Neurology Level 2.2 Flashcards
Definition of Parkinson’s disease?
- Chronic, progressive neurodegenerative condition resulting from loss of dopamine-containing cells of substantia nigra pars compacta (associated with Lewy bodies then cell loss) by mitochondrial DNA dysfunction
- Dopamine deficiency within basal ganglia leads to movement disorder
When does Parkinson’s disease become apparent?
Parkinson’s disease not clinically apparent until 50% cell loss
Definition of Parkinsonism?
- Umbrella term for syndrome of bradykinesia, tremor, rigidity and/or postural instability
- Causes: Parkinson’s disease, drug-induced, cerebrovascular disease, Lewy-body dementia
Epidemiology of Parkinson’s disease?
- Prevalence increasing sharply
- Mean age of onset 65 years old
Risk factors of Parkinson’s disease?
- Family History
- Genetics
- Opioid use
Symptoms of Parkinson’s disease?
Tremor
Rigidity
Bradykinesia
Types of tremor of Parkinson’s disease?
- 4-7Hz pill-rolling tremor over thumb
* Most obvious in hands and improved by involuntary movements
Type of rigidity of Parkinson’s disease?
- Increased tone, combined with tremor, makes cogwheel rigidity
- During rapid pronation/supination
Type of bradykinesia of Parkinson’s disease?
- Slow to initiate movement
- Lose facial expression
- Decreased blinking
- Slow and monotonous speech
- Writing micrographic and small
- Gait – Decreased arm swinging, shuffling steps with stooped trunk, freeze on turning
Other symptoms of Parkinson’s disease?
- Reduced smell
- Constipation
- Depression, hallucinations, dementia
- Drooling of saliva
- Weight loss
- Urinary difficulties
- Reflexes asymmetrical
Drugs that cause Parkinsonism?
• Reserpine, phenothiazines, metoclopramide, 1st gen antipsychotics
Diagnosis of Parkinson’s disease?
- Clinical Diagnosis based on UK Parkinson’s Disease Society Brain Bank Criteria
- Single photon emission CT (SPECT) if tremor cannot be clinically differentiated from parkinsonism
Management of Parkinson’s disease - referral?
- Urgent referral to neurologist
- If drug-induced, stop drug in primary care if possible
Management of Parkinson’s disease - general advice?
• Leaflet on Parkinson’s, support and drug treatment
• Inform DVLA and car insurer of disease
May drive if vehicle control is safe at all times, if condition disabling or significant variability in motor function then may not be able to drive
• Consider referral to SALT, physiotherapy, OT, dietetics
• Take vitamin D regularly
Management of Parkinson’s disease - drug management - first line treatments?
Levodopa, usually given with dopa decarboxylase inhibitor as co-beneldopa (Madopar) or co-careldopa (Sinemet)
- Efficacy reduces with time – increasing doses/frequency
- Off freezing and end of dose reduced response
If develop dyskinesia, weaning off, add:
- Dopamine agonists – pramipexole, ropinirole
- Monoamine oxidase-B inhibitors – selegilline, rasagilline
- Oral catechol-O-methyl transferase (COMT) - entacapone
Management of Parkinson’s disease - drug management - adjuvant treatments?
Apomorphine – used SC to even out end of dose effects
DBS for advanced Parkinson’s disease not controlled on best medical therapy
Management of Parkinson’s disease - managing complications - constipation?
- Increase dietary fibre and fluid intake
- Increase exercise levels
- Consider laxatives
Management of Parkinson’s disease - managing complications - N&V?
- If persistent – use low-dose domperidone or switch medications
Management of Parkinson’s disease - managing complications - sleep disturbance?
- Rapid eye movement sleep disorder – clonazepam or melatonin
- Nocturnal akinesia – levodopa or oral dopamine agonist
Management of Parkinson’s disease - managing complications - dementia?
- Reduce drugs causing cognitive impairment, seek specialist advice
Management of Parkinson’s disease - managing complications - psychotic symptoms?
- Mild- no treatment
- Severe – withdrawal of anti-Parkinsonism or quetiapine under specialist supervision
Management of Parkinson’s disease - managing complications - orthostatic hypotension?
- Increase salt and fluid intake, avoid caffeine at night and alcohol
- Elevate bedhead to 30-40o
- Reduce contributing medications
- Liase with specialist – midodrine or fludrocortisone
Management of Parkinson’s disease - managing complications - excessive salivation?
- Referral to SALT
- Glycopyrronium bromide or botulinum toxin A
Prognosis of Parkinson’s disease?
- Slowly progressive, rate depends on:
• Age of onset and disease duration
• Early-onset disease may have later onset of motor and cognitive impairments - Reduced life expectancy and increased risk of dementia
Complications of Parkinson’s disease - motor?
- Deteriorating function
- Loss of drug effect
- Motor fluctuations
- Dyskinesia
- Freezing of gait
- Falls
Complications of Parkinson’s disease - non-motor?
- Mental health complications
- Constipation
- Orthostatic hypotension
- Dysphagia and weight loss
- Bladder and sexual dysfunction
- Nausea and vomiting
- Pain
- Sleep Disturbance
Definition of epilepsy?
- Recurrent, tendency to spontaneous, intermittent, abnormal electrical activity in brain, manifesting as seizures
Epilepsy is defined as:
o >2 unprovoked seizures occurring >24 hours apart
Classification of epilepsy?
o Generalised – discharge arises from both hemispheres
o Partial – seizures arise from one or part of one hemisphere
o Complex – loss of consciousness
o Simple – maintained conscious level
Definition of status epilepticus?
- Status epilepticus is a continuous seizure for 30 minutes or longer, or recurrent seizures without regaining consciousness lasting 30 minutes or longer
Elements of epilepsy?
o Seizure – convulsion caused by paroxysmal discharge of cerebral neurones
o Epilepsy – tendency for seizures
o Partial Seizure – Epileptic activity confined to one area of cortex, can spread to secondary
o Generalised seizure – epileptic activity in both hemispheres
o Aura – Stereotyped perception caused by initial focal electrical events before partial seizure
o Prodrome – Lasting hours/days before seizure, change in mood or behaviour
o Post-ictal – may be headache, confusion, myalgia, sore tongue, weakness
Risk factors of epilepsy?
- Familial
- Genetic conditions (Neurocutaneous syndromes e.g. tuberous sclerosis)
- Febrile seizures – 2-7% increase in risk
- Intracranial infections
Aetiology of epilepsy?
- 2/3 idiopathic (often familial)
- Flashing lights/Flickering
- Structural defects
o Cortical scarring
o Lesion occupying space
o Stroke
o Vascular malformations
Epidemiology of epilepsy?
- Prevalence 5x greater in developed world
- Risk of seizure is 5%
- 1% said to have active epilepsy
Other causes of epilepsy?
- Trauma, stroke, haemorrhage
- Raised ICP, alcohol/benzo withdrawal
- Low glucose, oxygen, calcium, sodium
- High temperature
- Drugs (TCAs, cocaine, tramadol)
Types of generalised seizures?
- Absence Seizures (petit mal)
- Myoclonic seizures
- Tonic Seizure
- Tonic-clonic seizures (grand mal)
- Atonic Seizure
Description of absence seizure (petit mal)?
Brief (10s), transient loss of consciousness with abrupt onset/termination, may be some flickering of eyelids but no major muscle phenomenon
Description of myoclonic seizure?
Brief, often repetitive jerking movements of limbs, neck or truck
Child thrown suddenly to the ground
Description of tonic seizure?
Generalised increase in tone
Description of tonic clonic seizure (grand mal)?
Rhythmical contraction of muscle groups followed by tonic phase
Do not breath, cyanosed, saliva may accumulate in mouth
Tongue biting, incontinence of urine
There is unconsciousness or deep sleep for hours after
Description of atonic seizure?
Sudden loss of muscle tone, no LOC
Features present in generalised seizures?
Loss of consciousness
No warning
Symmetrical seizure
Bilaterally synchronous seizure discharge on EEG
Types of partial seizures?
• Simple
Awareness is unimpaired with focal deficits, no post-ictal phase
• Complex
Awareness impaired, may have aura
Common in temporal lobe and post-ictal phase
• Partial with 2o generalisation
2/3 of partial seizures
Characteristics of frontal seizures?
Involve motor cortex
Clonic movements, may travel proximally (Jacksonian march)
Paralysis of involved limb (Todd’s palsy)
Characteristics of temporal seizures?
Most common of all epilepsies Strange aura, with smell and taste abnormalities and distortions of sound and shapes Lip-smacking, rubbing face, running Deja-vu feelings Consciousness can be impaired
Characteristics of occipital seizures?
Cause distortion of vision, flashes, lines
Characteristics of parietal seizures?
Cause contralateral dysaesthesias (altered sensation) or distorted body image