Parkinson Disease: A Man With Bipolar Disorder and a Resting Tremor

Mindy Ledford, APA | 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.

This patient’s presentation is classic for Parkinson disease. 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 beliefs about medication.