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ANKI Neuro > [13] Idiopathic Parkinson's Disease > Flashcards

[13] Idiopathic Parkinson's Disease Flashcards

1
Q

What is Idiopathic Parkinson’s Disease more simply and commonly known as?

A

Parkinson’s Disease

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2
Q

What is Parkinson’s disease?

A

A long-term degenerative disorder of the CNS

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3
Q

What part of the nervous system does Parkinson’s disease mostly affect?

A

The motor system

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4
Q

What are the main pathological features of Parkinson’s disease?

A
  • Cell death in the brain’s basal ganglia
  • Presence of Lewy bodies in neurones
  • Death of astrocytes
  • Increases in microglia in substantia nigra
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5
Q

What cells die in the basal ganglia in Parkinson’s disease?

A

The dopamine secreting neurones of the substantia nigra pars compacta

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6
Q

What percentage of dopamine secreting neurones are affected by the time of death in people with Parkinson’s disease?

A

Up to 70%

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7
Q

What are Lewy bodies?

A

Accumulation of the protein alpha-synuclein

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8
Q

How many major pathways connect the basal ganglia to other brain areas?

A

5

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9
Q

What are the 5 major pathways connecting the brain to the basal ganglia?

A
  • Motor
  • Oculo-motor
  • Associative
  • Limbic
  • Orbitofrontal
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10
Q

Which of the 5 major communicating pathways to the basal ganglia are affected in Parkinson’s disease?

A

All of them

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11
Q

What is the result of the effect Parkinson’s disease has on the communicating pathways to the basal ganglia?

A

It explains many of the symptoms of the disease as the circuits are involved in a wide variety of functions

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12
Q

What functions are affected by Parkinson’s disease’s effect on the communicating pathways to and from the basal ganglia?

A
  • Movement
  • Attention
  • Learning
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13
Q

What is the normal role of the basal ganglia in motor control?

A

It exerts a constant inhibitory influence on a wide range of motor systems

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14
Q

What is the effect of the basal ganglia exerting a constant inhibitory influence on parts of the motor system?

A

Stops them from being active at inappropriate times

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15
Q

What happens to the basal ganglia’s inhibitory effects when a decision is made to perform a particular action?

A

The inhibition is reduced for the required motor system

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16
Q

What facilitates the reduction of inhibition?

A

Dopamine

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17
Q

What is the result of high levels of dopamine?

A

Promotion of motor activity

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18
Q

What is the result of low levels of dopamine?

A

Hypokinesia

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19
Q

What is the result of the hypokinesia caused by dopamine depletion, for example in Parkinson’s disease?

A

Greater exertion of effort required for any given movement

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20
Q

What are the risk factors for Parkinson’s disease?

A
  • Increasing age
  • History of familial PD (younger onset)
  • Mutation in the gene encoding glucocerebrosidase
  • MPTP exposure
  • Pesticide exposure
  • Male
  • Head injuries
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21
Q

What are the main features of Parkinson’s disease?

A
  • Tremor
  • Rigidity
  • Bradykinesia
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22
Q

What is the frequency of the tremor in Parkinson’s disease?

A

4-6 Hz

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23
Q

When is the tremor in Parkinson’s disease present?

A

At rest

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24
Q

What can be done to make the tremor more noticeable in assessing Parkinson’s disease?

A

Get the patient to concentrate e.g. recite months backwards

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25
Q

When is the Parkinson’s disease tremor absent?

A

During activity

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26
Q

Where does the tremor in Parkinson’s disease start?

A

Usually one limb on one side or both limbs on one side

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27
Q

How can the tremor in Parkinson’s disease progress?

A

Can become generalised

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28
Q

How is rigidity assessed in Parkinson’s disease?

A

Seen as an increase in resistance to passive movement

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29
Q

What can rigidity produce in many patients with Parkinson’s disease?

A

Flexed posture

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30
Q

What may cause the rigidity to increase in a patient with Parkinson’s disease?

A

Asking them to perform an action in the opposite limb

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31
Q

What is the term for increased rigidity in Parkinson’s disease when performing a task with the opposite limb?

A

Contralateral synkinesis

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32
Q

How does bradykinesia present in Parkinson’s disease?

A

Slowness of voluntary movement and reduced autonomic movements

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33
Q

When is bradykinesia particularly noticeable in Parkinson’s disease?

A

Reduced arm swing when walking

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34
Q

How can further symptoms of Parkinson’s disease be divided?

A
  • Physical

- Cognitive/psychiatric

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35
Q

What are the extra physical symptoms of Parkinson’s disease?

A
  • Gait disturbance
  • Balance issues
  • Anosmia
  • Nerve pain
  • Urinary incontinence
  • Nocturia
  • Constipation
  • ED
  • Postural hypotension
  • Hyperhidrosis
  • Dysphagia
  • Drooling
  • Insomnia
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36
Q

What gait disturbances may be seen in Parkinson’s disease?

A
  • Difficulty in starting to walk
  • Shuffling gait
  • Unsteadiness on turning
  • Difficulty in stopping
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37
Q

What are the cognitive and psychiatric symptoms of Parkinson’s disease?

A
  • Depression
  • Anxiety
  • Slight memory problems
  • Problems with planning and organisation
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38
Q

What long-term problems may patients with Parkinson’s disease suffer from despite treatment with L-dopa?

A
  • Motor fluctuations
  • Axial problems
  • Parkinson’s disease dementia
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39
Q

What percentage of people experience the long-term problems associated with Parkinson’s disease after L-dopa treatment?

A

50-90%

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40
Q

When may the long-term problems associated with Parkinson’s disease present?

A

After a ‘honeymoon period’ of 5-10 years post L-dopa initiation

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41
Q

What is the problem with long-term motor fluctuations seen in later Parkinson’s disease?

A

They are difficult to treat

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42
Q

What axial problems may be seen in later Parkinson’s disease?

A

Disturbance of gait, speech and balance that don’t respond to Parkinson’s disease medication

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43
Q

What is thought to cause the intractable (with Parkinson’s disease medications) axial problem’s seen in late Parkinson’s disease?

A

Axonal degeneration outside the substantia nigra where dopamine is not the neurotransmitter

44
Q

What are the treatment options for the axial problems of late Parkinson’s disease?

A
  • Physiotherapy
  • Occupational therapy
  • Speech and language therapy
45
Q

What is Parkinson’s disease dementia?

A

Dementia occurring more than one year after diagnosis with Parkinson’s disease

46
Q

What are the three typical features of Parkinson’s disease dementia?

A
  • Presence of Parkinsonism in limbs
  • Frequent visual hallucinations
  • Frequent fluctuations of lucidity
47
Q

Why is Parkinson’s disease dementia difficult to treat?

A

Confusion and hallucinations may be worsened by the treatment for Parkinson’s disease

48
Q

What medications can treat Parkinson’s disease dementia without worsening the Parkinsonism?

A

Atypical antipsychotics

49
Q

Who is less likely to get the long-term problems associated with later Parkinson’s disease?

A

People who are diagnosed after 70

50
Q

How is Parkinson’s disease usually diagnosed?

A

Clinically

51
Q

When may investigations in suspected Parkinson’s disease be helpful?

A

To exclude other causes of the presentation

52
Q

What investigations may be useful in Parkinson’s disease?

A
  • CT or MRI brain
  • SPECT
  • Genetic testing
  • Olfactory testing
53
Q

When might a CT or MRI brain be useful in assessing Parkinson’s disease?

A
  • In patients who fail to respond to therapeutic doses of L-dopa
  • To exclude rare secondary causes
54
Q

When might a SPECT scan be useful in patients with suspected Parkinson’s disease?

A

To diagnose when the tremor cannot be clinically differentiated from an essential tremor

55
Q

Why might genetic testing be needed in patient’s with suspected Parkinson’s disease?

A

To rule out Huntington’s disease

56
Q

Why is olfactory testing useful in suspected Parkinson’s disease?

A

To differentiate it from other Parkinsonian disorders

57
Q

What are the differentials for Parkinson’s disease?

A
  • Lewy-Body dementia
  • Progressive supranuclear palsy
  • Essential tremor
  • Antipsychotic use
  • Multiple systems atrophy
  • Alzheimer’s disease with parkinsonism
  • Metabolic abnormalities
  • Vascular Parkinsonism
  • Toxin exposure
  • Infections
58
Q

How can an essential tremor be distinguished from a Parkinsonian tremor?

A

It is worse on movement

59
Q

If a diagnosis of Parkinson’s disease is suspected what should be done?

A

Refer quickly to a specialist

60
Q

Why should anti-Parkinsonian medications not be withdrawn or allowed to fail suddenly?

A

It can cause acute akinesia or neuroleptic malignant syndrome

61
Q

What may cause anti-parkinosnian medication to fail suddenly?

A

Poor absorption e.g. gastroenteritis

62
Q

What is neuroleptic malignant syndrome?

A

Typically a life-threatening reaction to anti-psychotic medication

63
Q

What are the symptoms of neuroleptic malignant syndrome?

A
  • Fever
  • Altered mental status
  • Muscle rigidity
  • Autonomic dysfunction
64
Q

What is acute akinesia?

A

A life-threatening complication of Parkinson’s disease clinically similar to neuroleptic malignant syndrome

65
Q

What is the first-choice drug for Parkinson’s disease dependent on?

A
  • Age
  • Symptoms
  • Lifestyle
  • Preference
66
Q

What are the main first-line options for treating Parkinson’s disease?

A
  • Levodopa
  • Dopamine agonists
  • MAO-B inhibitors
67
Q

What are the advantages of Levodopa?

A
  • Most improvement in motor symptoms

- Fewer adverse side effects

68
Q

What is the disadvantage with L-dopa?

A

Most motor complications

69
Q

What are the disadvantages of dopamine agonists?

A
  • Less improvement in motor symptoms

- More adverse side-effects

70
Q

What is the advantage of dopamine agonists?

A

Less motor complications

71
Q

What are the advantages of MAO-B inhibitors?

A
  • Fewer motor complications

- Fewer adverse effects

72
Q

What is the disadvantage of MAO-B inhibitors?

A

Less improvement in motor symptoms

73
Q

What should be offered to people with early stage Parkinson’s disease and motor symptoms affecting QoL?

A

Levodopa

74
Q

What should be offered to patients with early stage Parkinson’s disease without motor symptoms affecting QoL?

A

Choice of:

  • L-dopa
  • Dopamine agonists
  • MAO-B inhibitors
75
Q

What should be given to patients and relatives orally and in writing when commencing treatment for Parkinson’s disease?

A

Information about risks and side-effects

76
Q

What are the important risks of starting Parkinson’s disease treatment?

A
  • Impulse control disorders
  • Excessive sleepiness and sudden onset of sleep
  • Psychotic symptoms
77
Q

What drugs to treat Parkinson’s disease cause impulse control disorders?

A

All, especially dopamine agonists

78
Q

What drugs to treat Parkinson’s disease can cause excessive sleepiness and sudden onset of sleep?

A

Dopamine agonists

79
Q

What drugs to treat Parkinson’s disease can cause psychotic symptoms?

A

All, especially dopamine agonists

80
Q

What should be offered as an adjunct to L-dopa if a patient with Parkinson’s disease develops dyskinesia or motor fluctuations?

A

Choice of:

  • MAO-B inhibitor
  • Dopamine agonists
  • COMT inhibitors
81
Q

What should be considered if dyskinesia in Parkinson’s disease is not managed by first-line adjunctive therapies?

A

An ergot-derived dopamine agonist. Failing that amantadine

82
Q

What other management aspects (besides medical) must be considered in a patient with Parkinson’s disease?

A
  • Physiotherapy
  • Occupational therapy
  • Speech and language therapy
  • Nutrition
83
Q

What physiotherapy is required in Parkinson’s disease?

A

Parkinson’s disease specific physiotherapy for those with balance or motor function problems

84
Q

What occupational therapy is require in Parkinson’s disease?

A

Parkinson’s disease specific OT for people having difficulties with ADL’s

85
Q

What group of patient’s with Parkinson’s disease is speech and language therapy good for?

A

People experiencing problems with communications, swallowing or saliva

86
Q

What additional speech and language assistance can be considered for those struggling to communicate with Parkinson’s disease?

A

Alternative and augmentative communication equipment

87
Q

What protein related nutritional measures should a person with motor fluctuations on L-dopa in Parkinson’s disease follow?

A

Eat most protein in the last meal of the day

88
Q

What supplements should people with Parkinson’s disease take?

A

Vitamin D

89
Q

What non-motor symptoms of Parkinson’s disease also require management?

A
  • Depression
  • Drooling of saliva
  • Impulse control disorders
  • Orthostatic hypotension
  • Parkinson’s disease dementia
  • Psychotic symptoms
90
Q

How can depression be managed in Parkinson’s disease?

A

Standard treatments for depression

91
Q

What is the first-line treatment for drooling in Parkinson’s disease?

A

SALT

92
Q

If SALT is ineffective at treating drooling in Parkinson’s disease what can be tried next?

A

Glycopronium bromide

93
Q

Which group of patients with Parkinson’s disease do impulse control disorders tend to develop in

A

Those on any dopaminergic therapy

94
Q

Who with Parkinson’s disease is at an increased risk of developing impulse control disorders?

A

Those with a history of previous impulsive behaviours or history of alcoholism

95
Q

What is the first step of managing impulse control disorders in Parkinson’s disease?`

A

Gradually reducing any dopamine agonists and monitoring for improvement and withdrawal symptoms

96
Q

What should be done to treat impulse control disorders in Parkinson’s disease if modifying dopaminergic therapy is not effective?

A

Offer CBT

97
Q

What steps should be considered when addressing orthostatic hypotension in Parkinson’s disease?

A
  • Review medication

- Consider midodrine

98
Q

What medications can contribute to orthostatic hypotension in Parkinson’s disease?

A
  • Anti-hypertensives
  • Dopaminergics
  • Anticholinergics
  • Antidepressants
99
Q

What can be given to treat Parkinson’s disease dementia?

A

Cholinesterase inhibitors

100
Q

What psychotic symptoms can occur in Parkinson’s disease (as a result of treatment)?

A
  • Hallucinations

- Delusions

101
Q

When should psychotic symptoms in Parkinson’s disease not be treated?

A

If it is well tolerated by the patient and their family

102
Q

How can psychotic symptoms be managed in Parkinson’s disease?

A
  • Reduce dose of Parkinson’s disease medications that may cause them
  • Consider quetiapine
103
Q

What must be taken into account when reducing Parkinson’s disease medications to reduce psychotic symptoms?

A

Possible withdrawal effects

104
Q

Who can quetiapine be given to for psychotic symptoms in Parkinson’s disease?

A

People with no cognitive impairment

105
Q

What can be given if no other treatments are effective at treating psychotic symptoms of Parkinson’s disease?

A

Clozapine

106
Q

What additional referral can be made at any time for patients with Parkinson’s disease?

A

Palliative care referral

107
Q

What are the potential complications of Parkinson’s disease?

A
  • Infections
  • Aspiration pneumonia
  • Bed sores
  • Poor nutrition
  • Falls
  • Contractures
  • Bowel and bladder dysfunction

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