Supplemental Reading

Grutzendler J and Morris JC. Cholinesterase inhibitors for Alzheimer's disease. Drugs 2001;61:41-52.

Mark MH. Treatment of Parkinson's disease. Med Lett 2001;14:151-161.

Olanow CW and Tatton WG. Etiology and pathogenesis of Parkinson's disease. Annu Rev Neurosci 1999;22:123-144.

Selkoe DJ. Alzheimer's disease: Genes, proteins and therapy. Physiol Rev 2001;81:741-766.

Case Study Early-Stage Parkinsonism

M. S. is a 60-year old architect who designs buildings. His drawings are very detailed and they must be drawn to a specific scale. During the past month he has developed a slight tremor in his right hand that causes some embarrassment but does not interfere with function. He has, however, noticed that his writing and drawing have gotten much smaller, causing problems with his work. His primary care physician has referred him to a neurologist for evaluation. On examination, the neurologist notes some motor rigidity in the right arm. He also observes a slight slowing in the patient's walk and a reduction in the swing of his arms as he walks. What is the diagnosis, and how should the patient be treated?

Answer: The patient is in early-stage parkinsonism, most likely idiopathic (Parkinson's disease). Clinically, the disease is very mild and the neurologist might consider not treating him at this point, but because the micrographia interferes with his work, the neurologist decides to prescribe medication. Several drugs can be used to treat early-onset parkinsonism. The most commonly used are the dopamine receptor agonists (pramipexole, ropinirole, pergolide; amantadine is also a possibility, and some people get an acceptable response to selegiline, the MAO inhibitor). Levodopa-carbidopa could also be used; however, most clinicians prefer to delay its use until absolutely needed because of the adverse effects, such as motor fluctuations and dyskinesias, that accompany long-term use of levodopa.

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