Micrographia

Abstract: A 72-year-old right-handed man with a 12-year history of Parkinson’s disease pre sents with a diminished response to medication and right-sided dyskinesia (involuntary movements). During the past several years, he has been taking multiple drugs for Parkinson’s disease, including a monoamine oxidase inhibitor, amantadine, a dopa mine agonist, and carbidopa–levodopa. He reports that with his current regimen, which includes 1.5 tablets of 25/100 carbidopa–levodopa taken every 2 hours, he has marked reductions in tremor, rigidity, and bradykinesia and substantial improvement in his walking. Despite multiple interval and dose adjustments, however, he also reports 6 hours per day of “off” time, when his symptoms are unresponsive to his current medication regimen. In addition, he has severe, disabling right-sided dyskinesia 4 hours per day. Symptoms affecting his left side are mild and not bothersome. His cognition is excellent, his neurologic examination is otherwise normal, and he has no other coexisting medical conditions. His neurologist refers him to a neurosurgeon for consideration of deep-brain stimulation. T h e C l i nic a l Probl e m Parkinson’s disease typically develops between the ages of 55 and 65 years and oc curs in 1 to 2% of persons over the age of 60 years. 1 Approximately 0.3% of the general population is affected, and the prevalence is higher among men than women, with a ratio of 1.6 to 1.0. 2 Motor manifestations of the disorder commonly include a resting tremor, a soft voice, small handwriting (micrographia), stiffness (rigidity), slowness of movements (bradykinesia), shuffling steps, and difficulties with balance. 3 A classic symptom is resting tremor, although 20% of patients do not have it. 4 Parkinson’s disease also has a multitude of nonmotor manifestations, including disturbances of mood (e.g., depression, anxiety, and apathy), cognition (e.g., frontal-lobe dysfunction, memory difficulties, and dementia), and sleep (e.g., apnea and sleep disorders), as well as autonomic dysfunction (e.g., sexual dysfunction, digestive problems, and orthostasis). 5 One third of patients with Parkinson’s disease lose employment within a year after diagnosis, and within 5 years, a majority are not employed full time. 6 Estimated costs of drug treatment range from $1,000 to $6,000 per patient per year. The annual health care cost per patient ranges from $2,000 to more than $20,000 per year. 7-10 The risk of death from any cause is nearly doubled for patients with Parkinson’s disease, regardless of the duration of the disease. 11 Referral to a neu

Abstract: Objective—To investigate whether micrographia in patients with Parkinson’s disease is lessened either by giving visual targets or by continually reminding them that they should write with a normal amplitude. Methods—Eleven patients with Parkinson’s disease (mean age 65.4 years) were compared with 14 control subjects (mean age 67.1 years). The subjects wrote with a stylus on a graphics tablet. There were three conditions: free writing, writing with dots to indicate the required size,and writing with continuous verbal reminders (“big”). Each condition was performed twice. Results—The patients wrote with a more normal amplitude when given either the visual cues or the auditory reminders. This improvement persisted when,shortly afterwards, the patients wrote freely without external cues. The increase in amplitude was achieved mainly by an increase in movement time rather than in peak velocity. Conclusion—Whereas the visual cues directly specified the required amplitude the auditory reminders did not.One effect of external cues is that they draw attention to the goal, and thus encourage the patients to write less automatically. (J Neurol Neurosurg Psychiatry 1997;63:429‐433)