15 - Movement Disorders in Older Ps Flashcards
Can children get Parkinsons?
Yes
Although highest instance is in those aged 80-84
What is the role of the basal ganglia?
Involved in control of movement and motor learning
What does the basal ganglia comprise of?
Caudate nucleus
Putamen
Globus pallidus
Substantia nigra
Subthalamic nucleus
What causes Parkinson’s disease?
Loss of dopamine containing neurons in the substantial nigra
Get Lewy bodies in the surviving neurons (clumping of α-synuclein)
Reduction of dopamine leads to movement disorders.
What is it called if you develop dementia at least a year after the onset of Parkinsons?
Parkinons disease with dementia
What would it be if you developed dementia WITHIN 1 year of onset of Parkinsonian symptoms?
Dementia with Lewy bodies
What are the Sx of Lewy body Dementia?
Cognitive impairment
Extrapyramidal Sx
Visual hallucinations
Myoclonus
Anti-Parkinson Rx makes hallucinations and Confusion worse
What is the gold-standard Rx for Parkinsons?
How should this Rx be started?
Levodopa (L-dopa)
Start at a low dose and increase slowly.
What is dopamine dysregulation syndrome?
Impulse control disorder linked to taking dopamine agonists (e.g. Ropinirole).
Can cause things like compulsive gambling, spending, hypersexuality
What Monoamine Oxidase B inhibitor can be given for Parkinsons?
Why is this given?
Rasagiline
Can prolong effectiveness of L-Dopa by decreasing its metabolism
What Rx can be given for complex or late stage PD?
Deep brain stimulation
What is a sudden, stereotyped movement or sound that occurs at an irregular interval?
Tic
What types of tics can you get with Tourette’s?
Motor and vocal tics
What disease presents with chorea + behavioural disorders + dementia?
Huntington’s Disease
Huntington’s is a AD condition. Which chromosome is affected in this condition?
Chromosome 4 - CAG gene
What is a fixed abnormal twisting posture called that may be associated with a jerky tremor?
Dystonia
What can cause dystonia?
Stroke
Brain injury
Encephalitis
PD
HD
Antipsychotics
What is the cause of a benign essential tremor?
GABA dysfunction in the cerebellum
Which drugs are dopamine receptor blocking agents?
Haloperidol
Chlorpromazine
Risperidone
What are the Sx of PD?
Bradykinesa is the single most important identifying factor
However non-motor impairments are of equal importance - e.g. cognitive impairment, sleeping disorders, mood disturbances
Can also get finger taps, microgrphia, intention tremor,
What are the 4 most common motor features of PD?
Fatiguable bradykinesia
Tremor
Rigidity (cogwheel rigidity - a catch when you move their limbs)
Postural Instability (stooped posture with arms held slightly away from the body)
What happens to gait in a P with PD?
Can get shuffling gait - due to shortened stride, loss of heel strike and leaning posture. Can be difficult to cross thresholds.
Do all Ps with PD have a tremor?
Not all - 2/3rds will, 1/3rd won’t. Is usually a resting tremor but some Ps can have atypical tremor.
How can PD affect function?
Can cause loss of manual function - difficulty with handwriting (micrographia), find motor control tasks are difficulty.
Can also cause quiet speech, loss of facial expression and loss of animation.
What scan is used to detect PD?
DAT Scan (Dopamine Transporter Scan)
What are the two clinical motor types of PD?
Tremor predominant
Postural instability and gait disturbance
What are the 5 stages of PD?
1 - Mild Sx
2 - Tremors and stiffness, poor posture and trouble walking
3 - Movement slows, loss of balance
4 - Severe Sx - unable to live alone
5 - walking / standing impossible - confined to bed or wheelchair, can have swallowing / nutritional impairment, incontinence and cog impairment
What are the differentials for a diagnosis of PD?
Vascular Parkinsons
Drug-induced Parkinsons
Demential with Lewy bodies
Other dementias
Essential tremor
What is multi system atrophy?
Multiple system atrophy (MSA) is a rare neurodegenerative disorder characterised by tremors, slow movement, muscle rigidity, and postural instability (collectively known as parkinsonism), autonomic dysfunction and ataxia. This is caused by progressive degeneration of neurons in several parts of the brain including the basal ganglia, inferior olivary nucleus, and cerebellum.
What are the clinical features of multi system atrophy?
Which disease presents with this?
Progressive supranuclear palsy
Which disease presents with
- asymmetrical akinetic rigidity
- cortical signs - apraxia, myoclonus, cortical sensory loss, alien limb
- variable tremor
- cognitive impairment?
Corticobasal degeneration
Which disease presents with
- dementia + motor features
- fluctuating cognition
- visual hallucinations
- motor parkinsonism
- postural hypotension
- lethargy
- misperception and delusions
- REM sleep disorder
Which drug for PD is a dopamine precursor + decarboxylase inhibitor?
Co-careldopa
Which dopamine agonist is given for Parkinsons disease?
Ropinirole
Which MAO-B Inhibitor is given for Parkinsons?
Rasagiline
What COMT Inhibitor is given for Parkinsons?
Entacapone
What drug under “others” is given for Parkinsons?
Amantadine
Which Rx are given as an adjunctive Rx for Parkinsons?
Ropinirole
Rasagiline
Entacapone
What are possible complications of dopaminergic Rx?
What drugs are given for the following non-motor Sx of Parkinsons?
- Postural hypotension
- Excessive daytime sleepiness
- REM Sleep Disorder
- Constipation
- Urinary frequency / incontinence
- Depression
- Hallucination or psychotic Sx
- Dementia
What is an inability to lift feet from floor and step forward - lesion in frontal lobe or basal ganglia.
Apraxia
What gait occurs when P can walk normally / Sx disappear only when distracted?
Astasia
Which gait occurs = impaired coordination due to cerebellar degeneration?
Ataxia
What is a limping gait called?
Antalgic gait
What is a gait called that includes stooping, rigid posture, with short fast steps to maintain centre of gravity?
Propulsive gait (Parkinsonian gait)
What gait involves the knees or thighs crossing in a scissors like pattern?
Scissors gait
Which gait involves a stiff leg whilst the other drags or circumducts? Often also have bent arm. Common in CP, MS.
Spastic gait (hemiplegic gait)
What is a high step gait called?
Neuropathic gait (high steppage gait)
Which gait involves walking without lifting the feet completely off the ground?
Shuffling gait
What is loss of a movement called?
Akinesia
What is a state of excessive restlessness called?
Hyperkinesia
What should we do for a P with sudden onset unsteady gait?
Assess for stroke / TIA
What tests can you do for gradually progressive gait ataxia?
Alcohol Hx
Check B12, Folate, Thyroid
Coeliac screen
What do you worry about with Ps with gait apraxia?
Need to exclude normal pressure hydrocephalus
What sign involves dropping of the pelvis when lifting the opposite leg?
Trendelenburg sign
- due to weak gluteus medius
What are the three areas of the motor cortex?
Primary motor cortex
Premotor cortex
Supplementary motor area
Which tract carries information for voluntary movement?
Corticospinal tract
Which disease causes neurodegeneration -> difficulties with ambulation, muscle weakness, loss of sensation and proprioception and impaired speech. Can present with mental function decline, and loss of reflexes and position sense.
Friedreich Ataxia
What is the commonest cause of death in Ps with Friedrich’s Ataxia?
Hypertrophic cardiomyopathy
What is the most common cause of cerebellar disorders?
Alcoholic Cerebellar Degeneration
What acquired things can cause ataxia?
Systemic disorders
MS
Cerebellar strokes
Traumatic brain injury
Toxins
Alcoholism
Thiamine deficiency (B1)
Coeliac disease
Heatstroke
Hypothyroidism
Vit E deficiency
CO
Heavy metals
Sodium valproate
Antiseizure drugs
Lithium
Phenytoin
Sedatives
What is alcoholic myopathy?
Breakdown of proximal muscles due to nutritional deficiency
What is alcoholic neuropathy?
Deadening of nerves throughout the PNS caused by excessive drinking.
What are the Sx of delirium tremens?
Which assessment tool can you use to assess gat and balance in determining whether Ps are at an increased risk for falls?
Timed Get Up and Go Test
Timed Up and Go Test (TUG)
> 15s = inc risk of falls, needs aids and support
