Title: A Case of Parkinson’s Disease with Multicomplexity
Prepared by Dr Tan Shin Wuei
Supervised by Dr Rosmahani binti Mohd Ali
Mdm YKW is a 76 years lady with following comorbidities, follow up under geriatric clinic Hospital Kuala Lumpur:
1. Idiopathic Parkinson’s disease diagnosed in 2017 with autonomic dysfunction and
concurrent Vascular Parkinsonism (lower limb parkinsonism)
2. Osteoporosis, L1 compression fracture 2022, Fosamax since 2017
3. Dyslipidemia
4. Left external capsule infarct (no neurological deficit)
5. Right Retinal Hole
6. Hypertension
7. Thyroid nodule with subclinical hypothyroidism
8. History of Adjustment Disorder – husband passed away December 2021
9. IHD with 3 vessel disease, STEMI Sept 2022
10. Recurrent admission for Aspiration Pneumonia
December 2022
December 2023- also diagnosed with significant postural hypotension
secondary to autonomic dysfunction
Medication list:
1. Madopar 187.5mg BD (5am, 2pm) 125mg BD (10am, 6pm)
2. Fosamax plus 70mg/5600IU weekly
3. Fludrocortisone 0.1mg bd
4. Mist KCL 15ml od
5. Cardiprin 100mg od
6. Atorvastatin 40mg on
7. Syrup lactulose 15ml on
8. Bisacodyl 5mg od
9. Ravin enema 11/11 PRN
Chronology:
August 2017 (1st Visit)
Madam YKW was referred to rule out Parkinson’s disease in 2017. She first presented with hand tremor and instability since 2016. Slowness of gait was noticed since 2016 and she became clumsier when doing housework, but iADL and bADL were still fully independent. Her main concern during the first review was significant loss of weight from 55 kg to 47kg in 1 year. Otherwise there was no memory impairment, non motor symptoms or constitutional symptoms.
On examination:
BP: 190/106 mmHg
PR: 100 bpm
Thin, frail and temporal wasting (Body weight 47kg)
Lung clear, CVS ejection systolic murmur over left sternal edge
Per abdomen soft, no mass palpable
Palpable neck nodule over left neck.
No breast mass
Scoliosis at midthoracic level
Neurological examination:
All limbs power all 5/5
Cogwheel rigidity over left upper and lower limbs
Sensation was intact
Bilateral Babinski reflexes down going
Bradykinesia over left more than right side
Postural tremor on both limbs, no resting tremor
Gait: no festination gait, reduce arm swing over left upper limb
Glabella tap positive
No hypomimia
No cerebellar signs
Cranial nerve examination: UMN 7th Cranial nerve palsy (no history of stroke)
MMSE 28/30
The diagnosis was explained, and she was started on
1. Madopar 62.5mg TDS (7.30am, 11.30am, 6pm)
2. Lactulose 15mg ON
3. Calcitriol 0.25mcg OD
4. Multivitamin 1/1 OD
5. Amlodipine 2.5mg OD
Question 1:
What is the diagnosis and management?
How do you differentiate between Idiopathic Parkinson’s Disease and vascular
parkinsonism?
September 2017:
During the second visit, she informed that there was no more limb stiffness. However, she only took madopar 62.5 mg BD (8am, 8pm), claiming TDS dose made her sleepier and experienced giddiness during micturition. She became more anxious after the diagnosis of Parkinson’s disease and it worsen after her maid ran away, stealing a huge amount of money from her. There was no memory impairment, no falls and she could pass motion on alternate days. Home BP monitoring range from 120-140/60-80.
On examination:
During examination, her last dose Madopar was 7.30 am and she was examined at 10 am: No parkinsonism: no cogwheel rigidity, bradykinesia, shuffling gait or reduce in arm swing Noted intention tremor over bilateral hand, no resting tremor MMSE 28/30, GDS 2/15, DASS 21- 11/21
Investigations:
CT brain reported as old right basal ganglia infarct, periventricular hypodensity consistent with small vessel ischemic changes. No intracranial hemorrhage or mass.
Tumor marker screen: normal
TFT suggestive of subclinical hypothyroidism
Echocardiogram: LVEF 62%, mild TR
Ultrasound neck showed left thyroid nodule
Discussed regarding aspirin but patient strongly refused to start in view of her husband had history of bleeding stomach ulcer due to aspirin.
Plan:
Madopar was off and trial of propranolol was given.
Question 2:
What is your management for the current visit?
What is the latest evidence regarding starting aspirin in silent brain infarct?
October 2017
Madam YKW complained of feeling tired, having generalized body stiffness and hand tremors on movement. She felt no improvement with propranolol. Otherwise, there was no falls or memory decline.
On examination:
Hypomimia
Gait swaying to left side with reduce arm swing on left arm
Rigidity left more than right
Bradykinesia left more than right
UPDRS: 11/56 (1- speech, facial expression, action tremor, finger tap, posture 2- resting
tremor, rigidity, body bradykinesia)
MMSE 29/30
TUG: 9 seconds
Investigation:
BMD: L1-L3: T score -3.4 BMD 0.670 g/cm2, NOF: T score -3.0, BMD 0.511 g/cm2
Plan:
Restart Madopar 62.5mg TDS and off propranolol
Start Fosamax plus (70mg/5600 IU) weekly
December 2021
Mdm YKW recently visited a private neurologist for a second opinion and Madopar dose was increased to 187.5 mg QID. Since then, she noted abnormal left arm dancing movement that lasted for 20-30 minutes at 4 p.m. almost daily, about 10 minutes before the next dose. She also complained of whole-body ache and headache and reported feeling sad since she had no one to talk to after her husband passed away. There is no suicidal ideation, no memory decline or falls. Her iADL and bADL remained independent.
On examination:
GDS 5/15
Hypomimia
Stooped posture.
Unassisted walk with shuffling gait, reduced arm swing and turn-en-bloc.
There was writhing hand movement over right hand.
She was diagnosed with Adjustment Disorder and the abnormal movement was addressed.
Plan:
Reduced Madopar to 125mg QID (7am, 10am, 1pm, 5pm)
Reassess GDS next TCA
Question 3:
What is this abnormal movement? How would you manage this abnormal movement?
Madam YKW’s gait subsequently becoming slower but she could still walk independently from year 2021 to 2022. She started using walking aid from December 2022. In 2022, her diagnosis was revised to Idiopathic Parkinson’s disease with vascular parkinsonism, noting that bilateral lower limb rigidity becoming more prominent. Madopar dose was maintained at 125 mg TDS from 2021 until August 2023.
August 2023
Mdm YKW fell 1 month prior to the clinic visit in Augst while trying to get up from a wheelchair which was only locked on one side. She had further functional decline- able to self-feed occasionally but most of the time she needed helper to feed her with rice mixed with soup. She had difficulty swallowing which was progressing and noted episodes of coughing with semisolid meal and thin fluid starting early 2023, but no problem in swallowing pills. She spent majority of the time on wheelchair and had difficulty climbing out of bed.
Input by speech therapist: delayed swallowing with good laryngeal excursion, no drops in Sa02. Allowed nectar consistency.
Plan:
Add Madopar 125mg HBS on night 10 pm (on top of Madopar 125mg QID)
Question 4:
How do you manage swallowing in Parkinson’s disease? Any indication for PEG tube referral?
What are the extrinsic and intrinsic risk factors of falls for this patient?
April 2024
Madam YKW was admitted to hospital in December 2023 for aspiration pneumonia and autonomic dysfunction with labile blood pressure. She was started T fludrocortisone 0.1 mg OD and titrated up to 0.1 mg BD. Madopar HBS was stopped and Madopar was adjusted to 187.5 mg BD (5 a.m., 2 p.m.) and 125 mg BD (10 a.m., 6 p.m.).
During the clinic review, it was noticed that the caregiver incorrectly served Madopar after meal. There was no evidence of dyskinesia. She complained of difficulty in breathing and drooling of saliva which required a cup to hold the drooling saliva. Her speech was also becoming more slurred. Since discharge, she had become more agitated and demanding more doses of madopar at home. bADl and iADL were all assisted by her caregiver and she could only take rice with soup. Otherwise, there was no more postural giddiness, no memory decline, and no constipation with daily senokot.
Plan:
Trial of entacapone 200 mg BD and continue the same dose of madopar 187.5 mg BD (5 a.m., 2 p.m.) and 125 mg BD (10 a.m., 6 p.m.).
Question 5:
What is the management of drooling of saliva in Parkinson’s disease?
How do you diagnosed and treat autonomic dysfunction in Parkinson’s disease?
September 2024
Madam YKW stopped taking entacapone after 1 day, claiming she developed panic attack, (described as shortness of breath and chest pain) and symptoms not responding to entacapone. She became more anxious and had brought forward all her madopar timing as she was worried of “off” episodes and worsening of tremors. She couldn’t swallow many pills hence her she only took madopar and cardiprin. She became bADL dependent. She still has high expectation that madopar can make her walk again just like 5 years ago.
On examination:
GDS 1/15
Wheelchair bound, unable to stand without 1 people maximum assistant.
Marked rigidity over bilateral upper limb and lower limb, no resting tremor.
No keen for MMSE assessment
The team discussed with her and her family to stop Fosamax. She was also counselled on switching osteoporosis treatment to denosumab in view of swallowing difficulty. However, she strongly refused to start denosumab; afraid of allergic reaction in view of her history of severe allergic reaction with 1 types of injection medication, unable to recall which medication.
Question 6:
What is your approach on osteoporosis treatment in advanced Parkinson’s disease?
How would you manage patient with advanced Parkinson’s Disease in a geriatric clinic?
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