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A 78-year-old man comes to your office complaining that his arm shakes. This had started a year ago and has gotten progressively worse. He noticed that it gets worse when he is nervous, watching TV, or just sitting. It gets better when he is working with his hands. The patient is concerned because his father had a similar disease, which eventually made him senile. He asks you for a cure. He has a mild resting tremor of both hands on examination and a tiny amount of muscular rigidity. He is not orthostatic, and his gait and facial movement are normal. What will you do for this patient?
(A) Levodopa/carbidopa
(B) Amantadine
© Benztropine
(D) Selegiline
(E) Beta-blockers
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(B) Amantadine
Explanation:
The presentation of Parkinson's disease (PD) consists of tremor, rigidity, and bradykinesia. To relieve mild symptoms of the disease, such as in this patient who has a tremor alone, patients can use Amantadine or anticholinergic agents, such as benztropine. Anticholinergic agents should not be used in older patients because they are less able to tolerate the adverse effects such as dry mouth, constipation, blurry vision, confusion, and hallucinations. Anticholinergics are a good choice in younger patients under the age of 60 with a tremor. Amantadine is the answer in this case because he is 78 years old and presents predominantly with a tremor. The tremor typical of essential tremor occurs with action, whereas the tremor of PD occurs at rest, such as in this case.
Patients with more severe disease, but not so severe that it interferes with activities of daily living, can use dopamine agonists, such as pramipexole and ropinirole. They may also have neuroprotective effects as well. Levodopa/carbidopa is used in the most severe forms of the disease and has the most bothersome side effects, such as dyskinesias and behavior abnormalities. Selegiline decreases oxidative damage and may decrease progression of the disease. Selegiline is best used as adjunctive therapy in those receiving levodopa. When the question asks what drug will delay the progression of disease, answer selegiline or the dopamine agonists. Beta-blockers are a wrong choice because they are used to control an "essential" tremor, but not the tremor of PD.
