September 2010 Volume 13 Number HIGHLIGHTS Supplement to Pharmacy Today Recognizing the Early Signs of Parkinson Disease and Optimizing Patient Outcomes Introduction Parkinson disease (PD) is the second most common neurodegenerative disorder after Alzheimer disease.1 Approximately million people in the United States have PD, and 50,000 to 60,000 new cases are diagnosed annually.2 Although characterized by motor symptoms, specifically tremor, rigidity, bradykinesia, and postural instability,1 PD has an insidious onset. Nonmotor symptoms may appear a decade or more before the onset of motor symptoms and are often present long before a definitive diagnosis of PD is made.3,4 Recognizing nonmotor symptoms and early motor symptoms can enable pharmacists to collaborate effectively with physicians to intervene sooner and help maintain quality of life. symptoms of PD are constipation, rapid eye movement sleep behavior disorder (RBD), olfactory impairment, and cardiac sympathetic denervation.11 RBD is characterized by the unconscious acting out of dreams. About half of patients with RBD develop PD.12 Constipation (<1 bowel movement daily) is associated with a nearly threefold increase in risk of PD in men.13 Cardiac sympathetic denervation probably occurs in most if not all patients with PD.11 This condition is defined as a loss of functional cardiac sympathetic nerve terminals, represented by abnormal blood pressure response to the Valsalva maneuver. It also can be referred to as long QT syndrome. Olfactory impairment (altered sense of smell) is a common early symptom that distinguishes PD from other parkinsonian syndromes.14 Pharmacists may be able to recognize early PD by being aware of the medications patients are using or complaints they have related to early nonmotor symptoms of PD. For instance, a patient may purchase several over-the-counter (OTC) remedies for constipation or have concerns about an altered sense of smell. A patient with cardiac sympathetic denervation may have episodic or persistent orthostatic hypotension,15 which pharmacists can recognize from complaints of fatigue, lightheadedness, and dizziness, particularly if these symptoms occur when the patient arises from a seated or supine position. These scenarios present pharmacists with opportunities to question patients about other nonmotor symptoms that may be early manifestations of PD. Cardinal Motor Signs and Other Symptoms of PD Tremor, rigidity, bradykinesia, and postural instability are the four cardinal signs of PD16; however, patients may have PD for years or even decades before the signs develop. These and other motor symptoms of PD are typically unilateral at onset, but usually become asymmetrically bilateral with disease progression. Tremor in PD commonly is more prominent when a patient is still or at rest. Rigidity is nearly universal in people with PD. A patient with rigidity may complain of muscle pain or soreness. Bradykinesia is a slowness of movement. Postural instability causes Pathophysiology PD is caused by the deterioration or loss of dopamine-producing neurons in the brain.5 This damage and consequent cell death occur in the substantia nigra region for an estimated years before any motor symptoms develop.6 In other areas of the brain, such as the medulla oblongata and pontine tegmentum, this damage is believed to occur even before the substantia nigra is affected.7 By the time motor symptoms appear, approximately 70% to 80% of dopaminergic neurons have already been lost.8 PD tends to be a disease of older people (>65 years of age), and rarely occurs before 40 years of age.9 Symptoms of early PD are often nonspecific and frequently attributed to Over time, people lose dopaminergic neurons in the substantia nigra, but in individuals with PD, this process is accelerated.10 Early Nonmotor Symptoms of PD The most common early nonmotor This issue of HIGHLIGHTS NEWSLETTER is based on the educational session Recognizing the Early Signs of Parkinson Disease and Optimizing Patient Outcomes presented by Melody Ryan, PharmD, MPH, and Stephen M. Setter, PharmD, DVM, CDE, CGP, FASCP, at APhA2010, the American Pharmacists Association Annual Meeting Exposition. Dr. Ryan and Dr. Setter also served as content reviewers for this publication. Continuing Pharmacy Education (CPE) Credit Available! 2010 by the American Pharmacists Association. All rights reserved. Printed in U.S.A.