Secondary parkinsonism

Answer 1

Definition

Secondary parkinsonism is similar to Parkinson's disease, but it is caused by certain medicines, a different nervous system disorder, or another illness.

Alternative Names

Parkinsonism - secondary

Causes, incidence, and risk factors

Parkinson's disease is one of the most common nervous system (neurologic) disorders of the elderly. "Parkinsonism" refers to any condition that causes Parkinson's-type abnormal movements. These movements are caused by changes in or destruction of the nerve cells (neurons) that produce the chemical dopamine in a certain area of the brain.

Secondary parkinsonism may be caused by disorders such as:

• Encephalitis
• Meningitis
• Stroke

Other disorders can also damage the dopamine neurons and produce this condition, including:

• Corticobasal degeneration
• Diffuse Lewy body disease
• Multiple system atrophy
• Progressive supranuclear palsy

Another common cause of secondary parkinsonism is medication, such as:

• Antipsychotics (haloperidol)
• Metoclopramide
• Phenothiazine medications

If they damage the area of the brain that contains the dopamine neurons, the following may cause secondary parkinsonism:

• Brain damage caused by anesthesia drugs (such as during surgery)
• Carbon monoxide poisoning
• Exposure to toxins
• Overdoses of narcotics

There have been cases of secondary parkinsonism among intravenous drug users who injected a substance called MPTP, which can be produced when making a form of heroin. These cases are rare and have mostly affected long-term drug users.

Secondary parkinsonism caused by antipsychotics or other medications is usually reversible if identified soon enough. However, it may not be reversible if it is caused by:

• Drug-related brain damage
• Infections
• Toxins

Symptoms

Symptoms of parkinsonism may include:

• Decrease in facial expressions
• Difficulty starting and controlling movement
• Soft voice
• Some types of paralysis
• Stiffness of the trunk, arms, or legs
• Tremor

Although cognitive problems are not as common in Parkinson's disease, they may be more likely in secondary parkinsonism. This is because the diseases that cause secondary parkinsonism often lead to dementia.

For a more detailed description of symptoms, see Parkinson's disease.

Signs and tests

The health care provider may be able to diagnose secondary parkinsonism based on your history, symptoms, and a physical examination. However, the symptoms may be difficult to assess, particularly in the elderly.

Examination may show:

• Difficulty starting or stopping voluntary movements
• Increased muscle tone
• Problems with posture
• Slow, shuffling walk (gait)
• Tremors of the Parkinson's type

Reflexes are usually normal.

Tests are not usually specific for secondary parkinsonism. However, they may be used to confirm or rule out other disorders that can cause similar symptoms.

Treatment

Treatment is aimed at controlling symptoms. If the symptoms are mild, no treatment may be needed.

If the condition is caused by a medication, the benefits of the medication should be weighed against the severity of symptoms. Medications should be stopped or changed if the risks outweigh the benefits.

Treating underlying conditions such as stroke or infections can reduce symptoms.

Medications may be used if symptoms interfere with the ability to perform daily activities. The medication, dose, timing, or combination of medications may need to be adjusted as symptoms change.

Many of the medications used to treat this condition can cause severe side effects. Monitoring and follow-up by the health care provider are important. Secondary parkinsonism tends to be less responsive to medical therapy than Parkinson's disease. However, medications are worth trying if the cause of the condition is not treatable.

Medications used to treat symptoms of Parkinson's disease are:

• Levodopa (L-dopa), Sinemet, levodopa and carbidopa (Altamet)
• Pramipexole (Mirapex), ropinirole (Requip), bromocriptine (Parlodel)
• Selegiline (Eldepryl, Deprenyl), rasagiline (Azilect)
• Amantadine or anticholinergic medications (to reduce early or mild tremors)
• Entacapone (to prevent the breakdown of levodopa)

For a more detailed description of treatment, see Parkinson's disease.

Support Groups

See: Parkinson's disease - support group

Expectations (prognosis)

What will happen varies and depends on the cause of the disorder. If the disorder is caused by medications, it may be treatable. All other causes are not reversible and tend to get worse over time.

Complications

• Difficulty performing daily activities
• Difficulty swallowing (eating)
• Disability (varying degrees)
• Injuries from falls
• Side effects of medications

Side effects from loss of strength (debilitation):

• Aspiration
• Deep vein thrombosis
• Malnutrition

Calling your health care provider

Call your health care provider if:

• Symptoms of secondary parkinsonism develop, come back, or get worse
• New symptoms appear, including:
  • Changes in alertness, behavior, or mood
  • Delusional behavior
  • Dizziness
  • Hallucinations
  • Involuntary movements
  • Loss of mental functions
  • Nausea or vomiting
  • Possible side effects of medications
  • Severe confusion or disorientation

Discuss the situation with your health care provider if you are unable to care for the person at home (after treatment begins).

Prevention

Treating conditions that cause secondary parkinsonism may decrease the risk.

Only use medications under a health care provider's supervision. People with conditions (such as schizophrenia) that require long-term use of antipsychotics should be carefully monitored to prevent the development of secondary parkinsonism. Newer antipsychotic medications are less likely to cause secondary parkinsonism.

References

Lang A. Parkinsonism. In: Goldman L, Ausiello D. Cecil Textbook of Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier;2007:chap 433.

Lang AE. When and how should treatment be started in Parkinson disease? Neurology. 2009;72(7 Suppl):S39-43.

Lewitt PA. Levodopa for the treatment of Parkinson's disease. N Engl J Med. 2008;359(23):2468-76.

Answer 2

Definition

Secondary parkinsonism is similar to Parkinson's disease, but it is caused by certain medicines, a different nervous system disorder, or another illness.

The term "parkinsonism" refers to any condition that involves the types of movement changes seen in Parkinson's disease.

Alternative Names

Parkinsonism - secondary; Atypical Parkinson's disease

Causes, incidence, and risk factors

Parkinson's disease is one of the most common nervous system disorders affecting the elderly.

Parkinson's disease occurs when the nerve cells in the brain that make a checmical called dopamine are slowly destroyed. Dopamine helps control muscle movement. Without dopamine, the nerve cells in that part of the brain cannot properly send messages. This leads to the loss of muscle function. The damage gets worse with time. Exactly why these brain cells waste away is unknown.

Secondary parkinsonism may be caused by health problems, including:

• AIDS
• Encephalitis
• Meningitis
• Stroke
• Diffuse Lewy body disease
• Multiple system atrophy
• Progressive supranuclear palsy

Certain medications can cause secondary parkinsonism, including:

• Antipsychotics (haloperidol)
• Metoclopramide
• Phenothiazine medications

Other causes of secondary parkinsonism include:

• Brain damage caused by anesthesia drugs (such as during surgery)
• Carbon monoxide poisoning
• Mercury poisoning and other chemical poisonings
• Overdoses of narcotics

There have been cases of secondary parkinsonism among IV drug users who injected a substance called MPTP, which can be produced when making a form of heroin. These cases are rare and have mostly affected long-term drug users.

Symptoms

Common symptoms include:

• Decrease in facial expressions
• Difficulty starting and controlling movement
• Loss or weakness of movement (paralysis)
• Soft voice
• Stiffness of the trunk, arms, or legs
• Tremor

Confusion and memory loss may be more likely in secondary parkinsonism. This is because the diseases that cause secondary parkinsonism often lead to dementia.

For a more detailed description of symptoms, see Parkinson's disease.

Signs and tests

The health care provider may be able to diagnose secondary parkinsonism after performing a physical exam and asking questions about your medical history and symptoms. However, the symptoms may be difficult to assess, particularly in the elderly.

Examination may show:

• Difficulty starting or stopping voluntary movements
• Increased muscle tone
• Problems with posture
• Slow, shuffling walk
• Tremors

Reflexes are usually normal.

Tests may be used to confirm or rule out other disorders that can cause similar symptoms.

Treatment

If the condition is caused by a medication, your doctor may recommend changing or stopping the medicine. However, the benefits of the medication should be weighed against the severity of symptoms. Medications should be stopped or changed if the risks outweigh the benefits.

Treating underlying conditions such as stroke or infections can reduce symptoms.

If your symptoms make it hard to do everyday activities, your doctor may recommend medication. Many of the medications used to treat this condition can cause severe side effects. It is important that you see your doctor for check-ups. Secondary parkinsonism tends to be less responsive to medical therapy than Parkinson's disease. However, medications are worth trying if the cause of the condition is not treatable.

For a more detailed description of treatment, see Parkinson's disease.

Support Groups

See: Parkinson's disease - support group

Expectations (prognosis)

Secondary parkinsonism caused by antipsychotics or other medications is usually reversible if identified soon enough. However, it may not be reversible if it is caused by:

• Drug-related brain damage
• Infections
• Toxins

All other causes are not reversible and tend to get worse over time.

Complications

• Difficulty performing daily activities
• Difficulty swallowing (eating)
• Disability (varying degrees)
• Injuries from falls
• Side effects of medications

Side effects from loss of strength (debilitation):

• Aspiration
• Deep vein thrombosis
• Malnutrition

Calling your health care provider

Call your health care provider if:

• Symptoms of secondary parkinsonism develop, come back, or get worse
• New symptoms appear, including:
  • Changes in alertness, behavior, or mood
  • Delusional behavior
  • Dizziness
  • Hallucinations
  • Involuntary movements
  • Loss of mental functions
  • Nausea or vomiting
  • Possible side effects of medications
  • Severe confusion or disorientation

Discuss the situation with your health care provider if you are unable to care for the person at home (after treatment begins).

Prevention

Treating conditions that cause secondary parkinsonism may decrease the risk.

People with conditions that require long-term use of antipsychotics should be carefully monitored to prevent the development of secondary parkinsonism. Newer antipsychotic medications are less likely to cause secondary parkinsonism.

References

Lang A. Parkinsonism. In: Goldman L, Ausiello D. Cecil Textbook of Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier;2007:chap 433.

Lang AE. When and how should treatment be started in Parkinson disease? Neurology. 2009;72(7 Suppl):S39-43.

Lewitt PA. Levodopa for the treatment of Parkinson's disease. N Engl J Med. 2008;359(23):2468-76.

Reviewed By

Review Date: 09/26/2011

Luc Jasmin, MD, PhD, Department of Neurosurgery at Cedars-Sinai Medical Center, Los Angeles, and Department of Anatomy at UCSF, San Francisco, CA. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.