Parkinson/Extrapyramidal Disease Flashcards

1
Q

What is the classical triad of Parkinsonism?

A

Tremor
Rigidity
Bradykinesia

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2
Q

What are the features of the Parkinsonian tremor?

A

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)

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3
Q

What are the features of Parkinsonian rigidity?

A

Increased tone throughout range of limb movement

Equal in opposing muscle groups - ‘lead pipe’

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4
Q

What are the features of Parkinsonian bradykinesia?

A

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

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5
Q

What is cogwheeling?

A

Jerky resistance to passive movement

-rigidity + tremor

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6
Q

What are the causes of Parkinson’s?

A
Idiopathic - PD
Drug induced
Vascular - Multiple cerebral infarcts
Toxin - Wilson's disease
Post-encephalopathy
Parkinson's plus syndromes
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7
Q

What are the drug induced causes of Parkinson’s?

A
Neuroleptics
Prochlorperazine
Metoclopramide
TCAs
Methyldopa
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8
Q

What are the Parkinson’s plus syndromes?

A

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

  • Progressive supranuclear palsy
  • Multiple system atrophy
  • Lewy body dementia
  • Vascular Parkinsonism
  • Corticobasal degeneration
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9
Q

What are the features of Progressive Supranuclear Palsy?

A
Symmetrical onset, tremor unusual
Early postural instability/speech problems
Dementia develops early
Vertical gaze palsy present
   -limitation of movement in down gaze
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10
Q

What are the features of Multiple System Atrophy?

A
Early autonomic features (postural hypotension, bladder dysfunction, excess sweating)
Cerebellar signs (nystagmus in horizontal gaze)
Pyramidal signs (extensor plantar, hyperreflexia)
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11
Q

What are the features of Lewy Body Dementia?

A

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

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12
Q

What are the features of Vascular Parkinsonism?

A

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

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13
Q

What are the features of Corticobasal degeneration?

A

Akinetic rigidity involving 1 limb

Cortical sensory loss

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14
Q

What is the underlying pathology of Parkinson’s?

A

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

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15
Q

What additional features are present in Parkinson’s?

A
Postural changes
Gait changes 
Speech changes 
GI/urological sx
Dermatological sx
Psychological sx
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16
Q

What are the postural changes present in Parkinson’s?

A

Characteristic swoop

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

17
Q

What are the gait changes present in Parkinson’s?

A

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

18
Q

What are the speech changes present in Parkinson’s?

A

Monotonous pronunciation

Progresses to slurring dysarthria/anarthria

19
Q

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

A

Dysphagia
Constipation
Urinary frequency

20
Q

What are the dermatological sx present in Parkinson’s?

A

Excessive sweating

Greasy skin

21
Q

What are the psychological sx present in Parkinson’s?

A
Cognition preserved til late stages
Dementia develops later in disease
Depression common (1/3)
REM behavioural sleep disorder
Insomnia
22
Q

What is the management of Parkinson’s?

A

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

23
Q

How does Levodopa work?

A

Precursor of dopamine, crosses BBB

Combined w/ carbidopa to prevent conversion peripherally

24
Q

What are the common side effects of Levodopa?

A

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

25
What are the late side effects of Levodopa?
After 2-5yrs pts develop late side effects - motor fluctuations - dyskinesias - dystonias
26
What are motor fluctuations?
Response to a given dose is shorter lived Rapid 'on-off' switching from well controlled state to akinesia Seemingly unrelated to dosage
27
What is dyskinesia?
Peak dose dyskinesias due to high dopamine levels
28
What is dystonia?
Painful 'wearing off' dystonia as dopamine levels fall
29
How are dopamine receptor agonists used to treat Parkinson's?
Adjuncts to L-dopa Less effective but fewer unwanted dyskinesias -ergot derivatives (bromocriptine, cabergoline) -d2 agonists (ropinirole) -d2/3 agonists (pramipexole)
30
What are the common side effects of dopamine receptor agonists?
Vomiting Haemolytic anaemia Ergot derivatives cause pulmonary/pericardial/retroperitoneal fibrosis
31
How do MAO-B & COMT inhibitors work?
Both prevent breakdown of dopamine by respective enzymes - MAO-B inhibitors (selegline, rasagline) - COMT inhibitors (entacapone)
32
What is the main side effect of MAO-B inhibitors?
Exacerbate postural hypotension
33
How can anticholinergic agents be used to treat Parkinson's?
Address dopamine/ACh imbalance in substantia nigra Help tremor Can cause confusion/anti-cholinergic effects in elderly
34
What are the surgical options for the management of Parkinson's?
Thalotomy/deep brain stimulation to interrupt overactive vasal ganglia circuits
35
What is the prognosis of Parkinson's?
If untreated pts will die due to complications w/i 10yrs