Parkinson Disease: A Man With Bipolar Disorder and a Resting Tremor
Mindy A. Ledford FNP-C, AP | Methodist Medical Group, Atoka, Tennessee
A 64-year-old White man with a history of bipolar disorder presents to your office with a worsening resting tremor that his wife has become concerned about over the past several months.
The patient reports that his wife has noticed decreased facial expressions for approximately several months. He also reports experiencing impaired balance, an abnormal gait, increasing cognitive impairment and memory loss, and generalized weakness.
While observing the patient, a prominent pill-rolling resting tremor, hypomimia, a mildly stooped posture, and a quick, shuffled gait with decreased swinging of his arms were noted. Upon physical examination, finger tapping with abnormal fine motor movements and low speech volume revealed bradykinesia, muscle stiffness, and resistance with flexion. Extension of the upper extremities indicated rigidity.
Although this patient’s presentation is classic for Parkinson disease, a referral to neurology for further evaluation is the recommendation of the Movement Disorder Society (MDS). While the gold standard to diagnose is based primarily on clinical findings, Parkinson disease requires the presence of bradykinesia accompanied by either a tremor or rigidity. The examination by the specialist is typically administered per the instructions of the MDS-Unified Parkinson Disease Rating Scale which usually takes approximately 30 minutes. Other appropriate imaging can also be utilized to rule out other disease processes, as well.
A shared decision-making approach between the patient and clinician should be employed to decide when to begin pharmacological therapy based on the progression of symptoms, such as the effects on the dominant hand, the presence of significant bradykinesia or gait impairment, and interference with activities of daily living and work while taking into account the patient’s belief on medication.
