Peter is a 76-year-old male who was diagnosed with Parkinson's disease 5 years ago. His condition has been worsening, especially over the last 6 months, making daily activities more difficult and causing increased embarrassment. He experiences tremors, stiffness, freezing episodes, difficulty initiating movement, and balance issues. Peter is looking for ways to decrease his symptoms so he can continue his active lifestyle and regular activities in the community.

1. PETER
Peter is a 76-year-old male who was diagnosed with Parkinson’s disease approximately 5 years ago.
He has been referred by his neurologist for a Physiotherapy and Occupational therapy consult. He
lives in a two story row home in Goodwood with his wife, Mary. Peter reports that he had a good
understanding of his disease initially, but now feels confused. He has tried to stay active in order to
maintain his level of function. He is very involved in the community and has many long-time friends.
He has been taking medication, Sinemet (drug given against tremor, weakness and muscle stiffness
caused by Parkinson's disease), for about 3 years and it has “helped tremendously.”
Peter states that his condition has been steadily worsening, especially over the last 6 months. When
he was diagnosed 5 years ago, his right arm and leg seemed stiff and he had trouble moving them.
Now he has more difficulty initiating his movements, especially in the morning and after he gets to the
bottom or top of the stairs. He says, “I get stuck, and I just can’t move.” He also states that it has
been taking him longer and longer to get to where he is going and he is often late for his community
activities, such as attending church, meeting friends for breakfast, and playing cards. He reported
falling twice within a week about 2 months ago, both times tripping over uneven sidewalks. Since
then Mary suggested he carry a cane that she used after her hip replacement surgery ten years ago.
He reports that he is “embarrassed” to use it.
He is experiencing increased shaking, and more recently has had some difficulty eating, holding
cards, and keeping his buttons on the bingo cards. Two weeks ago when he was calling numbers for
bingo, he pushed the wrong numbers several times and was very upset and embarrassed. His wife
reports that he has always carried the bags for their grocery shopping, but recently he has had
difficulty because he is “too tired.” Mary also reports that he has been getting extremely frustrated
with his condition, and wonders if he is depressed, as he has been leaving the house less frequently.
Previous Medical History:
• Benign prostate hypertrophy (normal enlargement of the prostate)
• Gastroesophageal reflux disease (heartburn)
• Hypertension (high blood pressure)
• Parkinson’s disease (PD)
Current medications:
• Terazosin 4mg PO daily (used for treatment of symptoms of an enlarged prostate_
• Omeprazole 20mg PO daily (used to treat gastroesophageal reflux disease)
• Atorvastatin 10mg PO daily (drug used for the treatment of high cholesterol, triglyceride
levels, and prevention of heart attack, strokes)
• Hydrochlorothiazide 25mg PO daily (a diuretic drug that acts by inhibiting the kidneys'
ability to retain water – used to treat high blood pressure)
• Sinemet (carbidopa/levodopa) 50/200 ER PO at 8am, noon, 3pm, and 7 pm
• Sinemet 25/100 IR at 8am, 10am and 5pm (drug given against tremor, weakness and
muscle stiffness caused by Parkinson's disease)
• Azilect (rasagaline) 0.5mg PO daily (used to treat the symptoms of Parkinson's disease).
• Comtan (entacapone) 200mg PO four times daily (used to treat Parkinson's disease)
At Peter’s appointment:
Vital signs:
• Blood pressure 100/68 mmHg
• Heart rate 82/minute
• Respiratory rate 25/minute
• Temperature 37°C
• Height 180cm
• Weight 82kg
On physical examination, Peter demonstrated decreased passive and active range of motion in
bilateral knee extension as well as bilateral shoulder flexion and abduction, the right being worse than
the left. He shows a slight thoracic kyphosis in both sitting and standing posture which can be
minimally corrected with cues, and almost completely corrected with manual assist. He shows
decreased active and passive range of motion in trunk extension, rotation and side bending.
There is limited shoulder range in movement, limitations in elbow extension bilaterally, decreased
flexion in fingers leading to decreased dexterity and coordination and in hand manipulation skills,
problems with fine motor tasks such as grasping utensils, manipulating fasteners, and handling small
items such as money/coins, and cards.
While walking throughout his home, he had some “freezing” episodes. He also displays some
intermittent resting tremors. Mild cogwheel rigidity is evident in all four extremities. Sensation appears
intact throughout.
Equilibrium reactions appear delayed as evidenced when challenged in standing on a flat surface. He
is afraid to stand on a balance beam. He can stand on right leg for 20 seconds with eyes open, on
left for 5 seconds. He starts to fall when he closes his eyes. When walking, there is diminished arm
swing and no trunk rotation. He also has a decreased step length and a slightly narrowed base of
support. Walking is worse when he is tired.
Peter manages his medications now with his wife’s help. He has a regimen of taking all his
medications at 8AM every morning with his breakfast that typically consists of eggs and bacon. He
used to be very good at remembering to take the other Sinemet doses at the scheduled times, but
lately is forgetting.
His activities include: playing cards and bingo 3 days a week at the local senior centre a few blocks
from his home, meeting at a breakfast club 3 days a week at the local diner, attending Sunday and
Wednesday Mass, and walking his dog, Paul, at least twice a day.
Peter likes the current lifestyle that he and Mary have established, especially assisting her in
household duties of shopping, carrying laundry, and chopping/prepping for meals. He is looking for
ways to decrease his symptoms.