Parkinson/Extrapyramidal Disease

Question 1

What is the classical triad of Parkinsonism?

Answer 1

Tremor
Rigidity
Bradykinesia

Question 2

What are the features of the Parkinsonian tremor?

Answer 2

4-7Hz
‘Pill-rolling’ movements w/ thumb & finger
Occurs at rest, decreases w/ action, increases w/ anxiety
-increased if clench opposite hand
Positive glabellar tap sign (excessive blinking)

Question 3

What are the features of Parkinsonian rigidity?

Answer 3

Increased tone throughout range of limb movement

Equal in opposing muscle groups - ‘lead pipe’

Question 4

What are the features of Parkinsonian bradykinesia?

Answer 4

Difficulty initiating movement
Progressive reduction in speed/amplitude of actions
Spontaneous blinking rate reduced
Hypomimia +/- hypersalivation

Question 5

What is cogwheeling?

Answer 5

Jerky resistance to passive movement

-rigidity + tremor

Question 6

What are the causes of Parkinson’s?

Answer 6

Idiopathic - PD
Drug induced
Vascular - Multiple cerebral infarcts
Toxin - Wilson's disease
Post-encephalopathy
Parkinson's plus syndromes

Question 7

What are the drug induced causes of Parkinson’s?

Answer 7

Neuroleptics
Prochlorperazine
Metoclopramide
TCAs
Methyldopa

Question 8

What are the Parkinson’s plus syndromes?

Answer 8

Rare alternative causes of PD, screen before diagnosing as idiopathic PD

• Progressive supranuclear palsy
• Multiple system atrophy
• Lewy body dementia
• Vascular Parkinsonism
• Corticobasal degeneration

Question 9

What are the features of Progressive Supranuclear Palsy?

Answer 9

Symmetrical onset, tremor unusual
Early postural instability/speech problems
Dementia develops early
Vertical gaze palsy present
   -limitation of movement in down gaze

Question 10

What are the features of Multiple System Atrophy?

Answer 10

Early autonomic features (postural hypotension, bladder dysfunction, excess sweating)
Cerebellar signs (nystagmus in horizontal gaze)
Pyramidal signs (extensor plantar, hyperreflexia)

Question 11

What are the features of Lewy Body Dementia?

Answer 11

Early dementia w/ fluctuating cognition & visual hallucinations
Symmetrical motor signs

Question 12

What are the features of Vascular Parkinsonism?

Answer 12

Strokes affecting basal ganglia
Sx worse in legs than arms
Pyramidal signs present

Question 13

What are the features of Corticobasal degeneration?

Answer 13

Akinetic rigidity involving 1 limb

Cortical sensory loss

Question 14

What is the underlying pathology of Parkinson’s?

Answer 14

Degeneration of nigrostriatal neurones w/ Lewy Body formation
Reduced dopamine activity w/i corpus striatum of basal ganglia

Question 15

What additional features are present in Parkinson’s?

Answer 15

Postural changes
Gait changes 
Speech changes 
GI/urological sx
Dermatological sx
Psychological sx

Question 16

What are the postural changes present in Parkinson’s?

Answer 16

Characteristic swoop

Fixed flexion of all joints (apart from PIPJ/DIPJ)

Question 17

What are the gait changes present in Parkinson’s?

Answer 17

Gait becomes quicker (festinant)
Narrow based, shuffling, reduced arm swing
Slow/unsteady on turn (may freeze)
Falls common

Question 18

What are the speech changes present in Parkinson’s?

Answer 18

Monotonous pronunciation

Progresses to slurring dysarthria/anarthria

Question 19

What are the GI/urological sx present in Parkinson’s?

Answer 19

Dysphagia
Constipation
Urinary frequency

Question 20

What are the dermatological sx present in Parkinson’s?

Answer 20

Excessive sweating

Greasy skin

Question 21

What are the psychological sx present in Parkinson’s?

Answer 21

Cognition preserved til late stages
Dementia develops later in disease
Depression common (1/3)
REM behavioural sleep disorder
Insomnia

Question 22

What is the management of Parkinson’s?

Answer 22

MDT care
Social care assessment
Levodopa
Adjuncts - dopamine receptor agonists, MAO-B inhibitors, COMT inhibitors

Question 23

How does Levodopa work?

Answer 23

Precursor of dopamine, crosses BBB

Combined w/ carbidopa to prevent conversion peripherally

Question 24

What are the common side effects of Levodopa?

Answer 24

N/V (treat w/ Domperidone)
Confusion
Visual hallucinations (treat w/ Olanzapine)
Chorea

Question 25

What are the late side effects of Levodopa?

Answer 25

After 2-5yrs pts develop late side effects

• motor fluctuations
• dyskinesias
• dystonias

Question 26

What are motor fluctuations?

Answer 26

Response to a given dose is shorter lived
Rapid ‘on-off’ switching from well controlled state to akinesia
Seemingly unrelated to dosage

Question 27

What is dyskinesia?

Answer 27

Abnormal, involuntary, uncontrolled movements

Peak dose dyskinesias due to high dopamine levels

Question 28

What is dystonia?

Answer 28

Painful muscle spasms

Painful ‘wearing off’ dystonia as dopamine levels fall

Question 29

How are dopamine receptor agonists used to treat Parkinson’s?

Answer 29

Adjuncts to L-dopa
Less effective but fewer unwanted dyskinesias
-ergot derivatives (bromocriptine, cabergoline)
-d2 agonists (ropinirole)
-d2/3 agonists (pramipexole)

Question 30

What are the common side effects of dopamine receptor agonists?

Answer 30

Vomiting
Haemolytic anaemia
Ergot derivatives cause pulmonary/pericardial/retroperitoneal fibrosis

Question 31

How do MAO-B & COMT inhibitors work?

Answer 31

Both prevent breakdown of dopamine by respective enzymes

• MAO-B inhibitors (selegline, rasagline)
• COMT inhibitors (entacapone)

Question 32

What is the main side effect of MAO-B inhibitors?

Answer 32

Exacerbate postural hypotension

Question 33

How can anticholinergic agents be used to treat Parkinson’s?

Answer 33

Address dopamine/ACh imbalance in substantia nigra
Help tremor
Can cause confusion/anti-cholinergic effects in elderly

Question 34

What are the surgical options for the management of Parkinson’s?

Answer 34

Thalotomy/deep brain stimulation to interrupt overactive vasal ganglia circuits

Question 35

What is the prognosis of Parkinson’s?

Answer 35

If untreated pts will die due to complications w/i 10yrs