Clinical Pharmacy & Therapeutics 1

CASE STUDY | PARKINSON’S DISEASE

Date: October 08, 2021

Group #: 5
Members & Task Bermudez, Paula Kristine - I. C and Question 5
Designation
Cuaresma, Jenesis Cairo - I. E and Question 4

Ferrer, Kaye Anne - Summary and Question 6

Hallascon, Quinnie - I. D and Question 3.b.

Lorzano, Julius - Question 1.a and 1.b.

Ordinario, Virlyn Valdez - I. B and Question 1.c and 1.d.

Ragandap, Aira Marie - I. D and Question 3.a.

Torres, Lyka Ryan - I. A and Question 2

I. Disorder Discussion

A. Briefly describe the disorder

Parkinson's disease (PD) is a neurodegenerative disorder that affects nerve cells in the brain
responsible for body movement or specifically the dopamine-producing (“dopaminergic”)
neurons in a specific area of the brain called substantia nigra. When dopamine-producing
neurons die, signs and symptoms such as tremors, slow movements (bradykinesia), muscle
stiffness, alteration of posture and balance, loss of automatic movements, changes in language
and changes in writing (micrographia) occur. The cause of Parkinson's disease is unknown, but
several factors seem to play a role, including genes and environmental triggers. Why? The
researchers have identified specific genetic mutations that can cause Parkinson's disease.
However, they are rare, except in rare cases in many family members with Parkinson's disease.
Environmental triggers are also a cause of Parkinson’s disease because an exposure to certain
toxins or environmental factors can increase the risk of developing Parkinson's later on
however the risk is relatively small. There are also risk factors for Parkinson's disease and
these include age, heredity, gender, and exposure to toxins. In addition, Parkinson's disease is
often associated with these additional treatable problems. These are difficulty thinking,
depression and emotional changes, swallowing problems, chewing and eating problems,
sleeping disorders and problems, bladder problems, and constipation. A person with
Parkinson’s may also experience changes in blood pressure, olfactory dysfunction, fatigue,
pain, and sexual dysfunction. Although there is no cure for Parkinson's disease, medications
can greatly improve the symptoms along with proper diet and exercise. At times, the doctor may
suggest surgery to regulate certain areas of the brain and improve the symptoms like deep
brain stimulation surgery.

B. Pathophysiology

The two hallmark features in the substantia nigra pars compacta are loss of neurons and the
presence of Lewy bodies. There is a positive correlation between the degree of nigrostriatal
dopamine loss and severity of motor symptoms. PD is relatively asymptomatic until profound
depletion (70% to 80%) of substantia nigra pars compacta neurons has occurred. Reduced
activation of dopamine-1 and dopamine-2 receptors results in greater inhibition of the thalamus.
Clinical improvement may be more tied to restoring activity at the dopamine-2 receptor than at
the dopamine-1 receptor. Loss of presynaptic nigrostriatal dopamine neurons results in
inhibition of thalamic activity and activity in the motor cortex. Degeneration of nigrostriatal
dopamine neurons results in a relative increase of striatal cholinergic activity, which contributes
to the tremor of PD.

C. Clinical Presentation & Diagnosis

● Based on the HPI and UPDRS, the patient’s symptoms are consistent with early, mild
Parkinson’s disease.
● Manifestation is somewhat slow and progressively smaller in size indicating signs of
micrographia during motor tests
● Patient’s reduced arm swing, left side rigidity, hand tremor and masked face manifests
Parkinson’s disease symptoms.
● Patient’s motor exam results indicate that there is a progress in bradykinesia and motor
abnormalities with the patient.
● Motor disturbances such as resting tremor (patient’s right side rigidity) and decreased
facial expression and eye blinking are mainly present and observable.
● Rigidity is observed on one side.
● Resting tremor frequently observed.
● No alteration of postural reflexes.
● None of her medications mimic the symptoms of PD.

D. Treatment and Goals (Pharmacological and Non-Pharmacological). Present

pharmacological agents in a table, organized and categorized.

● The treatment's goals are to reduce symptoms, impairment, and side effects while
preserving quality of life. Exercise, adequate diet, and patient and caregiver education
are all important.

PHARMACOLOGICAL NON-PHARMACOLOGICAL

Anticholinergic Medication Healthy eating

- Anticholinergic medications can be - While no one diet or combination of

used alone or in combination with foods has been proven to alleviate the
other antiparkinson medications. symptoms of Parkinson's disease,
Anticholinergic adverse effects several foods may aid. Consuming
include dry mouth, impaired vision, high-fiber foods and drinking enough
constipation, and urine retention. of water, for example, can help
Forgetfulness, disorientation, prevent constipation, which is
drowsiness, depression, and anxiety frequent in Parkinson's patients.
are among the more serious side
effects. Central anticholinergic - A well-balanced diet also contains
adverse effects are more likely in nutrients that may help persons with
patients with preexisting cognitive Parkinson's disease, such as omega-
impairments and the elderly. 3 fatty acids.
Amantadine
- Amantadine can help with tremor,
rigidity, and bradykinesia, although it's
most commonly used to treat L-dopa-
induced dyskinesia. Amantadine side
effects may include Sedation, dry
mouth, hallucinations, dizziness, and
disorientation. A common but
reversible adverse effect is livedo
reticularis (diffuse mottling of the skin
in the upper or lower extremities).
L-dopa and carbidopa
- The most effective medicine available
is l-dopa, which is a precursor to
dopamine. It passes the blood-brain
barrier, unlike dopamine, carbidopa,
and benserazide. L-dopa will
eventually be required for all
Parkinson's disease patients.
➢ L-dopa is converted to dopamine by l-
amino acid decarboxylase (l-AAD) in
the central nervous system (CNS) and
peripherally. Carbidopa or
benserazide can block l-AAD in the
peripheral nervous system, enhancing
CNS penetration of given l-dopa and
reducing dopamine side effects. The
typical maximum tolerated dose of l-
dopa is 1000 to 1500 mg per day.
Long-term motor complications
caused by l-dopa can be disabling.
"End-of-dose wearing off" and "peak-
dose dyskinesias" are the most
common of these. After a year of l-
dopa therapy, the chances of
developing motor fluctuations or
dyskinesias are about 10%. However,
5 to 6 months after starting l-dopa,
motor complications can occur,
especially if high doses are used at
first.
Monoamine Oxidase B Inhibitors
- Selegiline and rasagiline, which are
selective, irreversible MAO-B
inhibitors, are unlikely to cause a
"cheese reaction" (hypertension,
headache) at therapeutic levels
unless dietary tyramine is consumed
Tai chi
- Tai chi is an ancient Chinese type of
exercise that uses slow, flowing
motions to promote flexibility, balance,
and muscle strength. Tai chi may also
aid in the prevention of falls. There
are several types of tai chi that are
appropriate for persons of all ages
and physical abilities.
- Tai chi may enhance balance in
adults with mild to moderate
Parkinson's disease more than
stretching and weight training,
according to a study.
Exercise
- Exercising can help you strengthen
your muscles, improve your flexibility,
and improve your balance. Exercise
can also boost your mood and help
you cope with depression or anxiety.
● Try not to move too quickly.
● Aim for your heel to strike the
floor first when you're walking.
● If you notice yourself shuffling,
stop and check your posture.
It's best to stand up straight.
● Look in front of you, not directly
down, while walking.
Yoga
- Gentle stretching motions and poses
in yoga can help you gain flexibility
and balance. Most stances can be
altered to suit your physical abilities.
 in large proportions. Combining MAO-
B Inhibitors with meperidine or other
opioid analgesics, on the other hand,
is not recommended due to the
danger of serotonin syndrome.

➢ Selegiline inhibits dopamine

breakdown and can lengthen l-on
dopa's time by up to one hour. It
frequently allows for a one-half
reduction in l-dopa dosage. Selegiline
can aggravate underlying dyskinesias
or psychiatric symptoms like
delusions by increasing the peak
effects of l-dopa. L-methamphetamine
and l-amphetamine are selegiline's
metabolites. The oral disintegrating
tablet may offer a better response and
fewer side effects than the standard
version.

➢ Rasagiline also improves the effects

of l-dopa and can be used alone.
Early start could lead to superior long-
term results.It may also add an extra
hour of "on" time each day. It is used
to treat l-dopa motor fluctuations as a
first-line treatment (together with
entacapone).

Catechol-O-Methyltransferase Inhibitors Massage

➢ Tolcapone and entacapone are - Massage therapy can help relax and
used in combination with carbidopa/l- relieve muscle tension.
dopa to block the conversion of l-dopa
to dopamine in the peripheral nervous
system (increasing the area under the
curve of l-dopa by approximately 35
percent ). As a result, "on" time is
increased by 1 to 2 hours, and l-dopa
dosage requirements are reduced. To
avoid inhibiting the routes for normal
catecholamine metabolism, avoid
taking nonselective MAO inhibitors at
the same time. Tolcapone should
only be used in people who are
experiencing fluctuations that aren't
responding to other treatments.
Because entacapone has a shorter
half-life, 200 mg is given up to eight
times a day with each dose of
carbidopa/l-dopa. Adverse
dopaminergic effects can occur, and
they can be managed by lowering the
carbidopa/l-dopa dose. Although
brownish orange urine staining has
been recorded (as with tolcapone),
entacapone has not been linked to
 hepatotoxicity.

Dopamine Agonists

- The ergot derivative bromocriptine

and the non ergots pramipexole,
rotigotine, and Ropinirole are
beneficial adjuncts in patients
experiencing fluctuation in response
to l-dopa. They decrease the
frequency of “off” periods and provide
an l-dopa-sparing effect. The
nonergots are safer and are effective
as monotherapy in mild to moderate
PD and as adjuncts to l-dopa in
patients with motor fluctuations.
➢ Pramipexole is primarily renally
excreted, and the initial dose must be
adjusted in renal insufficiency. A
once-daily extended-release
formulation is available.
➢ Ropinirole is metabolized by
cytochrome P4501A2;
fluoroquinolones and smoking may
alter ropinirole clearance. A once-
daily formulation is available.
➢ Rotigotine patch provides continuous
release over 24 hours, and disposition
is not affected by hepatic or renal
impairment.
➢ Apomorphine is a non ergot
dopamine agonist given as a
subcutaneous “rescue” Injection. For
patients with advanced PD with
intermittent “off” episodes despite
optimized therapy, subcutaneous
apomorphine triggers an “on ''
response within 20 minutes, and
duration of effect is up to 100 minutes.
Most patients require 0.06 mg/kg.
Prior to injection, patients should be
premedicated with the antiemetic.
Trimethobenzamide. It is
contraindicated with the serotonin-3-
receptor blockers.

E. Evaluation of Therapeutic Outcomes

Upon analysis of her medications, three drug-related problems were identified;

Using verapamil together with calcium carbonate can decrease the effects of verapamil;
Rasagiline and verapamil may have additive effects in lowering your blood pressure; Using
pramipexole together with rasagiline may increase side effects such as dizziness, drowsiness,
confusion, and difficulty concentrating. Proper interventions were recommended and the patient
was monitored to ensure the safety and efficacy of the drug therapy. At the same time, the
patient was informed of non-pharmacologic therapy that will help manage his condition. If the
patient will be advised to be discharged, a patient medication education will be given.
II. Case Summary
53 year-old Lisa Farmer presents to the clinic because of a mild tremor in her right hand that
has worsened over the past 6 months and is affecting her work performance. She also
complains about feelings of stiffness, slowness, tremor, and sleep problems. In addition to that
are constipation, loss of sense of smell for about 2 years, decreased libido for 6–8months, night
sweats that cause nighttime awakenings, and very irregular menstrual periods for the past year.
Thus, she was diagnosed with early, mild Parkinson’s Disease and was prescribed Verapamil
SR 180 mg PO every morning for 1 year and Calcium carbonate 600 mg PO every morning and
night. The patient should be guided with the proper use of this medication to avoid unwanted
effects and to maintain the best possible quality of life until her next appointment for outcome
evaluation.

III. Questions

❶ PROBLEM IDENTIFICATION
1.a. List and assess each one of the patient’s complaints. Determine if there are
multiple potential etiologies that could account for the symptoms.
● The patient complains that her work performance has declined due to her tremor
which makes it difficult for her to type on the computer, and have been slower in
making tasks. Based on the complaint, the patient has been experiencing tremor
which is one of the features of Parkinson’s Disease which gives the patient a hard
time to type and can not finish tasks due to it.
● Based on the etiologies that may account for the symptoms, her mother has been
diagnosed with Alzheimer’s Disease which may be genetically acquired, the
Alzheimer’s with Parkinsonism. Moreover, the patient is a 53 years old woman which
is the age of onset of Parkinson’s Disease. Although men are more likely to have PD
than women with a ratio or 2:1, there is still a probability that sex has been an etiologic
reason for acquiring PD.
1.b. Assess the abnormalities in the physical examination and laboratory findings.
● PHYSICAL EXAMINATION
○ The patient is having a small amount of dry yellow scales in her eyebrows
known as seborrheic dermatitis.
○ The patient is having hypomimia or the decreased facial expression, decreased
eye blink, pupils are equally round, react briskly to light and a supranuclear
palsy.
○ The patient has been experiencing depression but in a normal state showing a
3/66 scale in the neurologic examination which results in her sleep and libido
problems.
○ The patient underwent Unified Parkinson Disease Rating Scale (UPDRS)
having a total score of 19.
■ In the first part, the patient had a score of 0/16 on her mentation,
behavior and mood which means the patient is normal.
■ In the second part, the patient has an ADL score of 5/52 which interprets
the patient's mild trouble in handwriting, cutting food, tremors and
dressing.
■ In the third part, the patient has a motor exam score of 7/108 which
interprets a mild problem with her facial expression and overall
bradykinesia.
● The patient has a right-sided rigidity and rest tremor which
appears like a classic pill-rolling tremor.
● The patient has problems with fine motor coordination on her right
side noted by the rapid alternating movement, finger taps, hand
movements and foot tap tests.
○ The patient is somewhat slow and progressively does handwriting in a smaller
size which indicates signs of micrographia.
● LABORATORY FINDINGS - There were no abnormalities in the patient.
1.c. List the cardinal motor and nonmotor symptoms of PD, and describe which signs
and symptoms of PD are present in this patient.

These are the cardinal motor and nonmotor symptoms of PD:

● cardinal motor symptoms
- decreased manual dexterity
- difficulty arising from a seated position
- diminished arm swing during ambulation
- dysarthria (slurred speech)
- dysphagia (difficulty with swallowing)
- festinating gait (tendency to pass from a walking to a running pace)
- flexed posture (axial, upper/lower extremities)
- “freezing” at initiation of movement
- hypomimia (reduced facial animation)
- hypophonia (reduced voice volume)
- micrographia (diminution of handwritten letters/ symbols)
● cardinal nonmotor symptoms
- bladder and anal sphincter disturbances
- constipation
- diaphoresis
- fatigue
- olfactory disturbance
- orthostatic blood pressure changes
- pain
- paresthesia
- paroxysmal vascular flushing
- seborrhea
- sexual dysfunction
- sialorrhea (drooling).

The patient has somewhat slow and progressively in size handwriting which is an indication
of micrographia. In her motor exam, the result shows that she has (mild problems with facial
expression and overall bradykinesia which all fall under cardinal motor symptoms. The patient
also complains of constipation, night sweats (diaphoresis), and decreased libido for 6–8
months which is an indication of sexual dysfunction which are examples of cardinal non-motor
symptoms.

1.d. According to the Hoehn–Yahr Scale, what stage is the patient’s disease?

● According to the Hoehn–Yahr Scale, the patient has stage 1 Parkinson’s disease based
on her symptoms and examinations. Stage 1 of Parkinson's disease is the earliest stage
in which the symptoms of PD are mild and only seen on one side of the body (unilateral
involvement), and there is usually minimal or no functional impairment. The patient has
the symptoms of an intermittent tremor of one hand for many years, didin`t swing one
arm as much as the other while walking, mild problems with facial expression and one
hand may have been clumsier than the other. These symptoms are so mild that the
person doesn’t seek medical attention or the physician is unable to make a diagnosis.

❷ DESIRED OUTCOME

2. What are the goals of therapy for patients with PD?

The goal of pharmacotherapy, in this case, is to:
● Improve motor symptoms or to reduce rigidity and tremor of the patient, improving the
 mobility and the function of a person as well the skills in writing and reversing the slowed
movements (bradykinesia) so that the patient could move freely and fast without a
problem or barrier.
● Maintaining her overall quality of life
● To balance cholinergic and dopaminergic activity in the brain

❸ THERAPEUTIC ALTERNATIVES

3.a. What nonpharmacologic alternatives may be beneficial for the treatment of PD in

this patient both now and in the future?
● Surgical Therapy - Surgery should be considered as an adjuvant to medication when
patients have frequent motor fluctuations, debilitating dyskinesia, or tremor despite
following an optimal medical regimen. A diagnosis of L-dopa–responsive PD and the
absence of cognitive impairment are among the criteria used to choose patients for
surgery. The thalamus, GPi, and the subthalamic nucleus are all targets anatomically
(STN). Deep-brain stimulation (DBS) is the chosen surgical method for bilateral,
persistent, high-frequency electrical stimulation. Both STN and GPi DBS are linked to
improvements in tremor, stiffness, bradykinesia, motor fluctuations, dyskinesia, and
everyday activities; however, STN DBS allows for a higher reduction in drugs. DBS
rarely improves gait or postural instability, as it does with medication.
-
3.b. Based on the patient’s signs and symptoms, what pharmacotherapeutic
alternatives are viable options for her at this time?

Symptoms Treatments

Anxiety - Cognitive behavioral therapy

- Selective Serotonin reuptake
inhibitors
- Venlafaxine
- minimize “off” times

Cognitive Impairment - Eliminate anticholinergic agents

- Add cholinesterase inhibitor

Constipation - Fiber
- Hydration
- Exercise
- Laxatives
- Stool Softeners

Daytime Sleepiness - Proper night time sleep hygiene

- Reduce dose of dopamine agonist
- referral to sleep specialist to rule out
apnea and sleep disorder

Depression - Selective Serotonin reuptake

inhibitors
- Newer generation serotonin
norepinephrine reuptake inhibitor
- Cognitive behavioral therapy

Drooling - Local injection of botulinum toxin

- Atropine
- Sublingual drop
- Glycopyrrolate
- Ipratropium
- Sublingual Spray
Dysphagia - Referral to speech therapist
- Dysphagia diet
- Avoid anticholinergic medications
- Manage Dry Mouth

Fatigue - Caffeine
- Armodafinil
- Modafinil
- Proper night time sleep hygiene
- Referral to sleep specialist to rule
out sleep disorder

Falling - Referral to Physical Therapy

- Assistance with ambulation
- Minimize risk for bone fractures
- Treat Osteoporosis

Hallucinations/Psychosis - Dose Reduction and/or elimination

of adjunctive medications
- Addition of Pimavanserin

Impulse Control Disorder - Discontinue dopamine agonist or

add clozapine
- Quetiapine or Naltrexone

Insomnia - Nonbenzodiazepine GABAa

agonists
- Trazodone

Orthostatic hypotension - Reduce dose of alpha-blockers

- Dopamine agonist
- Diuretics
- Vasodilators
- Abdominal Compression
- Add salt and water diet
- Water boluses
- Fludrocortisone
- Midodrine
- Droxidopa
- Pyridostigmine

Overactive Bladder - Behavioral Therapies

- Antimuscarinic agents
- Mairabegron
- Intradetrusor injections of botulinum
toxin

Pain - Treatment as per type of Pain

- Referral to orthopedics
- Physical Therapy
- Pain Specialist
- Rheumatology

REM sleep behavior disorder - Clonazepam

- Melatonin

Restless legs syndrome - Dopamine agonist at bedtime;

Gabapentin
❹ OPTIMAL PLAN
4. What drug, dosage form, dose, schedule, and duration of therapy are best for this
patient’s current problems?

● Hypertension
- Verapamil SR 180 mg PO every morning
● Mild Parkinson's
- Metamucil one tablespoonful PO twice daily
- Multivitamin one PO daily
- Vitamin D 1000 IU PO daily
- Pramipexole 1 mg PO three times daily
- Rasagiline 1 mg PO daily
● Nutrition and Obesity
- Refer patient to a nutrition counseling and weight loss
● Patient Education
- Parkinson’s Disease
- Nutrition
- Medication education

❺ OUTCOME EVALUATION
5. Which monitoring parameters should be used to evaluate the patient’s
response to medications and to detect adverse effects?

Verapamil

Monitoring: Effectiveness
Parameter Frequency Desired Range

Blood pressure Ongoing by patient; notify none or minimal

provider if noted
Monitoring: Toxicity/ Adverse Reaction

Hypotension Baseline and at every visit. None or minimal. If severe

If the patient can be taught or frequent, decrease the
to perform home blood dose of appropriate
pressure monitoring, antihypertensive.
encourage daily, then
weekly, then monthly
monitoring when stable.

Constipation Ongoing by patient; notify None or minimal

provider if bothersome or
intolerable.

Headaches Ongoing by patient; notify None or minimal

provider if bothersome or
intolerable.

Nausea Ongoing by patient; notify None or minimal.

provider if bothersome or
intolerable.

Rasagiline
 Monitoring: Effectiveness
Parameter Frequency Desired Range

Bradykinesia Ongoing by patient; notify None or minimal

provider if bothersome or
intolerable.

Rigidity Ongoing by patient; notify None or minimal

provider if bothersome or
intolerable.
Monitoring: Toxicity/ Adverse Reaction
Neurologic confusion Ongoing by patient; notify None or minimal. If severe or
provider if bothersome or frequent, decrease the dose
intolerable. of appropriate dopaminergic
agent.

Hallucinations Ongoing by patient; notify None or minimal. If severe or

provider if bothersome or frequent, decrease the dose
intolerable. of appropriate dopaminergic
agent.

Orthostatic hypotension Baseline and at every visit. None or minimal. If severe or

If the patient can be taught frequent, decrease the dose
to perform home blood of appropriate dopaminergic
pressure monitoring, agent.
encourage daily, then
weekly, then monthly
monitoring when stable.

Constipation Ongoing by patient; notify None or minimal

provider if bothersome or
intolerable.

Pramipexole
Monitoring: Effectiveness
Parameter Frequency Desired Range

Bradykinesia Ongoing by patient; notify None or minimal

provider if bothersome or
intolerable.

Rigidity Ongoing by patient; notify None or minimal

provider if bothersome or
intolerable.

Tremors Ongoing by patient; notify None or minimal

provider if bothersome or
intolerable.
Monitoring: Toxicity/ Adverse Reaction
Nausea Ongoing by patient; notify None or minimal
provider if bothersome or
intolerable.

Vomiting Ongoing by patient; notify None or minimal

provider if bothersome or
intolerable.
 Orthostatic hypotension Baseline and at every visit. None or minimal. If severe or
If the patient can be taught frequent, decrease the dose
to perform home blood of appropriate dopaminergic
pressure monitoring, agent.
encourage daily, then
weekly, then monthly
monitoring when stable.

Depression Ongoing by patient; notify If severe or frequent,

provider if bothersome or decrease the dose of
intolerable. appropriate dopaminergic
agent.

Hallucinations Ongoing by patient; notify None or minimal. If severe or

provider if bothersome or frequent, decrease the dose
intolerable. of appropriate dopaminergic
agent.

Tachycardia Ongoing by patient; notify None or minimal. If severe or

provider if bothersome or frequent, decrease the dose
intolerable. of appropriate dopaminergic
agent.

❻ PATIENT EDUCATION

6. What information should be provided to the patient to ensure successful

therapy, enhance compliance, and minimize adverse effects?

Parkinson's disease can't be cured, but medications can help control her symptoms,
often dramatically so it is important to follow the regimen well. Aside from that, it is also helpful
to consider lifestyle changes, especially by doing simple exercises that will work for her. It may
be walking, swimming, gardening, dancing, or stretching. Activities like these may slow the
progression of the disease and improve her balance.

These suggestions may also help:

● Try not to move too quickly.

● Aim for your heel to strike the floor first when she's walking.
● If already shuffling, she must stop and check her posture. It's best to stand up straight.
● Look in front, not directly down, while walking.

In addition to that, some foods may help ease some of the symptoms just like those that are
high in fiber and drinking an adequate amount of fluids may help prevent constipation that is
common in Parkinson's disease. A balanced diet that provides nutrients, such as omega-3 fatty
acids, may also be beneficial for her.

Reference:

● “Treatment Options for Parkinson’s Disease.” WebMD, WebMD, 20 Mar. 2002,

www.webmd.com/parkinsons-disease/guide/parkinsons-treatment-options.
● National Institute on Aging. “Parkinson’s Disease.” National Institute on Aging, 16 May
2017, www.nia.nih.gov/health/parkinsons-disease.
● Elkouzi, Ahmad. “What Is Parkinson’s?” Parkinson’s Foundation, 9 Jan. 2019,
www.parkinson.org/understanding-parkinsons/what-is-parkinsons.
● Moore, William. “What Is Parkinson’s Disease?” WebMD, WebMD, 17 Aug. 2017,
www.webmd.com/parkinsons-disease/parkinsons-disease-overview.
● Brain. “Parkinson's Disease.” Mayfieldclinic.com, 2018, mayfieldclinic.com/pe-pd.htm.
● Mayo Clinic. “Parkinson’s Disease - Diagnosis and Treatment - Mayo Clinic.”
Mayoclinic.org, 2018, www.mayoclinic.org/diseases-conditions/parkinsons-
disease/diagnosis-treatment/drc-20376062.
● Wells, Barbara. Pharmacotherapy Handbook. 7th ed., United States, The McGraw-Hill
Companies, Inc., 2009.
● MediLexicon International. (n.d.). Parkinson's treatment: Medication, therapy, alternative
remedies. Medical News Today. Retrieved October 7, 2021, from
https://www.medicalnewstoday.com/articles/323462#alternative-remedies