Alternate Names: Parkinsonism - secondary

Causes and Risks:

Parkinson’s disease is one of the most common neurologic disorders of the elderly. The term "parkinsonism" refers to any condition that causes any combination of the types of movement abnormalities seen in Parkinson’s disease.

Secondary parkinsonism may be caused by disorders such as a stroke, encephalitis, or meningitis. Other neurodegenerative disorders such as progressive supranuclear palsy, corticobasal degeneration, and multiple systems atrophy.

Medications including tranquilizers (such as haloperidol), metoclopramide, and phenothiazine medications; exposure to narcotics or anesthesia agents (such as for surgery); exposure to toxins, carbon monoxide poisoning, recreational use of MPTP or other drugs (a common cause in adolescents); or it may occasionally be caused by other conditions.

Secondary parkinsonism caused by medications is usually reversible. If it is caused by toxins, infections, or disorders it may or may not be reversible.

Parkinsonism causes abnormality of movements due to dysreguation of neurotransmitters in the brain. The most common abnormality is in dopamine. This may result in stiffness of the trunk, arms or legs, a decrease in facial expression, tremor as well as other symptoms.

Although cognitive dysfunction is not a major feature of Parkinson's disease, it may be more prominent in secondary parkinsonism as the diseases that cause secondary parkinsonism more commonly also result in dementia.

Prevention: The treatment of conditions that may cause secondary parkinsonism may decrease the risk of its development. Medication use should only be under the supervision of the health care provider. Some cases may not be preventable.

Symptoms: Initial symptoms may be mild and nonspecific (such as mild tremor, slight feeling that one leg/foot is stiff or dragging).

• Muscle rigidity:
  • Stiffness
  • Difficulty bending arms or legs
• Posture may be unstable, stooped, or slumped over
• Movement difficulties:
  • Loss of balance
  • Gait (walking pattern) changes
  • Shuffling
  • Slow movements
  • Difficulty beginning to walk, difficulty initiating any voluntary movement
  • Small steps followed by the need to run to maintain balance
  • Freezing of movement when the movement is stopped, unable to resume movement
• Muscle aches and pains (myalgia)
• Muscle cramps and dystonia
• Shaking, tremors (varying degrees, may not be present):
  • May occur at rest or at any time
  • May become severe enough to interfere with activities
  • May be worse when tired, excited, or stressed
  • Finger-thumb rubbing (pill rolling tremor) may be present
• Changes in facial expression:
  • Reduced ability to show facial expressions, "mask" appearance
  • Staring
  • Eye movement abnormality (difficulty moving eyes up and down)
  • May be unable to close mouth
• Voice or speech changes:
  • Slow speaking
  • Low pitched voice
  • Monotone
  • Difficulty speaking
• Difficulty chewing or swallowing
• Loss of fine motor skills:
  • Difficulty writing, may be small and illegible
  • Difficulty eating
  • Difficulty with any activity that requires small movements
  • Frequent falls
• Mild decline in intellectual function (may occur)

• Depression
• Confusion
• Dementia

Signs and Tests: The health care provider may be able to diagnose secondary parkinsonism based on the patient’s history, presenting symptoms, and physical examination. However, the symptoms may be difficult to assess, particularly in the elderly. For example, the tremor may not appear when the person is sitting quietly with the arms in the lap. The posture changes may be similar to osteoporosis or other changes associated with aging. The lack of facial expression may be a sign of depression.

Examination may show increased muscle tone, tremors of the Parkinson’s type, and difficulty initiating or completing voluntary movements. Reflexes are usually normal.

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

Treatment:

The treatment is aimed at control of symptoms. If the symptoms are mild, no treatment may be required.

If the condition is caused by a medication, the benefits of the medication may be weighed against the severity of symptoms. If appropriate, medications may be stopped or changed by the health care provider.

Treatment of underlying conditions (such as stroke, infections) may reduce symptoms.

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

Many of the medications may cause severe side effects, so monitoring and follow up by the health care provider are important. As a rule, response in secondary parkinsonism is less responsive to all medical therapy compared to Parkinson’s disease.

Medications include:

• Amantadine or anticholinergic medications
• Levodopa/carbidopa
• Dopamine agonists

Prognosis: The outcome varies and depends on the cause. If the disorder is caused by medications, it is potentially treatable. All other causes are not reversible and, to a greater or lesser degree, progressive.

Complications:

• Disability, varying degrees
• Difficulty swallowing (eating)
• Difficulty performing daily activities
• Injuries from falls
• Side effects of medications
• Debilitation and associated conditions:
  • Malnutrition
  • Aspiration
  • Deep vein thrombosis

Call your health care provider if symptoms of secondary parkinsonism recur, worsen, or progress.

Call your health care provider if new symptoms appear in a person with this disorder, including possible side effects of medications: involuntary movements, nausea/vomiting, dizziness, changes in alertness/behavior/mood, severe confusion or disorientation, delusional behavior, hallucinations, loss of mental functions, or any other new symptoms that develop (see also the specific medication).

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