Movement Disorders Flashcards
1
Q
Benign Essential Tremors (7)
A
- Familial Tremor, FmHx common
- Autosomal dominant
- May temporarily improve with alcohol
- No other abnormal findings
- Can start at any age and is enhanced by stress
- Postural tremor of the hands, head (or both) or voice (legs are spared)
- Little disability (manual skills, handwriting)
2
Q
Tx for Benign Essential Tremors
A
- Usually unnecessary
- Propanolol is 1st line
- Primidone, alprazolam, clozapine, topiramate, gabapentin, mirtazapine
- Botox (if localized)
- If unresponsive to meds try contralateral thalamotomy or unilateral high frequency thalamic stimulation
3
Q
Causes of Parkinsonism (6)
A
- Idiopathic parkinson’s dz (onset 45-65, rarely familial)
- Postencephalitic parkinsonism
- Secondary to toxin exposure
- Secondary to head trauma
- Neuroleptic drugs (reversible)
- Malignancy (rare!)
4
Q
Idiopathic Parkinson’d Dz
A
- Dopmine depletion d/t degeneration of the dopaminergic nigrostriatal system
- Dopamine and Ach imbalance in corpus striatum
5
Q
Clinical Presentation of Parkinsonism
A
- Tremor, rigidity, bradykinesia and postural instability are hallmarks
- Bradykinesia + tremor or rigidity
- Often the tremor starts on one side
- Tremor is most noticeable at rest and worsens with rapid motion of the opposite side
- Mild decline in intellectual fxn
6
Q
Rigidity- Parkonsonism
A
- Increased resistance to passive movements
- Cogwheeling (rigidity with passive movements)
- Characteristic flexed posture
7
Q
Bradykinesia- Parkinsonism (6)
A
- Slow voluntary movements
- Reduction in automatic movements (not swinging the arms while walking)
- Difficulty getting up from a chair
- Walking is difficult to start, but once they start it quickens. looks like they are falling forward
- Shuffling gait, difficulty turning, difficulty stopping
- Effective voluntary movement can be regained in an emergent situation
8
Q
Physical Features of Parksonism (7)
A
- Mask-like facies
- immobile face
- widened palpebral fissures (opening of the eye)
- infrequent blinking
- seborrhea on the face and scalp is common
- mild blepharoclonus (muscle spasms of the eye)
- tremor about the mouth
9
Q
Signs of Parkinsonism (7)
A
- Myerson’s sign (Pt continues to blink as you tap on their forehead, glabellar reflex)
- Drooling
- Soft, monotone voice
- Dysdiadochokinesia
- Micrographia
- No muscle weakness
- No alteration in DTR’s or Babinski’s reflex
10
Q
Differential Diagnosis for Parkinsonism (7)
A
- Slight tremor
- Depression
- Wilson’s dz
- Huntington’s dz
- Multisystem atrophy (Shy-Drager syndrome)
- Progressive supranuclear palsy
- Creutzfeld-Jakob dz
11
Q
Parkinsonism Medication Goals
A
- Tx is symptomatic
- Increase dopamine
- Decrease Ach
12
Q
Amantadine
A
- Parkinsonism medication
- Mild symptoms, no disability
- Mode of action is unclear
- *Improves all the types of symptoms
13
Q
Anticholinergic Drugs (6)
A
- Tx for Parkinsonism
- Help alleviate tremor and rigidity
- Does not help bradykinesia
- Dose is titrated up to response
- Contraindications: BPH, narrow angle glaucoma, obstructive GI dz, elderly
- Side effects: dry mouth, constipation, arrhythmias, confusion, increased ocular eye movements etc…
14
Q
Levodopa (5)
A
- Medication for Parkinsonism
- Improves all features of Parkinsonism
- Does not stop or progress the disease
- Early side effects: N/V, hypotension, cardiac arrhythmias
- Later on: dyskinesia, restlessness, confusion and behavioral changes
15
Q
Levodopa-Induced Dyskinesia (4)
A
- Many forms: chorea, athetosis, dystonia tremor, tics or myoclonus
- On/off phenomenon d/t changing levodopa serum levels
- On: dyskinesias are conspicuous but mobility is improved (high meds)
- Off: dyskinesias are better but mobility is limited (meds low)
16
Q
Levodopa- Carbidopa (Sinemet)
A
- Parkinsonism medication
- Carbidopa inhibits the breakdown of levodopa to dopamine in the periphery, does not cross the BBB
- Decreases overall dose of levodopa
- Lowers systemic side effects
- Does not prevent on/off phenomenon
- Dyskinesia, psychiatric complications may be increased
17
Q
How do you treat Levodopa-Induced Dyskinesias?
A
- Amantadine
- contraindicated in psychotic illness and narrow angle glaucoma
18
Q
Dopamine Agonists
A
- Parkinsonism medication
- Given before or in junction with levodopa
- Bromocriptine
- Pramipexole
- Ropinirole
19
Q
Dopamine Agonist Side Effects (9)
A
- Anorexia (bromocriptine)
- N/V/C
- postural hypotension
- digital vasospasm
- cardiac arrhythmias
- nasal congestion
- erythromelalgia
- pulmonary infiltrates
- pericardial/pleural/pulmonary fibrosis
20
Q
Selective Monoamine Oxidase Inhibitors (MAOI)
A
- Parkinsonism medication
- Rasagiline/Selegiline
- Adjunctive therapy in patients with response fluctuations to levodopa
- Reduce metabolism of L-dopa, more sustained plasma levels, more constant dopaminergic stimulation to the brain
21
Q
MAOI side effects
A
- Tyramine rich foods may cause hypertension
- May slow progression?
22
Q
COMT inhibitors
A
- tolcapone/entacapone
- reduce the metabolism of levodopa
- more sustained plasma levels
23
Q
COMT side effects
A
- fulminant hepatic failure (tolcapone)
- Entacapone does not have hepatotoxicity
24
Q
Atypical Antipsychotics
A
- Used for Parkinsonism
- Used for confusion and psychotic symptoms
- olanzapine, quetiapine, risperdone, clozapine
- Improves iatrogenic dyskinesias
25
Q
Parkinsonism Management (5)
A
- PT
- Speech therapy
- Aids to daily living
- Devices to amplify voice
- High frequency thalamic stimulation
26
Q
Huntington’s Dz Characteristics
A
- Characterized by chorea and dementia
- Inherited, autosomal dominant dz
- huntington gene is at 4p16.3
- Onset 30-50
- Fatal within 15-20yrs
27
Q
Initial S/S of Huntington’s
A
- Abnormal movement or intellectual changes
- Early mental changes are behavioral: irritability, antisocial behavior, moody
- progress to more obvious dementia
