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Parkinson's disease and tremor
Parkinson's is a clinical diagnosis: slowness of movement (bradykinesia) with rest tremor or rigidity, usually asymmetric; levodopa (with carbidopa) is the most effective drug, and drug-induced parkinsonism is always excluded before labelling.
Why it matters in the exam
The question presents an older adult with a "pill-rolling" tremor of one hand at rest, a short-stepped gait, an expressionless face and handwriting that keeps shrinking. The important distinction is from essential tremor: tremor with action and posture, two-sided, sometimes of the head and voice, with a family history and mild improvement with alcohol — treated with propranolol or primidone. Drug-induced parkinsonism (haloperidol, metoclopramide, prochlorperazine) is usually symmetric and improves when the drug is stopped. No test diagnoses Parkinson's; MRI serves to exclude other causes when the picture is atypical.
Levodopa is the first choice in most patients; dopamine agonists (pramipexole, ropinirole) may cause impulse-control disorders (gambling, shopping) and sleepiness; anticholinergics are avoided in the elderly (confusion). Levodopa must never be stopped abruptly — a state resembling neuroleptic malignant syndrome. Psychosis in Parkinson's is treated with quetiapine or clozapine — not haloperidol. Signs that suggest atypical parkinsonism: early falls and vertical gaze palsy (PSP), early autonomic failure (MSA), dementia and visual hallucinations in the first year (Lewy bodies), and a poor response to levodopa. Beyond movement, the disease includes non-motor symptoms that sometimes precede it by years: constipation, loss of smell, depression, REM sleep behaviour disorder and a fall in blood pressure on standing — and it is important to ask about and treat them. Physiotherapy and regular exercise improve gait and reduce falls.
Key points
- Bradykinesia + rest tremor or rigidity — a clinical diagnosis.
- Levodopa with carbidopa is the most effective.
- Essential tremor: with action — propranolol.
- Psychosis: quetiapine or clozapine; not haloperidol.
- Agonists: impulse disorders; do not stop levodopa abruptly.
Summary table
| Condition | Clue | Treatment | Exam note |
|---|---|---|---|
| Parkinson's | Bradykinesia + rest tremor or rigidity, asymmetric | Levodopa with carbidopa | A clinical diagnosis |
| Essential tremor | Action tremor, two-sided, head and voice, family | Propranolol or primidone | Improves with alcohol |
| Drug-induced parkinsonism | Haloperidol, metoclopramide, symmetric | Stop the drug | Always ask about drugs |
| Agonist side effects | Gambling, shopping, sleepiness | Lower the dose | Pramipexole, ropinirole |
| Psychosis in Parkinson's | Hallucinations | Quetiapine or clozapine | Not haloperidol |
| Atypical | Early falls, vertical gaze, autonomic failure, early dementia | Refer to a neurologist | Poor response to levodopa |
Free exam questions
בן 60 סובל מרעד דו- .צדדי סימטרי בפעולה, הגורם להפרעה תפקודית משמעותית טופל בשלושה קווי טיפול ללא הטבה מספקת. כעת מועמד להשתלת קוצב DBS (. Deep brain stimulation ) לאיזה מבנה אנטומי יוכנסו האלקטרודו ת על מנת לקבל את התוצאה המיטבית? (the question as examined, in Hebrew)
- א. Ventro medial Thalamic Nucleus
- ב. Anterior Thalamic Nucleus
- ג. Subthalamic Nucleus
- ד. Head of Caudate
מה נכון לגבי מיפוי DaT ? (the question as examined, in Hebrew)
- א. לא מבדיל בין חולים במחלת פרקינסון לבין חולים בתסמונות פרקינסון פלוס
- ב. הוכח כיעיל לבדיקת סקר למחלת פרקינסון ולניטור התגובה לטיפול
- ג. לא מבדיל בין חולי אלצהיימר לבין חולים בדמנציה עם גופיפי לואי )DLB
- ד. לא מבדיל בין חולים פרקינסוניים לבין חולים עם רעד ראשוני) Essential Tremor
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Sources
- MDS Clinical Diagnostic Criteria for Parkinson's Disease, 2015 — Core features, red flags, atypical parkinsonism
- NICE Guideline NG71: Parkinson's disease in adults, 2017 — Treatment and non-motor symptoms
- Harrison's Principles of Internal Medicine, 21st edition (2022) — Parkinson's Disease
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.