Parkinson-plus syndromes

Question 1

What is the main triad of symptoms in Parkinson’s disease?

Answer 1

Bradykinesia (slow movements)

Cogwheel Rigidity (resisting passive movement)

Resting tremor

Question 2

What is the underlying cause of Parkinson’s disease?

Answer 2

Where there is a progressive reduction in dopamine in the basal ganglia, leading to disorders of movement.

The symptoms are characteristically asymmetrical (affects one body side more).

Question 3

Pattern for resting tremor in Parkinson’s?

Answer 3

More noticeable when resting and improves on voluntary movement.

It gets worse when the patient is distracted.

Performing a task with the other hand (e.g., miming the act of painting a fence) exaggerates the tremor.

Question 4

Bradykinesia describes slower and smaller movements, how can this present?

Answer 4

Handwriting gets smaller and smaller (micrographia)

Small steps when walking (“shuffling” gait)

Rapid frequency of steps to compensate for the small steps and avoid falling (“festinating” gait)

Difficulty initiating movement (e.g., going from standing still to walking)

Difficulty in turning around when standing and having to take lots of little steps to turn

Reduced facial movements and facial expressions (hypomimia)

Question 5

Additional features of Parkinson’s?

Answer 5

Depression

Sleep disturbance and insomnia

Loss of the sense of smell (anosmia)

Postural instability (increasing the risk of falls)

Cognitive impairment and memory problems

Question 6

What are Parkinson-plus syndromes?

Answer 6

Conditions that include the main triad of Parkinson’s symptoms along with additional symptoms.

Question 7

Main 4 types of Parkinson-plus syndromes?

Answer 7

Dementia with Lewy Bodies

Multiple system atrophy

Corticobasal degeneration

Progressive supranuclear palsy

Question 8

What is multiple system atrophy?

Answer 8

A rare condition where the neurones of various systems in the brain degenerate, including the basal ganglia.

Question 9

Multiple system atrophy features?

Answer 9

Typical parkinsons triad along with other features leading to:

Autonomic dysfunction (causing postural hypotension, constipation, abnormal sweating and sexual dysfunction).

Cerebellar dysfunction (causing ataxia).

Question 10

What is dementia with Lewy bodies?

Answer 10

A type of dementia associated with features of Parkinsonism. It causes a progressive cognitive decline.

Question 11

Features of dementia with Lewy bodies?

Answer 11

Visual hallucinations, delusions, REM sleep disorders and fluctuating consciousness

Question 12

How is parkinson’s disease diagnosed?

Answer 12

With patient history and examination findings

Question 13

Main treatment options for Parkinson’s disease?

Answer 13

Levodopa (combined with peripheral decarboxylase inhibitors)

COMT inhibitors

Dopamine agonists

Monoamine oxidase-B inhibitors

Question 14

What is the main side-effect of levodopa?

Answer 14

Dyskinesia (abnormality or impairment of voluntary movements)

Question 15

What is dyskinesia?

Answer 15

Refers to abnormal movements associated with excessive motor activity. Examples are:

• Dystonia (where excessive muscle contraction leads to abnormal postures or exaggerated movements)
• Chorea (abnormal involuntary movements that can be jerking and random)
• Athetosis (involuntary twisting or writhing movements, usually in the fingers, hands or feet)

Question 16

Use of amantadine in Parkinson’s?

Answer 16

Can be used to manage the dyskinesia associated with levodopa

Question 17

What are dopamine agonists used for?

Answer 17

They are less effective than levodopa in reducing symptoms.

They are typically used to delay the use of levodopa, then used in combination with levodopa to reduce the required dose.

Question 18

What is the main risk of using dopamine agonists in the long-term?

Answer 18

Pulmonary fibrosis

Question 19

Examples of dopamine agonists?

Answer 19

Bromocriptine
Pergolide
Cabergoline

Question 20

What do Monoamine oxidase-B inhibitors do?

Answer 20

Monoamine oxidase-B inhibitors block the action of monoamine oxidase-B enzymes, helping to increase the circulating dopamine.

Monoamine oxidase enzymes break down neurotransmitters such as dopamine, serotonin and adrenaline.

Question 21

Why are Monoamine oxidase-B inhibitors used with levodopa?

Answer 21

They are typically used to delay the use of levodopa, then in combination with levodopa to reduce the “end of dose” worsening of symptoms.

Question 22

Along with the Parkinson’s triad, what else is a feature of cortico-basal degeneration?

Answer 22

Also involves spontaneous activity by an affected limb or akinetic rigidity of that limb.

Question 23

Along with the Parkinson’s triad, what else is a feature of progressive supranuclear palsy?

Answer 23

Features include: postural instability, vertical gaze palsy, axial rigidity, and early dementia.

Question 24

What is a Parkinson’s medication used alongside levodopa that can cause compulsive behaviors?

Answer 24

Ropinirole (a dopamine agonist) - associated with compulsive behaviours, including impulsive spending and sexual disinhibition.

Question 25

What medications are used as first line in the treatment of parkinson’s disease?

Answer 25

Levodopa combined with carbidopa

Levodopa = first line treatment. It is converted to dopamine in the brain.

Carbidopa = decarboxylase inhibitor which inhibits peripheral metabolism of levodopa in order to prevent peripheral side effects i.e. nausea and vomiting.

Question 26

What parkinson’s medications are avoided in patients with impulse control i.e. gambling addiction?

Answer 26

Dopamine agonists i.e. pramipexole