Geriatric's Medical Potpourri 2

Question 1

Parkinson’s Dz
1. What is it? 3

2. PP?

Answer 1

1. An idiopathic, slowly progressive degenerative CNS disorder characterized by:
   - Tremor (usually resting)
   - Muscular rigidity
   - Bradykinesia
2. Striatal dopamine is deficient and dopaminergic neurons are lost in the substansia nigra

Question 2

Some patients will develop what from this?

Answer 2

Some patients develop dementia

Question 3

How should we Dx parkinson’s Dz?

2

Answer 3

1. By history and physical exam

2. Diagnosed clinically if 2 of the 3 cardinal features (tremor, rigidity, bradykinesia) are present

Question 4

Parkinson’s
1. Symptoms & signs in PD typically begin where and move where?

2. Symptoms reported by patients can include the following:
   10

Answer 4

1. one extremity or one side but eventually involve other limbs and trunk
2. • Stiffness & slowed movements
   • Tremor or shaking at rest
   • Difficulty getting out of chair or rolling in bed
   • Frequent falls or tripping
   • Difficulty walking
   • Memory loss
   • Speech changes (whispering, rapid speech)
   • Small handwriting
   • Slowness in performing activities of daily living
   • Sialorrhea

Question 5

Physical findings in Parkinson’s disease

What is initially affected and what does it move to?

Answer 5

Hands initially affected but legs, chin and head are involved with advanced disease.

Question 6

Physical findings in Parkinson’s disease:

14

Answer 6

1. Muscle rigidity, cog wheeling type
2. Bradykinesia
3. Postural instability , assumes a stooped forward posture
4. Decreased arm swinging in ambulatory activity
5. Resting tremor / pill-rolling tremor
6. Masked facies
7. Micrographia
8. Dysarthria, hypokinetic, monotonous low volume
9. Painful dystonia
10. Dementia
11. Depression up to 50%
12. Akathisia inability to sit still
13. Seborrheic dermatitis face & scalp
14. Autonomic dysfunction e.g. orthostatic hypotension

Question 7

Initial Treatment for Parkinson’s

Answer 7

Initial drug treatment includes carbidopa/levodopa or dopamine agonists
-After 2 to 5 years levodopa becomes less effective

Question 8

Other options include: Parkinson’s?

4

Answer 8

1. monoamine oxidase type B inhibitors
2. Catechol-O-methyltransferase inhibitors
3. Amantadine
4. Deep brain stimulation (electrodes placed in subthalamic nucleus connected to a pacemaker) for drug resistant tremor or levodopa induced motor complications

Question 9

What is a common problem in this?

How should it be managed?

Answer 9

Constipation is common and should be

prevented or relieved with dietary fiber, fruit juices, sometimes laxatives

Question 10

Parkinson’s-end of life issues

5

Answer 10

1. Many patients eventually become severely impaired and immobile and are at risk for aspiration
2. Eating may become impossible
3. Dementia
4. Discuss end-of-life care issues early
5. Advise patient to appoint a surrogate to make medical care decisions if they become incapacitated

Question 11

Polymyalgia Rheumatica characterized by what?

2

Answer 11

characterised by

1. severe bilateral pain and
2. morning stiffness of the

shoulder, neck and pelvic girdle.

MEDIUM VESSEL VASCULITIS

Question 12

Polymyalgia Rheumatica:
1. There is an increased incidence of the disorder where?

2. Women are more frequently affected than men with a M:F ratio of approximately what?

Answer 12

1. At higher latitudes

2. 1:3.

Question 13

1. Polymyalgia Rheumatica: What genes is it linked to?

2. What else has been linked to? 5

Answer 13

1. HLA-DRBI*04 and *01 alleles
2. • antibodies to respiratory syncitial virus and
   • adenovirus in PMR and the association between the increased incidence of the disorder and epidemics of
   • Mycoplasma pneumoniae,
   • chlamydia pneumoniae and
   • Parvovirus B19.

Question 14

Polymyalgia Rheumatica: Other symptoms and signs may include?
8

Answer 14

1. Pain on active and passive movement of joints ( shoulders 70-95%, hips and neck 50-70%)
2. Morning stiffness of more than one hour and also after periods of rest.
3. Myositis
4. Lethargy
5. Loss of weight
6. Depression
7. Fever
8. Joint effusions

Question 15

Polymyalgia Rheumatica: May or may not see symptoms of what?

3

Answer 15

± Asymmetric peripheral arthritis ( mainly knee and wrist)
± Carpal tunnel syndrome
± edema of hands, wrists, ankles and feet

Question 16

Polymyalgia Rheumatica: Labs?

3 (whats the most important test)

Answer 16

1. ESR…the most useful laboratory test -
   although up to 20% of patients may have a normal ESR at diagnosis. Plasma Viscosity can be used instead of ESR.
2. C-reactive protein
3. IL-6 levels
4. CBC –
5. Rheumatoid and ANA
6. LFTs

Question 17

What levels of ESR?

Answer 17

raised to a level of at least 40 mm/hour and often 100 mm/hour

Question 18

How are the following changed in Polymyalgia Rheumatica:

1. IL-6 levels?
2. CBC?
3. Rheumatoid and ANA?
4. LFTs?

Answer 18

1. usually raised, and a useful marker of disease activity
2. normochromic, normocytic anemia
3. not elevated!!
4. mildly elevated in 1/3 of patients

Question 19

Polymyalgia Rheumatica Associated Dzs?

Answer 19

Giant cell arteritis co-exists in about 30% of patients with PMR and shares many features of the disease

Question 20

Polymyalgia Rheumatica:

Advise people with PMR to seek medical attention if they developed any symptoms of GCA. Such as? 3

Answer 20

1. any new headache,
2. jaw claudication or
3. visual disturbances.

Question 21

Polymyalgia Rheumatica:

Monitor response to treatment by assessing changes in clinical features and inflammatory markers– Such as? 2

Answer 21

1. ESR

2. CRP

Question 22

DOC for PMR?

Answer 22

Prednisone remains the drug of choice for treating PMR.

-Treatment is generally initiated at 15mg/day per day

Question 23

What should be given to all PMR patients who are receiving doses of prednisone (or equivalent)>5mg daily for >6 months?
2

Answer 23

1. Bisphosphonates, or

2. if they are not tolerated, Calcium and vitamin D supplementation

Question 24

1. PMR occurs in patients who on average are > how old?
2. Cardinal symptoms are what?
3. Clinicians must be alert to mimics, including what? 4
4. What is usually raised at disease onset?
5. ___________ is present in about 30% of patients
6. PMR is treated with what?

Answer 24

1. 70 years of age.
2. shoulder & hip girdle pain with pronounced stiffness lasting at least one hour.
3. • infection,
   • malignancy,
   • metabolic bone disease, and
   • elderly onset rheumatoid arthritis.
4. ESR or CRP , or both,
5. Giant cell arteritis
6. oral glucocorticoids.