about increased drooling. The patient and his wife report that he is taking carbidopa-levodopa 25/100 mg (Sinemet), 1 tablet an hour before breakfast and 1 tablet 2 hours after lunch, and carbidopa-levodopa 50/200 mg (Sinemet CR), 1 tablet at bedtime. On the previous visit they were encouraged to try taking the carbidopa-levodopa (Sinemet) more times throughout the day, but they report that he became very somnolent with that dosing regimen. He also reports that his dyskinetic movements appear to be worse just after taking his carbidopa-levodopa.

1. What are the clinical manifestations of Parkinson’s disease? Place a * net to the symptoms L.C. has mentioned.

2. L.C.’s wife asks you, “How do the doctors know L.C. has Parkinson’s disease? They never did a lot of tests on him.” How is the diagnosis of PD made?

3. Levodopa is always given in combination with carbidopa. Why?

4. L.C.’s wife asks, “They can do surgery for everything else. Why can’t they do surgery to fix Parkinson’s? What types of surgical treatments are available for patients with PD?

5. You are a case manager. Identify things you would assess to determine if L.C. could be cared for in his home.

Answer 1

Parkinson’s disease:

The clinical manifestations of Parkinson’s disease include:

• Tremor: A tremor, or shaking, usually begins in a limb, in the hand or fingers. A pill-rolling tremor is the rubbing of thumb and fore finger back and forth. The hand may tremor when it's at rest.
• Bradykinesia (Slowed movement). The slowing of the movement occurs over the time and this makes even simple tasks, difficult to perform. The steps become shorter, when the person walks and he may drag the feet while walking. It may be difficult to get out of a chair.
• Muscular rigidity: It can occur anywhere in the body and it’s painful. This restrict the range of motion.
• Lack of balance and posture: Your posture may become stooped, or you may have balance problems as a result of Parkinson's disease.
• Dcreased unconscious movements: like blinking, smiling, arm swinging etc..
• Changes in Speech:   The speech will be soft, quick, slur or hesitant. Its monotonous without normal inflections.
• Changes in Writing: It may become hard to write, and the writing may appear small.

The symptoms on the patient:

• tremor
• Increased drooling
• Unsteady gait
• Dyskinesia

2. Diagnosis

The diagnosis is based on the medical history, signs and symptoms and neurological and physical examination.
SPECT acan called a Dopamine Transporter (DAT) scan can be done.

Blood tests to rule out any other diagnosis.

Imaging tests like MRI, CT, USG and PET scans are used to rule out other diseases, not to diagnose Parkinson’s disease.

3. Levodopa is always given in combination with carbidopa. Why?

Carbidopa protects Levodopa from early conversion to Dopamine outside the brain, in the body. This prevents side effects of Levodopa like nausea.

So levodopa is always given in combination with Carbidopa.

4. What types of surgical treatments are available for patients with PD?

DBS (Deep brain stimulation) is the surgical management of Parkinson’s disease. In this procedure, surgeons implant electrodes into a specific part of your brain. The electrodes are connected to a generator implanted in your chest near your collarbone that sends electrical pulses to your brain and may reduce your Parkinson's disease symptoms.

DBS is useful in advanced conditions, as this can stabilize the medication fluctuations, reduce dyskinesia, tremor and rigidity.

5. Home care note:

• Provide nutritious diet with high fiber and fluids.
• Make him do regular and simple exercise to promote muscular relaxation
• Take measures to avoid falls
• Assist in activities of daily living
• Alternative therapeutic methods like yoga, meditation, massage , pet therapy also improves the quality of client’s life.