Movement Disorders Flashcards
What is the Parkinson’s triad?
Bradykinesia
Tremor
Rigidity
What causes Parkinson’s disease?
The degeneration of dopamine producing neurons in the brain
- Degeneration of substantia nigra
- Lewy body deposition in neurons
How does Parkinson’s disease present?
Parkinsonism
(triad, shuffling gait, masked face, postural instability)
Neurocognitive disturbance
(depression, dementia)
What are the aims of Parkinson’s disease treatment?
Increase dopamine signalling and control symptoms
What is considered to be the best treatment for Parkinson’s disease? How does it work?
Levodopa
Levodopa crosses the BBB and is converted to dopamine
What is levodopa administered with and why?
Cabidopa
Blocks peripheral effects of levodopa (arrhythmia)
Patient with longstanding Parkinson’s disease presents with dyskinesia.
What is dyskinesia and why has it occurred?
Abnormal, uncontrolled movement
Patient likely prescribed levodopa. Levodopa has a good response initially but this wears off and it can cause dyskinesia.
Name an adjuvant therapy used to treat Parkinson’s disease which
- increases dopamine signalling
- helps control symptoms
Monoaine oxidase B inhibitor (rasagiline): increases dopamine signalling by inhibiting the breakdown of dopamine
Benztropine: an anticholinergic which controls symptoms by lowering ACh levels (which are usually high in Parkinson’s due to the abnormal dopamine levels)
Name an monoamine oxidase B inhibitor. What are its indications in Parkinson’s disease?
Adjuvant therapy with levodopa
First line in young patient where levodopa induced dyskinesia is a concern
What is the difference between Parkinson’s disease dementia (PDD) and Lewy body dementia?
Dementia late feature of PDD
Dementia early/first feature of Lewy body dementia
What are the characteristics of Lewy body dementia?
Dementia
Parkinsonism
Visual hallucination
What are the characteristics of Multiple System Atrophy?
Parkinsonism
Autonomic dysfunction
Cerebellar dysfunction
What might be seen on MRI in multiple system atrophy?
Putamen atrophy Pons atrophy (hot cross bun sign)
What are the characteristics of progressive supranuclear palsy?
Parkinsonism
Dementia
Difficulty moving eyes
What might be seen on MRI in progressive supranuclear palsy?
Midbrain atropy (hummingbird sign)
What are the characteristics of vascular Parkinsonism?
Slow progression
Gait disturbance predominated
Lower body affected more
Possibly in patient with poor cardiovascular health or history of strokes
How can you distinguish vascular Parkinsonism from other causes?
SPECT scan
What drugs can cause Parkinsonism?
Antiepileptics
Antipsychotics
Antiemetics
Lithium
What is the commonest action tremor?
How does it present?
How do you treat it?
Essential tremor
Slow progressing action tremor over years
Propranolol
What is ‘enhanced physiological tremor’? What can cause it?
Exaggeration of the physiological tremor which occurs with contraction
Stress, fatigue, exercise, caffeine
Tremor worsening on approaching a target.
Diagnosis?
Part of brain injured?
Intention tremor
Cerebellum
What are the clinical signs of a psychogenic tremor?
Abrupt onset tremor starting in arms and spreading to head/legs. May have changing characteristics.
(psychogenic tremor not a disgnosis of exclusion)
What is on orthostatic tremor?
Leg/trunk tremor on standing up
What is the commonest cause of a tremor at rest?
Parkinson’s disease
What are the characteristics of a Parkinsonian tremor?
Unilateral initially
4-6 Hz
Pill rolling
Tremor at rest, movement which worsens on approaching a target.
Diagnosis?
Part of brain injured?
Holmes (rubral) tremor)
Cerebellum
What non neurological causes are there for tremor?
Hyperthyroidism
Hypoglycaemia
Alcohol withdrawal
Drugs
What is dystonia and what causes it?
Spasming and abnormal posturing
Co-contraction of agonist and antagonist muscles
Clinical name for dystonia affecting: eyes (blinking) and neck (twisting)?
Eyes: blepharospasm
Neck: cervical torticollis
How do you manage
- acute dystonia?
- focal dystonia?
- generalised dystonia?
Acute: antihistamine (diphenhydramine) or anticholinergic (benzatropine)
Focal: botox
Generalised: levodopa
What inheritance pattern does Huntington’s disease show?
Autosomal dominant with genetic anticipation (condition worsens as it passes down the generations)
What causes Huntington’s disease?
Excess CAG repeats on huntingtin gene forms excess huntingtin protein which forms neurotoxic protein aggregates in neurons
Describe the presentation of Huntington’s disease.
Early: personality change, depression, clumsiness, abnormal eye movements
Late: chorea, rigidity and dementia
What medications can be given to Huntington patients to:
- stop disease progression?
- relieve symptoms?
Stop progression: none
Symptom relief: tetrabenazine
What is Synenham’s chorea?
Self limiting chorea in 5-15 year old girls caused by rheumatic fever.
Associated with behavioural disturbance and OCD
What is Tourette’s syndrome and how does it present?
Neurodevelopmental disorder causing tics
Simple and complex vocal/phonic tics (blinking often first tic) which worsen with stress
What condition is Tourette’s syndrome associated with?
ADHD
How do you treat Tourette’s syndrome?
Psychosocial interventions
Rispiradone (+ clonidine if ADHD) if psychosocial interventions fail
How do you treat restless leg syndrome?
Prampipexole (dopamine agonist)
What is chorea?
continuous, spontaneous and random jerky movements
What is myoclonus?
sudden brief ‘shock-like’ movement caused by muscular contraction/inhibition
What is hemibalism and what causes it?
flinging movement of limb
cerebrovascular lesion of subthalamic nucleus
