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Neurology > Movement Disorders > Flashcards

Movement Disorders Flashcards

1
Q

Core features of PD?

A

Core features
- resting tremour
- bradykinesia
- Cogwheeling tremour

Later postural instability often involved but this is later than the other core features

Note pts with PD often present asymnetically, then other side affected when more advanced

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2
Q

Non motor features of PD?

A

Cognition - PD dementia

Behavioural - hallucination (small people, children, animals)

Sleep - REM sleep disorder

Mood - depression, anxiety

Autonomic (later onset) - Orthostatic hypotension, nocturia and urinary freq, constipation, errectile dys, etc

Additional changes
- hypomimia (mask faces)
- Micrographia (small handwriting)
- hypophonia (soft voice)
- Dysphagia

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3
Q

What are some potential prodromal features of PD?

A

REM sleep disorder
Mood distirbances (ie depression)
Anosmia (loss of smell)

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4
Q

Pathophys of PD?

A

Classed as a Alpha synucleinopathy
- Accumulation of intraneuronal protein agregates in the substantia nigra pars compacta
- this affects primerily the dopaminergic neurons in the basal ganglia

Dopamine neurons originating in the substantia nigra pars compact project to the striatum (putamen and caudate).
- There is the indirect (D2) and direct (D1) pathway
- Over-activation of teh Global palidus (internal segment) and the Substantia nigrea pars reticularis causes inhibition of the thalamus
- This leads to inhibition of the cortical pathways causing the impaired movement

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5
Q

PD treatment?

A

Medications
- Levodopa / aromatic amino acid decarboxylase inhibitor
-> aromatic amino acid decarboxylase inhibitor is included to prevent breakdown of levodopa to dopamine in the peripheries, therefore limiting to brain action
- Levadopa/carbidopa
- Levodopa/benserazide

Dopamine agonists
- Pramipexole - D3 target
- Ritigotine patch - D3 target
- Cabergoline - D1/2 target (not used much anymore due to retroperitoneal fibrosis

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6
Q

Aside from behavioral side effects of cabergoline, what is the main AE?

A

Retroperitoneal fibrosis

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7
Q

Explain the progressive motor fluctuations and dyskinesias that develop with progressive parkinsons disease?

A

Effectivly the theraputic window for dopamine gets more narrow as PD progresses
- WIll often need more dose to achieve the effect, but will have more side effects with that dose than before (ie narrow theraputic window)

The progressive dysklinesias are due to increased sens of Dop receptors in brain as disease progresses

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8
Q

How to change dosing regime in pt getting motor fluctuations and dyskinesias due to PD?

A

Increase freq dosing, decrease each dose (ie aim to sustain more constant controlled level)

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9
Q

2x relevant enzymes involved in dopamine metabolism?

A

MAO
COMT

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10
Q

Examples of MAOB inhibitors?

A
  • Rasaligine
  • Selegiline (Old)
  • Safinamide (new MAO B inhibitor that includes a glutamate release inhibitor to increase the ‘on’ time without dyskinesias)
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11
Q

COMT examples?

A

Entacapone
- Combination with levadopa/carbiudopa is called Stalevo

Opicapone
- same as entacapone but once a day formulations

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12
Q

Other PD treatment specifically for dyskinesias?

A

Amantadine (initially dev for flu A, but found to have dopaminergic action)

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13
Q

What are the three main advanced treatments for PD (pharm and non pharm)?

A

Apomorphine injection / infusions pump
- Dopamine agonists

Duodopa (levidopa/carbidopa intestinal gel)
- infusion pump PEJ tubeto avoid stomatch

Deep brain stimulation
- electrode into subthalamic nucleus (STN) or globus palidus internal segment (GPi)

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14
Q

Treatment of PD hallucination (if troubling)? what about when cant decreased levadopa?

A

Initially reduce dopamine medication

If cant reduce dopamine then clozapine in examinations
- only drug with evidence in this space
- Side effect of neutropenia
Practically used quitiepine but no evidence to support this

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15
Q

Treatment of depression in PD?

A

TCAs (amytriptaline and nortryptiline) and Pramipexole are only drugs with evidence in trial

Practically just use standard depression drugs

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16
Q

Treatment of PD REM sleep disorder?

A

Usually clonazapam or TCAs
- nil trials in this space

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17
Q

Features of LBD?

A

Fluctuating attention and congition
REM sleep disorder
Visual hallucinations + non visual hallucinations
Delusions
Antipsychotic sensitivity
Parkinsonism - usually not all the features of PD

18
Q

PD dementia vs LBD main difference

A

PD = motor sx for >12 months prior to dementia
LBD = dementia predominate, with additional motor features

19
Q

LBD pathyphys?

A

Like PD it is alpha synuceilopathy with Lewy bodies more in the cortex in addition to substantia nigra par compacta

20
Q

Treatment of LBD?

A

Can use levodopa but can sig exacerbate cognitive and behaviours Sx

Beware antipsychotics (1st and second gen) because highly sensative ands will develop neuroleptic SE quickly

Can use acetyl cholinesterase inhibitors for cognitive Sx

Antidepressants

21
Q

Features of essential tremour? What is ET plus?

A

Classic action temour - bilateral UL +/- head +/- postural tremour 4-12Hz (ie higher frequ than PD pill rolling which is usually 4Hz)
Can also have voice tremous or LL tremour less commonly

usually early onset, gradual progression
Often improves with etoh

ET plus is ET but with additional features such as dystonic posturing, some cognitive impariment etc

22
Q

Treatment for ET? medications and more advanced therapoies?

A

Beta blockers (usually propanolol)
Primidone
Others: topirimate, clonaz

Advanced:
- DBS and focused ultrasound thalamotomy

23
Q

Subtypes of Multiple system Atrophy?

A

Parkinsonian subtype
- Parkinsonism features

Cerebellar subtype
- ataxia / apendicular ataxia

24
Q

How to differentiate parkinsonian subtype MSA from PD?

A

early autonomic dysfunciton in MSA (wont have this until late PD)

25
Q

Features of MSA?

A

Prominent autonomic dysfunction
- erectile dysfunction, urinary incontiunence, postrural instability hypotension
- Features of parkinsonism (if PD subtype) OR features of ataxia (if cerebellar subtypes)

Other features:
- Stridor and OSA
- Dysphonia, dysarthria, dysphagia
- Tremour (much more jerky than PD, not typical looking)
- Postural instability (antecollis, pisa syndrome)
- Emotional instability and REM sleep disorder

26
Q

Pathophy of MSA?

A

alpha synucleinopathy (inclusions in glial cells)
- If affects the nigrostriatal structure = PD subtype
- If affects other structures = cerebellar subtype

27
Q

Treatment of MSA?

A

Levodopa for MSA-P (often exacerbates teh orthostatic hypotension so difficult balance)

FLudrocortisone, midodrine for management of orthostatic Hypotension

Mirabegron, oxybutanynin for urinary dysfunction

28
Q

What are the features of Progressive supranuclear palsy?

A
  • Falls, often backwards
  • Slowed down saccades, OR (when more advanced) Inability to look up, but dolls head positive
  • Impaired postural reflexes (more than 3 steps backwards to get balance back)
  • Axial rigidity and retrocollis

Other features:
reduced facial expression
reduced arm swing
Difficulty doing up buttons

29
Q

Pathyphys of PSP?

A

Tau protein deposition around perinuclear glial inclusions
- Atrophy of midbrain causes humming bird sign on sagital imaging

30
Q

Treatment of PSP?

A

Levodopea (usually doesnt work)
Amantadine

31
Q

Features of corticobasal degeneration?

A
  • Difficulty brushing teeth, using cutlery on one side
  • Sensory inatention and dysgraphesthesia
  • Ideomotor dyspraxia
  • Limb apraxia (alien limb)
  • Slowed speech with long pauses between words, speech apraxia (expressive aphasia)
  • Parkinsonism
32
Q

Features of huntingtons disease?

A

Chreiform movements of trunk and upper and lower limbs

Imperistance of tongue protrusions
saccadic intrusion of smooth pursuit and slow initiation of saccades
Cognitive impariment
Often unaware that there is an issue, may have personality changes

33
Q

What neurons does huntingtons disease effect?

A

GABAergic neurons in basal ganglion (ie caudate and putamen)

34
Q

Treatment of huntingtons disease

A

antipsychotics

35
Q

How does a triplet repeat lead to huntingtons disease?

A

Translates to a long protein

36
Q

Tardive dyskinesia. what is it?
How is it different from drug induced parkinsonism?

A

Delayed onset of orofacial dyskinesias in the context of antipsychotic use
- Treatment: reduce dose, change to newer antipsychotic, tetreabenezine, benztropine

Drug induced parkinsonism can also be uinduced by antipsychotic use. Presentation is symmetrical extrapyradidal signs

37
Q

Hemibalismus. Where is the leision?

A

contralateral subthal nucleus

38
Q

Liver affected + neurological signs and sympotms. what is the disease?

A

Wilsons

39
Q

Ix in WIlsons disease?
Treatment?

A

Low serum cearuloplasmin, high urinary copper
High copper on liver Bx

Chelating agents such as penicillamine, zinc

40
Q

Restless legs can be primary or secondary. what are some causes of secondary?

A

Peripheral neuropathy, Iron deficiency, end stage renal disease, preg, drugs

41
Q

What is one difficulty about treating restless legs?

A

Augentation
- more drug is often required to manage condition

42
Q

Gait disturbance + urinary incontinence+ cognitive impariment. what is the condition?

A

NPH

Neurology (6 decks)

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