parkinson's Flashcards
what is parkinson’s
progressive idiodegeneration of the dopaminergic pathways in the substantia nigra
loss of dopaminergic neurones in the substantia nigra that leads to inadequate dopamine transmission.
characteristic neuropathological finding
lewy body formation in affected neurones
gold standard for diagnosis for parkinsons
brain bank criteria
brain bank criteria for the diagnosis of Parkinson’s disease
step 1:
clinical syndrome involving bradykinesia (+rigidity important
plus at least one of
- tremor - 4-6 Hz - corase, pill-rolling, disappears during voluntary movement, asymmetrical
- rigidity
- postural instability
step 2: exclude other potential conditions
step 3
PLUS 3 OR MORE
- Unilateral onset
- stooped posture
- loss of arm seing
• Rest tremor present
• Progressive disorder
• Persistent asymmetry affecting side of onset most
• Excellent response (70-100%) to levodopa
• Severe levodopa-induced chorea
• Levodopa response for 5 years or more
• Clinical course of ten years or more
Other parkisonian features apart from the triad
- Depression, anxiety, and fatigue.
- Reduced sense of smell.
- Cognitive impairment.
- Sleep disturbance.
- Constipation.
- lack of facial expression
- lsck of spontanrous movements
- greasy skin - autonomic dysfunction
- decreased blinking
tibulation - nodding head involuntarily - dribbling of saliva
- festinating gait
- stooped posture
- increased tone
- impotence
- sweating
what is lead pipe rigidity
constant resistance felt when a limb is passively flexed in the presence of increased tone without tremor,
what is cogwheel rigidity
regular intermittent relaxation of tension felt when a limb is passively flexed in the presence of tremor and increased tone.
what may be seen when examining a parkinson patient
reduced facial expression
slow
shuffling, festinating gait
pill rolling
‘pull test’ - tendency to fall back when pulled by examiner
other causes of parkinsonism
drug-induced parkinsonism
antipsychotics
antiemetics
- prochlorperazine
- metocloperamide
amiodarone
antidepressants - SSRIs
wilson’s
repeated head injury
cerbrovascular disease
other causes of tremor
1) essential tremor
- bilateral stress, caffeine, sleep deprivation
exaggerated psychological tremor
dystonic tremor
hyperthyroidism
drugs - B2 agonists
2) intention - cerbellar
name of scales used to assess progression of parkinson
Hoehn and Yahr
Unified Parkinson’s Disease Rating Scale
classification of Unified Parkinson’s Disease Rating Scale
Part 1: non-motor experiences of daily living
Part 2: motor experiences of daily living
Part 3: motor examination
Part 4: motor complications
drugs available for parkinson
SEs
levodopa - pass thru BBB - converts levodopa into dopamine
neuroepileptic malignant syndrome
monomine oxidase B inhibitors - dizzy, insomnia, orthostatic hypotension, joint pain
and COMT - coloured urine, diarrhoea, liver damage, impulsive and compulsive behaviours
stop breakdown of dopamine
4 phases of parkinson
- Early stage - Soon after diagnosis, symptoms are mild and normal life possible
- Maintenance stage - Good response to treatment and no major disability
- Advanced stage - Poor response to drugs with motor side effects
- Palliative stage - Unable to live independently and in need of multidisciplinary support
clinical features of vascular pseudoparkinsonism
- bilateral symmetrical rigidity;
- bradykinesia, predominantly involving - lower limbs
- postural instability; shuffling gait
- falls;
- dementia
- corticospinal findings.
resting tremor maybe absent
clinical features of benign essential tremor
Begin gradually, usually more prominently on one side of the body
Worsen with movement
Usually occur in the hands first, affecting one hand or both hands
Can include a “yes-yes” or “no-no” motion of the head
May be aggravated by emotional stress, fatigue, caffeine or temperature extremes
dementia with lewy bodies
cognitive symptoms develop within the year whereas IPD is after a year
features of progressive supranuclear palsy
postural instability and falls
— patients tend to have a stiff, broad-based gait
impairment of vertical gaze (down gaze worse than up gaze - patients may complain of difficultly reading or descending stairs)
parkinsonism
— bradykinesia is prominent
cognitive impairment
— primarily frontal lobe dysfunction
pseudobulbar palsy
supranuclear opthalmoplegia
progressive supranuclear palsy ?
brain cells in certain parts of the brain are damaged as a result of a build-up of a protein called tau
features of multiple system atrophy
alpha synuclein build up
parkinsonism + autonomic disturbance
- erectile dysfunction: often an early feature
- postural hypotension
- atonic bladder
POOR RESPONSE TO LEVODOPA
- rapid progression
- pronounced autonomic failure
cerebellar signs
autonomic NS affected
bladder problems
low BP
Problems with co-ordination, balance and speech
slow moving and feeling stiff
types of multiple system atrophy
1) MSA-P - Predominant Parkinsonian features
2) MSA-C - Predominant Cerebellar features
first line treatment for parkinson
if the motor symptoms are affecting the patient’s quality of life: levodopa
if the motor symptoms are not affecting the patient’s quality of life: dopamine agonist (non-ergot derived), levodopa or monoamine oxidase B (MAO‑B) inhibitor
impulse control disorders more significant
features
- dopamine agonist therapy
- a history of previous impulsive behaviours
- a history of alcohol consumption and/or smoking
SEs of levodopa
dyskinesia (involuntary writhing movements), ‘on-off’ effect, dry mouth, anorexia, palpitations, postural hypotension, psychosis, drowsiness
what happens if you stop levodopa acutely
acute dystonia
examples of dopamine receptor agonists
bromocriptine, ropinirole, cabergoline, apomorphine
SEs fo dopamine receptor agonists
(bromocriptine, cabergoline) have been associated with pulmonary, retroperitoneal and cardiac fibrosis.
impulse control disorders
excessive daytime somnolence
more likely to cause hallucinations comapred to levodopa
nasal congestion
postural hypotension
examples of monoamine oxidase B inhibitors
e.g. selegiline
inhibits the breakdown of dopamine secreted by the dopaminergic neurons
SEs of amantadine
ataxia, slurred speech, confusion, dizziness and livedo reticularis
COMT eg
entacapone, tolcapone
COMT is an enzyme involved in the breakdown of dopamine, and hence may be used as an adjunct to levodopa therapy
antimuscarinics?
block cholinergic receptors
now used more to treat drug-induced parkinsonism rather than idiopathic Parkinson’s disease
help tremor and rigidity
e.g. procyclidine, benzotropine, trihexyphenidyl (benzhexol)
DDx fro parkinson
vascular pseudoparkinsonism
benign essential tremor
parkinsonism + syndromes
drugs
antipsychotics
toxins - CO, MPTP
depression
What is meant by on/off fluctuations in patients who are taking levodopa
preparations and why do they occur?
Unpredictable fluctuations in motor function due to “wearing off”.
causes of parkinsonism
Parkinson's disease drug-induced e.g. antipsychotics, metoclopramide* progressive supranuclear palsy multiple system atrophy Wilson's disease post-encephalitis dementia pugilistica (secondary to chronic head trauma e.g. boxing) toxins: carbon monoxide, MPTP
excessive daytime sleepness remedy
modafinil reviewed every 12 months
cant drive infrom DVLA
orthostatic hypotension remedy
midodrine hydrochloride
then
fludrocortisone acetate
drooling of saliva
glycopyrronium bromide
2nd line botulinum toxin A
Managing motor Sx of parkinsons
offer levodopa w carbedopa or benserazide in early stages of parkinson’s disease whose motor Sx impact their quality of life
QOL not affected OFFER levodopa, non-ergot-derived dopamine-receptor agonists (pramipexole, ropinirole or rotigotine) or monoamine-oxidase-B inhibitors (rasagiline or selegiline hydrochloride).
ADJUVANT THERAPY
Patients who develop dyskinesia or motor fluctuations despite optimal levodopa therapy should be offered a choice of
- non-ergotic dopamine-receptor agonists (pramipexole, ropinirole, rotigotine)
- MAOI (rasagiline or selegiline hydrochloride)
- COMT inhibitors (entacapone or tolcapone) as an adjunct to levodopa.
ergot-derived dopamine-receptor agonist (bromocriptine, cabergoline or pergolide) should only be considered as an adjunct to levodopa if symptoms are not adequately controlled with a non-ergot-derived dopamine-receptor agonist.
If dyskinesia is not adequately managed by modifying existing therapy, amantadine hydrochloride should be considered.
What info should be given when starting Mx for motor Sx
impulse control disorders esp w dopamine agonists
excessive sleepiness
sudden onset of sleep w dopamine agonists
Psychotic Sx THESE 3 Sx more likely to be seen with dopamine receptor agonists
Levodopa treatment is associated with motor complications, including response fluctuations and dyskinesias. Response fluctuations are characterised by large variations in motor performance, with normal function during the ‘on’ period, and weakness and restricted mobility during the ‘off’ period.
Long term problems of parkinsons
50-90% of people who have received L-dopa for 5-10 years may experience the following
- motor fluctuations-> when the dose is wearing off, “on” may experience involuntary movements DYSKINESIAS
- Axial problems are balance, speech and gait disturbance which do not respond to Parkinson’s disease medication -> Due to degeneration outside the substantia nigra where dopamine is not the NT -> Mx- SALT and physio, OT
Parkinson’s dementia -> occurs more than one year after diagnosis of Parkinson’s
- Presence of Parkinsonism in the limbs.
- Frequent visual hallucinations.
- Frequent fluctuations in lucidity.
Mx of nocturnal akinesia
levodopa or oral dopamine-receptor agonists should be considered
2nd line -> rotigotine
Mx of psychotic Sx
No CI -> quetiapine to treat hallucinations and delusions.
above ineffective -> clozapine offered
Mx of rapid eye movement sleep behaviour disorder
clonazepam
melatonin
Mx of advanced parkinson’s disease
apomorphine hydrochloride w domperidone if they ahve N/V
chech ECG due to cardiac effects
deep brain stimulation - IF DRUG DO NOT WORK
what is impulse control disorders
compulsive gambling, hypersexuality, binge eating, or obsessive shopping
on dopaminergic therpay
modify Mx
