Neurocognitive 2 - Parkinsons +

Question 1

Parkinson’s disease

Answer 1

syndrome of resting tremor, rigidity, bradykinesia, postural instability

degeneration of dopaminergic neurons in basal ganglia

Question 2

basal ganglia components

Answer 2

“middle manager”

composed of substantial migrant, striatum, gobs pallid us, subthalamic nucleus, thalamus

Question 3

basal ganglia function

Answer 3

control and regulate activity of motor and premotor cortical ares so that voluntary movements are smooth

INHIBIT number of motor systems

Question 4

Parkinson’s patho

Answer 4

loss of dopaminergic neurons in substantia nigra

loss of excitatory input from thalamus to cerebral cortex

increased inhibition to cerebral cortex form other nuclei in basal ganglia

Question 5

etiologies of Parkinson’s

Answer 5

genetic (10%) - suspect if <50 @ diagnosis

environmental risk factors (rural environment, exposure to pesticides, well water)

Question 6

Parkinson’s disease epidemiology

Answer 6

more common in older individuals, men > women

mc in white boys

Question 7

Parkinson’s disease presentation

Answer 7

MC INITIAL IS RESTING asymmetric TREMOR of finger/thumb

rigidity, bradykinesia, postural instability, dystonia

general decreased dexterity

Question 8

rigidity in PD

Answer 8

stiff limbs, poor mobilization of face

Question 9

bradykinesia in PD

Answer 9

slowed movement BUT muscle strength is NOT weak on exam

facial (decreased blinking, drooling)

truncal (difficulty turning in bed, worse in small areas)

UE (micrographia)

LE (scuffing/dragging of feet)

Question 10

dystonia

Answer 10

foot inversion or dorsiflexion

adduction of arm and Hand causing it to rest

Question 11

other presenting symptoms of PD

Answer 11

decreased arm swing

soft voice, monotone, less distinct

decreased sense of smell

sleep disturbances

symptoms of autonomic dysfunction

weakness/malaise

depression or anhedonia

slowness in thinking/major neurocognitive dysfunction

Question 12

cardinal signs of PD

Answer 12

1. resting tremor (goes away with movement!!!)
2. rigidity (resistance to moving wrist)
3. Bradykinesia
4. postural instability

Question 13

dementia of PD

Answer 13

executive functioning, short term memory and visuospatial ability impaired

typically doesn’t occur right away (>1 yr following diagnosis)

Question 14

making PD diagnosis

Answer 14

if pt presents with tremor = no workup

lack of tremor = imaging and lab work (will be normal)

MUST asses for depression (@ diagnosis and periodically)

Question 15

meds used in PD tx

Answer 15

levodopa
MAO-B inhibitors
dopamina agonists

typically good for 4-6 yrs

Question 16

drug class that will WORSEN PD symptoms

Answer 16

deplete central dopamine

antipsychotics, prochlorperazine, Reglan

Question 17

levodopa/carbidopa

Answer 17

L = metabolic precursor of dopamine, but if given alone causes n/v

c= inhibits systemic breakdown of levodopa so more effective in CNS, can’t cross BBB

Question 18

levodopa/carbidopa ADRs + brand

Answer 18

orthostatic HoTN, syncope, dizziness, anorexia, n/v, confusion, dark urine

Sinemet

Question 19

why do we delay levodopa/carbidopa

Answer 19

delay use = delay onset of motor fluctuations

these are when pts wear off the med and have to continually increase dose to sustain normal function

Question 20

MAOIs used in PD

Answer 20

Selegiline (Eldepryl/Zelapar)

Rasagiline (Azilect)

Question 21

MAOIs use and Moa

Answer 21

initial or add on tx (can delay motor fluctuations)

block degradation of dopamine, extend action of L-Dopa

Question 22

MAOIs drug facts (ADRs_

Answer 22

excellent profiles, improved long term outcomes

nausea, confusion, hallucinations, HA, bitterness, orthostasis

Question 23

what meds are not good mixed w/ MAOIs

Answer 23

antidepressants, pain meds, cold and weight loss meds

esp. dextromethorphan, tramadol, methadone

Question 24

dopamine agonists used inPD

Answer 24

Ropinirole (Requip)

Pramipexole (Mirapex)

Question 25

dopamine agonists MOA

Answer 25

stimulate dopamine receptors in striatum mono therapy in early dz or add on therapy in later PD

Question 26

why aren't dopamine agonists mainstay of tx

Answer 26

cause increased ADRS such as somnolence, sudden onset sleep, halucinations, edema, impure control disorder

Question 27

amantadine

Answer 27

symmetrel antiviral drug that has beneficial effects on PD thru mechanisms unknown improves symptoms in mildly affected pts reduces motor fluctuations and dyskinesias in pts with advanced dz

Question 28

ADRs of amantadine and symmetrel

Answer 28

``` confusion hallucinations nausea HA dizziness insomnia lived reticulars peripheral edema anticholinergics ```

Question 29

anticholinergics in PD

Answer 29

Benztropine mesylate (cognentin) Trigexyphenidyl (artane) benefit for tremor in 50% of pts, don't improve bradykinesia or rigidity avoid in pts > 70

Question 30

anti cholinergic side effects

Answer 30

``` dry mouth blurred vision constipation cognitive impairment hallucinations urinary retention ```

Question 31

Later stages of PD

Answer 31

over time, levodopa stops working (have to add on other medications or increase does) will get peak dose dyskinesia

Question 32

COMT inhibitors

Answer 32

Catechol o methy transferase inhibitor inhibits metabolism of dopamine so longer effects may cause liver failure, removed from markets

Question 33

COMT inhibitors used in PD

Answer 33

entacapone (Comtan) Carbidopa/levodopa.entacapone (Stalevo) tolcapone (tasmar)

Question 34

surgical PD tx

Answer 34

create lesions in overactive part of brain to improve symptoms can also implant DBS into a patient

Question 35

parkinsonian plus syndrome is suspected when

Answer 35

poor response to therapy with L dopa in patient who displays Parkinson's syndrome

Question 36

Normal Pressure hydrocephalus

Answer 36

buildup of too much CSF in cranium when patient does not reabsorb CSF adequately or overproduce CSF

Question 37

NPH results in

Answer 37

transiently high pressure ad compression of brain and spinal cord causing edema of brain

Question 38

NPH pathophys

Answer 38

enlarging ventricles to relieve pressure = shrinkage of brain parenchyma may be 2/2 SAH, tumor, meningitis, head injury

Question 39

classic NPH symptoms

Answer 39

1. abnormal gait (earliest, responds to tx) 2. urinary incontinence 3. dementia

Question 40

diagnosis of NPH

Answer 40

labs are normal CT/MRI will show ventricular enlargement out of proportion to sulcus atrophy

Question 41

NPH tx

Answer 41

VP shunt to drain CSF from ventricle into the abdomen to be absorbed risk of pump dysfunction and infection