Clinical Presentation of Parkinson's Disease & Atypical Parkinson's Disease Flashcards
What can movement disorder be classified into?
- Hypokinetic: too little movement
2. Hyperkinetic: too much movement
What is Parkinson’s disease?
- 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
What are the clinical features of Parkinsonism?
- Akinesia
- Rigidity
- Tremor
- Postural Abnormality
What is Akinesia?
Lack of movement, spontaneous movement are slow
- Get them to do a repetitive movement
What is Rigidity?
- 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
What is Tremor?
- 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
What is Epidemiology of PD?
- 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
What are the early ‘non-motor’ features?
- Olfactory loss
- REM sleep behaviour disturbances
- Constipation
- Memory/mood, speech, swelling, urine and bladder function, pain, fatigue
When do motor symptoms/signs typically start?
Asymmetrically
- Asymmetric onset
- Symmetric conditions - atypical parkinsonism
What are the profound psychotic features?
- Late in the condition
- Delusion jealousy
- Paranoid ideas
What is the core feature of parkinsonism and what does it encompass?
- Akinesia
- Bradykinesia: slowness of movement
- Poverty of movement
- Progressive fatiguing and decrement of repetitive movement
- Difficulty with initiating movement
What are examples of Rigidity?
- 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
Tremor
- Typically, a 3-6Hz rest tremor, usually affecting the hands (‘’pill-rolling’’)
- Sometimes a 6-10Hz postural tremor
- Sometimes both tremors
- Sometimes no tremor
Postural Instability
- Impaired postural stability is often seen in the later stages of Parkinson’s disease
- Early postural instability suggests an atypical parkinsonian condition
What is Gait in Parkinson’s disease?
• 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
What is the pathology of PD?
- 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
What are the treatment of Parkinson’s disease?
• 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
What is Levodopa given together with?
A peripheral dopa-decarboxylase inhibitor
Levodopa+benserazide=
co-beneldopa (Madopar)
Levodopa+carbidopa=
co-careldopa (Sinemet)
What is the function of Levodopa?
Stops the breakdown of levodopa in the periphery
- helps to prevent side effects such as nausea
- Increases central availability
What is the side-effects of L-dopa?
Long-term use associated with development of dyskinesias and fluctuations, which can be severe
What are Dopamine agonist?
These drugs directly stimulate dopamine receptors
What are examples of Dopamine agonists?
- Bromocriptine
- Pergolide
- Cabergoline
- Roprinirole
- Pramipexole (oral)
- Apomorphine (subcutaneous)
What are common side effects of dopamine agonist?
- Hallucination
- Nausea
- Faintness
- Sleepiness
What are the other drugs for Parkinson’s disease?
- MAO-B inhibitors: Selegiline, Rasagiline
- COMT inhibitors: Entacapone, Opicapone
- Amantadine
- Anticholinergics
What is the function of Amantadine?
- Antiviral treatment
- Dopaminergic effect
- Stimulate dopamine receptors
- Reduces dykinesia
what was the surgical approaches previously?
Destructive operations were used to help improve symptoms
What has largely replaced surgical approaches?
Stimulation of the sub-thalamic nucleus
What are drug-induced parkinsonism?
- 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
What are vascular Pseudo-parkinsonism?
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
What is Progressive Supranuclear Palsy?
A parkinsonian condition combining:
- A supranuclear vertical gaze palsy
- Early falls
- Bulbar failure
- Axial rigidity
- Pyramidal signs
What is Multiple System Atrophy MSA-P/MSA-C?
Parkinsonism (poorly levodopa responsive) +/ or a cerebellar syndrome
What is MSA-P/MSA-C a autonomic failure of?
- Urinary incontinence
- Erectile dysfunction
- Postural hypotension
- Striatonigral degeneration, sporadic olivopontocerebellar atropy, Shy-Drager syndrome
What is Dementia with Lewy Bodies?
- Dementia as initial symptoms
- Executive functions, attention, visuospatial disorder - Parkinsonism
- Visual hallucinations
- REM sleep behaviour disorder
- Sensitivity to neuroleptics
