Emergency Diagnosis and Management

Although most PD patients present to the ED already diagnosed, some might present undiagnosed with motor or sensory symptoms that may not be related immediately to the diagnosis of PD. Patients may experience motor symptoms such as freezing episodes, dysphagia, or abnormalities of whole-body movement. Sensory complaints may include akathesias, paresthesias, muscles aches, or extremity pain. Although severe pain is usually related to the loss of medication efficacy, it can be the prominent symptom of undiagnosed PD.

Complications related to the motor, gait, and truncal disability of PD include deep venous thrombosis, pulmonary embolism, aspiration pneumonia, and compressive neuropathies. Trauma related to falls is common. Autonomic disturbances such as orthostatic hypotension, intestinal motility disorders, and bladder dysfunction can occur. Facial seborrhea also is common. Behavior abnormalities caused by frontal lobe dysfunction and dementia also are seen.

Dyspnea, respiratory distress, and pneumonia are more likely during the "off" periods, when drug efficacy is reduced. The most common cause of death in severe PD is respiratory failure.

Dopaminergic therapy toxicities can include psychiatric and sleep disturbances, cardiac dysrhythmias, orthostatic hypotension, dyskinesias, and dystonias. Patients may manifest lingual, facial, or bucchal dystonias and can demonstrate choreic movements similar to those seen with Huntington's chorea or tardive dyskinesia. These drug effects unfortunately are relatively common but can be alleviated with a drug holiday or a decrease in levadopa dosage. Depression and panic attacks are also common, independent of dopaminergic therapy.

Psychiatric complication can occur with dopaminergic therapy, including sleep disturbances, vivid nightmares, auditory and visual hallucinations, paranoia, and frank psychosis. The severity of psychiatric side effects, especially visual hallucinations, is related to the treatment dose and duration and can be improved by a drug holiday or a reduction in drug dosage. Psychotropes that are known to cause tardive dyskenesia, such as haloperidol, must be used cautiously in patients with PD due to an increased risk of this complication.

Adjustment of chronic PD therapies should be done in consultation with the patient's primary care physician, who can help determine which symptoms reflect dopaminergic excess and whether prior drug holidays have improved the patient's symptoms.

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