Movement disorders Flashcards
What are types of ‘Movement disorders?
- Tremor
- Bradykinesia (Slowness of initiation of voluntary movement with a progressive reduction in speed and amplitude of repetitive actions)
- Muscle jerks
- Chorea (choreiform movements) (jerky flexion and extension movements)
- Athetosis (athetoid movements) (writhing movements)
- Hemiballismus (flailing, ballistic, movements)
- Dyskinesia
- Dystonia: abnormal tones
- Ataxia: abnormal gate abnormal walking patterns
- Usually due to chronic, progressive neurodegenerative conditions or drug-induced
What are key points to look at in the history of someone with movement disorders?
- Duration, which limbs,
- Parkinosian conditions tend to affect both sides, however, true parkinsonism affects one side more than the other
- Precipitating/relieving factors
- Essential tremor: better with alcohol, worse with stress
- Rest vs intention
- What do you have difficulty doing (handicap)?
- Essential tremor is more disabling, parkinsonism loss of fine motor movement
- Family history
- Past history - co-morbidities
- diabetes→ vascular effects causing mini-strokes
- Medication, alcohol, (smoking → protective of parkinsonism)?
- Cognitive function (thinking and memory)?
What are key parts of an examination for someone with a movement disorder
- Watch; exaggerate tremor
- Feel the tremor (hold hands).
- Speed of tremor?
- Hold out arms (posture), finger-nose (action)
- Bradykinesia
- Rest of CNS examination
- Cognitive function test
- Gait and balance
What are examples of named movement disorders?
- Essential tremor
- Parkinson’s disease
- Drug related
- Stroke related
- Cerebellar tremor
- Huntington’s chorea
What is Parkinson’s disease?
*‘Slowness of initiation of voluntary movement with a progressive reduction in speed and amplitude of repetitive actions’
- Bradykinesia and at least one of the following
- Muscular rigidity (‘lead pipe’, ‘cogwheel’)
- 4-6 Hz rest tremor (complex)
- Postural instability
(Absence of other complicating factors e.g. neuroleptic treatment, head injury, stroke disease etc.)
What is the epidemiology of Parkinson’s disease?
Prevalence 1-2%
Commonest onset is 7th decade
1 in 20 diagnosed are under 40 years old
Male: female = 1.3: 1
What is the cause/ pathology of Parkinson’s disease?
- Slow loss of dopamine-producing neurons in the substantial nigra and other parts of the nervous system
- Cell death with Lewy bodies, neurofibrillary tangles and plaques
- overlap with Alzheimer’s disease and Lewy body dementia: cognitive impairment happens later on down the line in parkinsons
What is the symptoms of Parkinsons
Non-motor symptoms: fatigue, pain, postural hypotension
How is Parkinson’s disease diagnosed
Clinical diagnosis based on history and examination: Trial of dopaminergic agents to confirm. Symptoms should improve
DATscan: looking at the uptake of L-dopa
What variations of Parkinson’s disease could a person be presenting with
- Idiopathic Parkinson’s disease
- Vascular Parkinsonism
- would have cardiovascular risk factors
- effects mainly lower limbs, not as many up limb symptoms
- treatment not always as effective
- ‘PD plus’ syndrome (Lewy body dementia, progressive supranuclear palsy (falls, swallows), multi-system atrophy (urinary retentions, sexual dysfunction), corticobasal degeneration)
- present earlier in lif3
What is the treatment for Parkinson’s disease?
- no real treatment and no way to really slow down the condition progression
- Drugs can improve symptoms
- COMT inhibitors (inhibit break down of levodopa): Entacapone/Opicapone
- Co-careldopa/ Co-beneldopa: get converted to DA increasing the amount of DA available to release
- Dopamine agonists: Ropinorole/ Pramipexole/ Rotigotine (patch)
- MAO-B inhibitors (preserve pre-existing dopamine): Rasagiline/Safinamide
What are the stages of Parkinson’s disease
- Diagnostic (1- 3 years): one drug treatment
- Maintenance (3 – 10 years): one or two
- Complex (8-15 years): complicated drug regime
- Palliative (13 – 20+ years):
What are late features of Parkinsons?
- Falls (can be earlier on)
- Cognitive problems
- Vivid dreams / hallucinations
- Autonomic dysfunction
- Major functional limitations
- Loss of swallowing
What drugs cause movement disorders?
- Neuroleptics (antipsychotics e.g. flupenthixol, chlorpromazine)
- Anti-emetics (prochlorperazine, metoclopramide, cyclizine)
- Anti-convulsants (valproate, carbemazepine)
- SSRI
- Salbutamol
Give an example of Dopamine precursors with metabolic inhibitors that are used for the treatment of motor symptoms in Parkinson’s disease
What are their side effects?
Levodopa/carbidopa (Co-careldopa/ Co-beneldopa)
- Nausea and vomiting
- Orthostatic hypotension
- Vivid dreams
- Hallucinations and delusions
- Impulse control issues
Give an example of MAO inhibitors that are used for the treatment of motor symptoms in Parkinson’s disease
What are their side effects?
Rasagiline/ Selegiline/ Safinamide
- Hypertension/ orthostatic hypotension
- potentiation levodopa-related side effects (N&V, hallucinations, vivid dreams)
Give an example of COMT inhibitors that are used for the treatment of motor symptoms in Parkinson’s disease
What are their side effects?
Entacapone/ Tolcapone
- potentiation levodopa-related side effects (N&V, hallucinations, vivid dreams)
- Entacapone: diarrhoea, orange colour urine, yellow mouth, mouth ulcers
- Tolcapone: hepatoxicity
Give an example of Dopamine receptor agonists that are used for the treatment of motor symptoms in Parkinson’s disease
What are their side effects?
Rotigotine/Apomorphine/Roprinorole/Pramipexole
- N&V,
- hallucinations
- psychosis
- orthostatic hypotensions
- impulse control disorders: e.g extravagant spending, hypersexual behaviour
- Peripheral oedema
Give an example of Anticholinergics that are used for the treatment of motor symptoms in Parkinson’s disease
What are their side effects?
Trihexyphenidyl/ Benztropine
- Dry mouth, dry eyes
- Confusion
- Hallucinations
- Constipation
- Urinary retention
What systems allow us to maintain posture and balance?
- The motor system: propulsive movements
- Lower limb musculature and joints
- The postural system: body orientation & balance
- Vestibular system
- Cerebellum
- Proprioception (and broader sensation)
- Visual input
- Goal-directed aspects of locomotive behaviour
- Motivation to get somewhere
- Cognition- hazard awareness
Which alterations with age effect our ability to maintain balance and posture?
- Visual (and hearing) impairment
- Proprioceptive loss
- Loss of vestibular function
- Reduced muscle mass
- Increased postural sway
- Increased step width but shorter stride
- Slowed walking speed
- Reduced reaction times
- Executive dysfunction: walk and talk difficult
- Cardiovascular changes
Which Cardiovascular changes that occur with age affect our ability to maintain balance and posture?
- Reduced baroreceptor response
- Changes to vascular compliance
- Intravascular volume depletion
- Orthostatic hypotension: reduced venous return
- Cerebral small vessel disease
What are the causes of falls, according to body systems and extrinsic factors?
What are the causes of Total Loss of Consciousness?
- Syncope
- pathology causing a global reduction in cerebral blood flow
- Seizure
- transient signs or symptoms due to abnormal electric activity in the brain, leading to disturbance of consciousness, behaviour, emotion, motor function or sensation
What features in a history suggest an episode of syncope being the cause of total loss of consciousness?
- triggering fator
- distinct prodrome
- ‘convulsion’ after LOC <15 seconds
- short duration
- quick recovery
- ongoing lethargy but no confusion
What features in a history suggest a seizure being the cause of total loss of consciousness?
- having an Aura
- Automatisms: performance of activities without conscious thought (lip-smacking)
- Convulsion at onsent of LOC
- Longer duration
- Post-ictal phase: longer period of confusion, and loss of memory up to a particular point
- Tongue biting
- Incontinence
How to assess/ take a falls history?
Before/ During/ After
- Before the fall:
- Have they been well? Any intercurrent medical issues
- Have there been other falls leading up to this or change in mobility
- one off vs recurrent? falling recently? - may be acute trigger. Is there a pattern?
- Where were they and what were they doing?
- Was there a change in posture? Do you get dizzy/light-headed if you stand up quickly?
- Were they doing anything out of the ordinary – walking without aid etc
- Early identification of environmental risk factors
- During the fall:
- Did you have any warning? Prodrome/presyncope/giddy/dizzy/vertigo
- Did you see yourself fall to the ground? Could you have lost consciousness?
- Cardio symptoms: Chest pain, palpitations, shortness of breath
- Neuro symptoms: weakness, back pain, bladder/bowel, vertigo, feel your feet ok?
- After the fall:
- Did you know who you were and where you were? (if not ?LOC)
- Could you get yourself up? If not how long on the floor? How did you get help?
- Any injuries? Particularly head injury
What drugs are associated with falls?
- Central nervous system
- Anti-psychotics, benzodiazepines, sedatives (‘Z-drugs’) and antidepressants (all classes), opiates
- Antihypertensives and cardiovascular medications
- Vasodilators (nitrates, alpha-blockers, calcium channel blockers)
- ACE inhibitors and ARBs
- Lesser effect Beta blockers and diuretics.
- Anticholinergics
- Bladder drugs
- Alcohol use
- Also sedating antihistamines, PD drugs, anti-epileptics
What is vertigo?
a problem of the vestibular system: inner ear/ cerebellum
the sensation of the rotational movement of the space, when a person is stationary
What examinations are useful when assessing a patient following a fall?
- Postural blood pressure (≥20mmHg SBP, ≥10 DBP)
- Cardiovascular examination
- Visual acuity and hearing
- Spine and lower limb joints
- Examination of the extremities
- feet - bunions, callouses, and arthritic deformities
- Sensory neuropathies
- Full neurologic examination
- Lower limb strength, sensation, and postural stability
- Watch them walk
- Cognitive assessment
What investigations are useful when assessing a patient after a fall?
- Bedside:
- Capillary blood glucose (hypoglycaemia = medical emergency)
- ECG – essential in all fallers
- Postural BP
- Bloods
- Glucose (hypoglycaemia, autonomic neuropathy)
- U&E (dehydration)
- FBC (anaemia, intercurrent infection)
- Broader electrolytes- Mg++ Ca++ (? Syncope)
- B12, folate in all (deficiency can affect proprioception)
- Vitamin D (myalgia, weakness, gait change, fracture risk)
What are consequences of falls?
- Injury in around 1/3
- Soft tissue
- Fractures (10-15% falls): hip, spine – fragility fractures
- Serious soft tissue injury/head injury (5%)
- Long lie if they can’t get up:
- Rhabdomyolysis (high creatine kinase, high potassium) +/- AKI
- Hypothermia
- Pressure damage
- Hypostatic pneumonia
- Functional decline and reduction ADLs
- Increased risk of institutionalisation
- Fear of falling
- Anxiety & depression, social withdrawal
- Death
What does lactate indicate in a VBG/ABG?
- reflects tissue perfusion or hydration status
- high lactate → poor tissue perfusion and dehydration
What extra tests may be useful in a hyponatraemia
Blood: serum osmolality, cortisol, thyroid function
Urine: osmolality, sodium (paired with blood)
What is the pathway for identifying the cause of hyponatremia?
