Clinical Presentation of Parkinson's Disease & Atypical Parkinson's Disease

Question 1

What can movement disorder be classified into?

Answer 1

1. Hypokinetic: too little movement

2. Hyperkinetic: too much movement

Question 2

What is Parkinson’s disease?

Answer 2

• Described in 1817 by James Parkinson in an essay on ‘’The Shaking Palsy’’
• It is now recognised that Parkinson’s disease has idiopathic and genetic forms, both autosomal dominant and recessive
• Idiopathic forms come at the age of 60-70 – there is not one single cause

Question 3

What are the clinical features of Parkinsonism?

Answer 3

1. Akinesia
2. Rigidity
3. Tremor
4. Postural Abnormality

Question 4

What is Akinesia?

Answer 4

Lack of movement, spontaneous movement are slow

- Get them to do a repetitive movement

Question 5

What is Rigidity?

Answer 5

• Stiffness
• Increase in the tone of a body part e.g. Upper motor neuron is damaged, spasticity
• E.g. move arm about and legs – floppiness to the limb

Question 6

What is Tremor?

Answer 6

• Rest tremor – hand is at rest, or that body part is at rest
• Where it is and the activation that causes it
• Rest leg tremor, tongue tremor- Parkinsonism

Question 7

What is Epidemiology of PD?

Answer 7

• Lifetime risk of 1 in 40
• Prevalence of Parkinson’s disease is approximately 1 in 500
• Most often presents in the 6th or 7th decade of life
• Incidence rises with age
• 5% of cases start below the age of 40

Question 8

What are the early ‘non-motor’ features?

Answer 8

1. Olfactory loss
2. REM sleep behaviour disturbances
3. Constipation
4. Memory/mood, speech, swelling, urine and bladder function, pain, fatigue

Question 9

When do motor symptoms/signs typically start?

Answer 9

Asymmetrically

• Asymmetric onset
• Symmetric conditions - atypical parkinsonism

Question 10

What are the profound psychotic features?

Answer 10

• Late in the condition
• Delusion jealousy
• Paranoid ideas

Question 11

What is the core feature of parkinsonism and what does it encompass?

Answer 11

1. Akinesia
   - Bradykinesia: slowness of movement
   - Poverty of movement
   - Progressive fatiguing and decrement of repetitive movement
   - Difficulty with initiating movement

Question 12

What are examples of Rigidity?

Answer 12

• Often ‘’lead-pipe’’, mostly equal in flexors and extensors, as opposed to pyramidal increase in tone – ‘’clasp-knife’’, e.g. after stroke
• ‘’cog-wheel’’ rigidity occurs when rigidity and tremor combine

Question 13

Tremor

Answer 13

• Typically, a 3-6Hz rest tremor, usually affecting the hands (‘’pill-rolling’’)
• Sometimes a 6-10Hz postural tremor
• Sometimes both tremors
• Sometimes no tremor

Question 14

Postural Instability

Answer 14

• Impaired postural stability is often seen in the later stages of Parkinson’s disease
• Early postural instability suggests an atypical parkinsonian condition

Question 15

What is Gait in Parkinson’s disease?

Answer 15

• Sometimes described as ‘’festinating’’ (hurrying)
• Patients may have:
- Difficulty initiating gait
- Poor arm swing
- Small shuffling steps
- Difficulty turning
- ‘’Freezing’’ (feet sticking to the floor) – worse when cognitive overload

Question 16

What is the pathology of PD?

Answer 16

• The most important lesion in PD is a loss of dopaminergic neurons from the substantia nigra
• Accompanied by the presence of Lewy bodies – intracytoplasmic eosinophilic inclusion bodies – which stain with antibody to alpha-synuclein
• Other brain areas are involved

Question 17

What are the treatment of Parkinson’s disease?

Answer 17

• Current treatment is symptomatic
• Medical treatment aims to increase the amount of dopaminergic transmission in the brain
• Surgical treatment aims to improve the disordered messages from the diseased basal ganglia
- Deep brain stimulation: put pacemaker into brain into subthalamic nucleus and stimulate at high frequency
• Dopamine agonist
• Other drugs that prolong the release of dopamine
• Inhibitors of these breakdown enzymes

Question 18

What is Levodopa given together with?

Answer 18

A peripheral dopa-decarboxylase inhibitor

Question 19

Levodopa+benserazide=

Answer 19

co-beneldopa (Madopar)

Question 20

Levodopa+carbidopa=

Answer 20

co-careldopa (Sinemet)

Question 21

What is the function of Levodopa?

Answer 21

Stops the breakdown of levodopa in the periphery

• helps to prevent side effects such as nausea
• Increases central availability

Question 22

What is the side-effects of L-dopa?

Answer 22

Long-term use associated with development of dyskinesias and fluctuations, which can be severe

Question 23

What are Dopamine agonist?

Answer 23

These drugs directly stimulate dopamine receptors

Question 24

What are examples of Dopamine agonists?

Answer 24

1. Bromocriptine
2. Pergolide
3. Cabergoline
4. Roprinirole
5. Pramipexole (oral)
6. Apomorphine (subcutaneous)

Question 25

What are common side effects of dopamine agonist?

Answer 25

1. Hallucination
2. Nausea
3. Faintness
4. Sleepiness

Question 26

What are the other drugs for Parkinson’s disease?

Answer 26

1. MAO-B inhibitors: Selegiline, Rasagiline
2. COMT inhibitors: Entacapone, Opicapone
3. Amantadine
4. Anticholinergics

Question 27

What is the function of Amantadine?

Answer 27

1. Antiviral treatment
2. Dopaminergic effect
3. Stimulate dopamine receptors
4. Reduces dykinesia

Question 28

what was the surgical approaches previously?

Answer 28

Destructive operations were used to help improve symptoms

Question 29

What has largely replaced surgical approaches?

Answer 29

Stimulation of the sub-thalamic nucleus

Question 30

What are drug-induced parkinsonism?

Answer 30

• Caused by dopamine blocking or depleting drugs
• Neuropletic drugs used in psychiatric practice, and anti-emetic drugs such as metoclopramide are common offenders
• Effects are reversible, but may take weeks to months

Question 31

What are vascular Pseudo-parkinsonism?

Answer 31

Patients with small vessel cerebrovascular disease

• Lower body parkinsonism
• No rest tremor or upper limb akinesia
• Marche a petit pas, wide-based gait, freezing
• Dementia, UMN signs, postural instability common

Question 32

What is Progressive Supranuclear Palsy?

Answer 32

A parkinsonian condition combining:

• A supranuclear vertical gaze palsy
• Early falls
• Bulbar failure
• Axial rigidity
• Pyramidal signs

Question 33

What is Multiple System Atrophy MSA-P/MSA-C?

Answer 33

Parkinsonism (poorly levodopa responsive) +/ or a cerebellar syndrome

Question 34

What is MSA-P/MSA-C a autonomic failure of?

Answer 34

1. Urinary incontinence
2. Erectile dysfunction
3. Postural hypotension
4. Striatonigral degeneration, sporadic olivopontocerebellar atropy, Shy-Drager syndrome

Question 35

What is Dementia with Lewy Bodies?

Answer 35

1. Dementia as initial symptoms
   - Executive functions, attention, visuospatial disorder
2. Parkinsonism
3. Visual hallucinations
4. REM sleep behaviour disorder
5. Sensitivity to neuroleptics