Dementia & Parkinson's Flashcards
2 commonest degenerative diseases of the CNS
Dementia
Parkinson’s
Define Parkinsonism
A clinical syndrome with ≥2 of:
Tremor
Rigidity
Akinesia/ bradykinesia (slowness) - IDEALLY 1 OF THEM SHOULD BE THIS
Postural instability (unsteadiness)
What is the pathology in Parkinson’s disease
Dopamine deficiency in the substantial nigra
Which dementias are more late onset (65+) (3)
Alzheimer’s disease
Vascular dementia
Lewy body dementia
Causes of young onset dementia (4)
doesn’t necessarily mean they affect young more than old, but just the common causes of dementia in younger people
Alzheimer's disease Vascular dementia Frontotemporal dementia Other -alcohol -genetics (huntington's) -MS
Most common cause of dementia
Alzheimer’s disease
Mimics/reversible causes of dementia (6)
B12 deficiency Thyroid disease Infection - HIV Hydrocephalus - normal pressure hydrocephalus Brain tumour Depression
Conditions featuring parkinsonism (4)
Idiopathic Parkinson’s disease - COMMONEST
Drug induced Parkinsonism
Vascular parkinsonism - affects those with restricted blood to brain
Parkinson-plus syndrome (those that have parkinsonian features but don’t respond to normal treatment)
Parkinsonism is not the same as Idiopathic Parkinson’s disease
Term that covers a range of conditions that have similar symptoms to idiopathic Parkinson’s disease (referred to as Parkinson’s)
Name 3 Parkinson-plus syndomes (those that have parkinsonian features but don’t respond to normal treatment)
Multiple system atrophy
Progressive supra nuclear palsy
Dementia with lewy bodies
Lewy body dementia in its advanced stages has features that mimic what degenerative disease
Idiopathic parkinson’s disease (full name for colloquial “Parkinson’s”)
Most common form of parkinsonism
Idiopathic Parkinson’s disease (full name for colloquial “Parkinson’s”)
If parkinsonian patients present with early dementia then the dementia is probably what type
Lewy body dementia
Diagnosis steps of dementia
- history questions (3)
- cognitive examination (list 6 domains that can be examined + 2 screening tests of mental status)
- investigations (8) - most are to exclude other causes of dementia
History
- type of cognitive deficit
- speed of progression
- risk factors - family history, age, down’s, smoking, hypertension
Cognitive function examination
- memory
- attention/concentration
- language
- emotion
- executive functions - handling complex tasks, reasoning,
- perceptual motor functions, e.g. visuospatial
- mini mental state examination (MMSE)
- montreal cognitive assessment (MoCA)
Investigations
- FBC - rule out anaemia
- BG
- U+Es - rule out hypo/hypernatraemia etc
- TFTs - rule out hyper/hypothyroidism
- B12 - rule out B12 induced dementia
- Urinalysis - to rule out illicit drug induced
- CT - to rule out space occupying lesions, NPH
- MRI
definitive diagnosis of dementia and Parkinson’s disease
Post mortem
Diagnosis of Parkinson’s disease
- history
- examination
History:
-Clinical diagnosis of:
Bradykinesia
+ ≥1 of tremor, rigidity, postural instability
-Slowly progressive (5-10 years)
-Tremor is usually asymmetric and when resting
Examination
- all of above
- slow shuffling gait
NO ADDITIONAL DIAGNOSTIC TEST NEEDED IF EXAMINATION FINDINGS CONSISTENT WITH HISTORY
Lab tests and imaging etc only needed to help diagnose Parkinson’s in what circumstances (5)
*NO ADDITIONAL DIAGNOSTIC TEST NEEDED IF EXAMINATION FINDINGS CONSISTENT WITH HISTORY
Atypical features:
acute onset, rapidly progressive disease, early cognitive impairment, symmetrical findings, or upper motor neuron signs
What can confirm the diagnosis of idiopathic Parkinson’s disease
A trial of dopaminergic agent (levodopa)
Alzheimer’s dementia also known as
+ pathophysiology
Temporo-parietal dementia
Beta amyloid rich senile plaques in grey matter + neurofibrillary tangle formation –> impaired neurone signalling –> neurone apoptosis/death
Clinical features of Alzheimer’s dementia (temporo-parietal dementia) (7)
EARLY memory loss
Decline of daily activities - executive function decline
Disorientation (confused) - getting lost or misplacing items
Nominal dysphasia - difficulty naming people/things
LATER personality/behavioural change
-e.g. apathy (lack of interest or concern), social disengagement
Mood changes - mood swings from depression to very irritable
Risk factors of Alzheimer’s dementia (4)
Old age >65
Family history of it
Genetic mutations - APP, presenilin 1/2
Down’s syndrome
Clinical features of frontotemporal dementia (a younger onset dementia) (5)
EARLY change in personality/social behaviour - impulsive, no empathy
Early dysphasia (loss of language fluency and comprehension)
LATER memory loss
Progressive self-neglect - not caring about personal hygiene, dishevelled appearance
Altered eating habits
Is memory loss and personality change an early or later symptom in Alzheimer’s dementia (temporo-parietal dementia) and frontotemporal dementia
Memory loss:
early in alzheimer’s
late in frontotemporal
Personality change:
late in alzheimer’s
early in frontotemporal
Describe the progression pattern of vascular dementia
Stepwise, gradual progression
2nd commonest type of dementia in elderly
Vascular dementia
Causes of vascular dementia (2)
Multiple infarction of brain tissue (often due to stroke/TIA)
- Ischaemia
- Haemorrhage
Small vessel changes
Clinical features of vascular dementia (5)
PROMINENT EARLY EXECUTIVE FUNCTION DEFICIT
- EARLY slowness of thought/slowed processing of information
- Difficulty planning - EARLY
- Difficulty solving problems - EARLY
Poor attention/concentration
Apathy - lack of interest or concern
Memory loss LESS prominent
Memory loss not so prominent in what type of dementia
Vascular
What type of drugs are used to treat the abnormal behaviour of dementia but increase mortality
Anti-psychotics
Specific treatment of Alzheimer’s disease
-for mild/moderate disease (1)
-for severe disease or if above drug is ineffective (1)
+/- other pharmacological treatment for co-existing symptoms (2)
-non-pharmacological treatment (2)
Cholinesterase inhibitors
-donepezil, rivastigmine
NMDA (N-methyl D-aspartate antagonist) antagonist
-memantine
Antidepressants
Antipsychotics
Carer support
Environmental modification/enhance safety - sound + motion detectors, changing to electric hob
Is there any specific treatment of vascular dementia + if not then how is it managed (4)
None
Treat the risk factors that cause vascular dementia, i.e. control atherolosclerotic/cardioembolic disease
- antiplatelets
- anticoagulants
- BP control (anti-hypertensives)
- statins
Is there specific treatment for frontotemporal dementia + if not then what are the management options
No
May give benzodiazepines, SSRIs - to control severe impulsive behaviours
Treatment of Parkinson’s disease (4 classes of drugs + name example of each)
Dopamine replacement - levodopa + carbidopa (needs to be taken together to prevent levodopa being changed into dopamine before it reaches the brain)
Dopamine agonists
- pramipexole
- ropinirole
MAO-B inhibitor
- rasagiline
- selegiline
COMT inhibitor
-entacapone
Why does levodopa have to be combined with carbidopa when taking it
Prevents levodopa being metabolised into dopamine before it reaches the brain/outside the CNS (i.e. increases levodopa availability)
Carbidopa is a peripheral decarboxylase inhibitor that prevents peripheral conversion of levodopa into dopamine (which cannot cross the BBB), and therefore increases the availability of levodopa in the CNS
Non-drug induced complications of Parkinson’s disease (4)
Depression
Dementia
Bladder/bowel incontinence
Dysphagia
Side effects of dopaminergic drugs (i.e. dopamine replacement, dopamine agonists) (4)
Nausea
Vomiting
Psychosis/ Impulsive behaviour
Dyskinesias
Dopamine antagonists are obviously contra-indicated in parkinson’s as you want dopamine agonists instead to improve the dopamine deficiency (= pathology of parkinson’s)
However, dopamine agonists cause nausea/vomiting whereas dopamine antagonists improve this
What is the only dopamine antagonist that can be used in parkinson’s to improve vomiting due to the vomiting centre being outside the BBB
DOMPERIDONE
