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LEARNING OBJECTIVES

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LEARNING OBJECTIVES

Upon completion of the chapter, the reader will be able to:

  1. Describe the pathophysiology of Parkinson's disease (PD) related to neurotransmitter involvement and targets for drug therapy in the brain.

  2. Recognize the cardinal motor symptoms of PD and determine a patient's clinical status and disease progression based on the Unified Parkinson's Disease Rating Scale (UPDRS).

  3. For a patient initiating therapy for PD, recommend appropriate drug therapy and construct patient-specific treatment goals.

  4. Recognize and recommend appropriate treatment for nonmotor symptoms.

  5. Formulate a plan to minimize patient "off-time" and maximize "on-time" including timing, dosage, and frequency of medications.

  6. Recognize and treat various motor complications that develop as PD progresses.

  7. Construct appropriate patient counseling regarding medications and lifestyle modifications for a patient with PD.

  8. Develop a monitoring plan to assess effectiveness and adverse effects of treatment.

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KEY CONCEPTS

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  • Image not available. Parkinson's disease (PD) is a slow, progressive neurodegenerative disease of the extrapyramidal motor system that features classic motor symptoms of tremor, rigidity, akinesia/bradykinesia, and postural/gait instability (TRAP).

  • Image not available. The most useful diagnostic tool is the clinical history, including both presenting symptoms and associated risk factors. The Unified Parkinson's Disease Rating Scale (UPDRS) is used to define the degree of disability.

  • Image not available. The goals of treatment are to maintain patient independence, activities of daily living (ADLs), and quality of life (QOL) by alleviating the patient's symptoms, minimizing the development of response fluctuations, and limiting medication-related adverse effects.

  • Image not available. The treatment of PD is categorized into three types: (1) lifestyle changes, nutrition, and exercise; (2) pharmacologic intervention, primarily with drugs that enhance dopamine concentrations; and (3) surgical treatments for those who fail pharmacologic interventions.

  • Image not available. Drug therapy is aimed at enhancing dopaminergic activity in the substantia nigra. The best time to initiate dopaminergic therapy is controversial and patient specific.

  • Image not available. Medication schedules should be individualized. The doses are divided throughout the day to maximize on time and minimize off time.

  • Image not available. The treatment of nonmotor symptoms should be based on whether they are worse during an off state or potentially related to other neurotransmitter dysfunction.

  • Image not available. As the disease progresses, most patients develop response fluctuations. Treatment is based on optimizing the pharmacokinetic and pharmacodynamic properties of PD medications.

  • Image not available. Patient monitoring should involve a regular systematic evaluation of efficacy and adverse events, referral to appropriate specialists, and patient education.

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Parkinson's disease (PD) is a slow, progressive neurodegenerative disease of the extrapyramidal motor system. Dopamine neurons in the substantia nigra are primarily affected, and degeneration of these neurons causes a disruption in the ability to generate body movements. Cardinal features of PD include tremor at rest, rigidity, akinesia/bradykinesia, and postural instability. There is no cure, and treatment is aimed at controlling symptoms and slowing disease progression.

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EPIDEMIOLOGY AND ETIOLOGY

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PD affects approximately 1 million Americans, with a lifetime risk of developing the disease of 1.5%. The median age of onset is 60 years of age, but ...

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