9. Movement Disorders

Headshot of Dawn Elise DeWitt, MD, MSc, CMedEd, MACP, FRACP, FRCP-London · Senior Associate Dean, Collaboration for InterProfessional Health Education Research & Scholarship (CIPHERS)
Dawn Elise DeWitt
MD, MSc, CMedEd, MACP, FRACP, FRCP-London · Senior Associate Dean, Collaboration for InterProfessional Health Education Research & Scholarship (CIPHERS)
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Watch the movie Awakenings.

Characterize as hypokinetic vs. hyperkinetic 

Hypokinetic disorders: Parkinson disease

  • Bradykinesia + at least one other sx/sign and absence of red flags; head CT to rule out vascular dz or hydrocephalus.
  • Trial of levodopa is often helpful.
  • "Dopamine transporter scans"  or PET-CT are not necessary unless significant dx uncertainty.
  • Other sx include autonomic issues (constipation, sweating, bladder, etc.)
  • May have slow processing, micrographia, sleep problems, depression, anxiety, emotional incontinence (pseudobulbar affect).

Think Parkinson Variant If...

Article on SGP

How to spot ocular abnormalities in progressive supra nuclear palsy? A practical review

MSA formerly known as Shy-Drager syndrome.

Starting medications

  • Patients with a clear dx (>65 y.o.): Levodopa/carbidopa combination medication is first-line therapy.
    • Levodopa (dopamine precursor).
      • Most effective: Use controlled-release for night-time, rapid for on-off sx.
      • Complications: Loss of effect (wearing off) and dyskinesia (invol mvts) affect 50%.
    • Carbidopa, peripheral decarboxylase inhibitor, blocks adverse systemic effects.
  • Other meds are used to control side-effects:
    • Dyskinesia, tremor, fatigue → add amantadine (Glutamate NBMA antagonist).
    • Tremor/dystonia → add anticholinergic (e.g., benztropine); constipation, urinary retention, etc are limiting side-effects.

 

Less frequently used

  • Mild cases: Consider Monoamine oxidase B (MAOB) inhibitors (e.g., selegiline).
  • In younger patients (<65 yo), 1st-line is dopamine agonists: Pramipexole, ropinerole, or cabergoline (decrease levodopa exposure and SE).
  • If neurogenic orthostatic hypotension (Parkinson +), can use droxidopa (norepinephrine precursor) with carbidopa.
    • Also salt, fludrocortisone, or midodrine.
  • Deep brain stimulation (DBS) to subthalamic nucleus and globus pallidus interna → if responding to levodopa but have severe fluctuations or severe tremor.
  • Medication psychosis → reduce levodopa if possible.
  • Pimavanserin (PD-specific) or quetiapine. 

New York Times Article

"The Woman Who Could Smell Parkinson’s," by Scott Sayare, June 14, 2024.
She first noticed the scent on her husband. Now her abilities are helping unlock new research in early disease detection.