Neurology: Parkinsonism Flashcards
What is Parkinson’s disease?
Idiopathic Parkinson’s Disease (IPD) is a progressive degenerative disorder characterised by neuronal loss in the brainstem and basal ganglia. There is loss of dopaminergic neurones in the substantia nigra that leads to inadequate dopamine transmission. The characteristic neuropathological finding is Lewy Body formation in affected neurones. The condition is usually sporadic in nature, but some genetic variants do exist.
Distribution of symptoms in Parkinson’s disease?
Asymmetirical, with one side affected more than the other
Classic triad of Parkinson’s Disease symptoms?
Resting tremor
Rigidity
Bradykinesia
Basic pathophysiology of Parkinson’s Disease?
Gradual but progressive fall in production of dopamine by the substantia nigra (part of the basal gangila (group of structures situated in middle of brain responsible for coordinating habitual movements, controlling voluntary movements and learning specific movement patterns)
Loss of dopamenergic neurones leadys to loss of inhibitionin the neostriatum ,which allows increased production of Ach (excitatory)
Chain of abnormal signalling leads to impaired mobility
What demographic of patient typically present with Parkinson’s Disease?
Male, older age (70s)
What signs may suggest Parkinson’s Disease when a patient walks?
Stooped posture
Facial masking
Forward tilt
Reduced arm swing
Shuffling gait
Characteristics of tremor in Parkinsons?
4-6Hz
‘Pill rolling tremor’
More pronounced on resting, improving on voluntary movement
Tremor worsened as patient is distracted
When unilateral, tremor is exaggerated when pt asked to do a task with unaffected hand
What is ‘cogwheel’ rigidity?
Resistance to passive movement of a joint
Tension will be felt and joint moves in small incriments
What is bradykinesia?
Slower and smaller movements
How might bradykinesia present?
Their handwriting gets smaller and smaller (this is a classic presenting complaint in exams)
They can only take small steps when walking (“shuffling gait”)
They have difficulty initiating movement (e.g. from standing still to walking)
They have difficulty in turning around when standing, having to take lots of little steps
They have reduced facial movements and facial expressions (hypomimia)
What is hypomimia?
Reduce facial movements and expressions
Features of Parkinsons Disease?
Resting tremor
Bradykinesia
Cogwheel rigidity
Depression
Sleep distrubance and insomnia
Loss of the sense of smell (anosmia)
Postural instability
Cognitive impairment and memory problems
Parkinson’s Tremor vs Benign Essential Tremor - symmetry
Parkisons: Asymettrical, 4-6Hz, worse at rest, improves with intentional movement, other parkinsons features present, not affected by alcohol
Benign essential tremor; Symmetrical, 5-8Hz (Higher frequency), improves with rest but worse with intentional movement, no other parkinsons features present, IMPROVES WITH alcohol
What is benign essential termor?
(Differential in Parkinson’s presentation)
Common condition associated with old aged
Fine tremor affecting all the voluntary muscles, most notable in the hands but affects many other areas e.g. head tremor, jaw tremor, vocal tremor.
What can worsen a benign essentiel tremmor?
Voluntary movement
Tiredness
Stress
Caffeine
When would a benign essentiel termor always be absent?
Sleep
Differentials for patients presenting with a tremor?
Benign essential tremor?
Parkinson’s disease
Multiple sclerosis
Huntington’s Chorea
Hyperthyroidism
Fever
Medications (e.g. antipsychotics)
There is no definitive treatment for benign essential tremor as it is not harmful, but what medications can be trialed if it causes psychological or functional problems?
Propranolol
Primidone
What are Parkinson-plus syndromes?
Parkinson-plus syndromes ( PPS) are a group of neurodegenerative diseases featuring the classical features of Parkinson’s disease ( tremor, rigidity, akinesia / bradykinesia, and postural instability) with additional features that distinguish them from simple idiopathic Parkinson’s disease (PD).
Types of Parkinson’s-plus Syndromes?
Multiple System Atrophy
Dementia with Lewy Bodies
Progressive Supranuclear Palsy
Corticobasal Degeneration
What is multiple system atrophy?
A Parkinson’s plus Syndrome.
Rare condition.
Multiple systems in the brain degenerate, affecting the basal ganglia as well as multiple other areas.
The degenertation of the basal ganglia lead to a Parkinson’s presentation.
Degeneration in other areas lead to autonomic dysfunction and cerebellar dysfunction
Notable consequences of autonomic dysfunction?
Postural hypotension
Constipation
Abnormal sweating
Sexual dysfunction
Notable consequence of cerebellar dysfunction?
Ataxia
What is Dementia with Lewy Bodies?
This is a type of dementia associated with features of Parkinsonism. It causes a progressive cognitive decline.
There are associated symptoms of visual hallucinations, delusions, disorders of REM sleep and fluctuating consciousness.
How is Parkinson’s diagnosed?
Parkinson’s disease is diagnosed clinically based on symptoms and examination.
The diagnosis should be made by a specialist with experience in diagnosing Parkinson’s.
NICE recommend using the UK Parkinson’s Disease Society Brain Bank Clinical Diagnostic Criteria.