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CNS Module: Exam 2 > Parkinson's > Flashcards

Parkinson's Flashcards

1
Q

What are the motor complications associated with Parkinson’s?

A
  • decreased ability to perform ADL’s (activities of daily living)
  • increased risk for falls and fractures
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2
Q

What are the NON-motor complications associated with Parkinson’s?

A
  • cognitive impairment/dementia
  • apathy, depression and/or psychosis affect QoL
  • swallowing, GI, speech difficulties
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3
Q

What are thought to be the causes of Parkinson’s?

A
  • head trauma
  • genetic
  • environmental (exposure to pesticides, well water?)
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4
Q

why is DA deficiency important?

A

DA deficiency is responsible for the core motor features
- neuronal injury/loss of substantia nigra pars compacta (MAJOR source of DA projections to basal ganglia)

  1. prion-like pattern spread of misfolded proteins from peripheral tissue to brainstem (early premotor and non-motor sx)
  2. motor symptoms present
  3. cortical regions! = late onset dementia
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5
Q

What mechanisms cause PD?

A
  • mitochondrial dysfunction
  • oxidative stress
  • neuroinflammation
  • faulty protein degradation
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6
Q

Bradykinesia definition

A

slowness of movement

  • gait
  • facial expressions
  • ask them to snap, stand/sit
  • tremor
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7
Q

Parkinsonism diagnosis:

A

Bradykinesia + (tremor OR rigidity)

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8
Q

Parkinson’s diagnosis:

A
  • clinical exam
  • MRI (to rule out hydrocephalus, diffuse vascular disease or mass/lesions if UNUSUAL presentations)
  • SPECT (single-photon emission computed tomography): nuclear imaging scan that integrates computed tomography and a radioactive tracer
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9
Q

Parkinsonism vs Parkinson’s

A

ParkinsonISM:

  • secondary to neurodegenerative disorders
  • Drugs (metoclopramide, FGA & SGA)

PD:
- idiopathic (unknown cause)

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10
Q

What are the symptoms of PD?

A
  • stooped posture
  • masked face
  • back rigidity
  • forward tilt of trunk
  • flexed elbows and wrists
  • hand tremor
  • reduced arm swing
  • tremors in the legs
  • slightly flexed hip and knees
  • shuffling/short stepped gait
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11
Q

What features support diagnosis of Parkinson’s?

A
  • unilateral onset of tremor, bradykinesia, rigidity
  • persistent asymmetry of motor signs
  • falls (later in progression)
  • significant loss of smell
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12
Q

What features exclude diagnosis?

A
  • essential tremor (postural & kinetic vs resting)
  • symmetry of motor signs at onset
  • falls at presentation or EARLY
  • strokes with stepwise progression of parkinsonian feature
  • head injuries
  • encephalitis
  • neuroleptic tx at onset of sx
  • sustained remission
  • early/severe autonomic involvement, disturbances of memory, language, and praxis
  • cerebral tumor
  • supernuclear gaze palsy
  • negative response to lots of levodopa
  • MPTP exposure
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13
Q

How do PD patients typically respond to levodopa?

A

excellent response
> 10 yr response

(severe levodopa induced chorea)

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14
Q

What are the motor related S&S?

A

T remor
R igidity
A kinesia/bradykinesia
P ostural instability

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15
Q

What are the NON-motor related S&S?

A
  • malaise
  • easily fatigued
  • subtle personality changes
  • sleep disorder
  • constipation
  • pn
  • depression
  • dementia
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16
Q

What does a tremor of PD look like?

A

slow frequency; AT REST

  • inhibited during movement & sleep
  • aggravated by emotional stress
  • pill rolling quality
  • look at upper & lower extremeties @ rest
  • have pt reach out hands, tremor would reemerge after several seconds delay
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17
Q

Rigidity defintion:

A

resistance to efforts by the clinician to elicit passive joint movement
- may be any part of the body & related to stiffness/pn

  • examine for rigidity & ask about stiffness/pn
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18
Q

Bradykinesia definition:

A

generalized slowness of movements & repetitive movement fatigue
- may be decr. facial expression, difficulty with fine motor tasks, speaking softer, difficulty turning/getting out of bed/chair/car, shortened or dragging steps

  • observe sitting/walking
  • pt complains of: weakness, sluggishness, tiredness
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19
Q

Surgical intervention?

A
  • ablative surgery
  • pallidotomy (posterolateral part of the globus pallidus interna – contralateral dopamine)
  • thalamotomy (ventral intermediate nucleus – contralateral intractable tremor)
  • deep brain stimulation
  • –> thalamic stimulation (ventral intermediate nucleus)
  • –> pallidal stimulation
  • –> subthalamic stimulation (best at decr. contralateral bradykinesia & tremor)
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20
Q

Non-pharm options

A
  • PT
  • OT
  • Speech
  • Psychology

generally VERY beneficial

  • exercise may help improve motor function
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21
Q

What meds do we use in early disease?

A

MAO-B (selegiline, rasagiline, safinamide)
Amantadine
Anticholinergics (cogentin, artane)
DA agonists (requip, mirapex, neupro)

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22
Q

When do we avoid anticholinergics?

A

patients > 70 yo

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23
Q

When do we want to use DA agonists?

A

< 65 yo

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24
Q

Selegiline

A

early stages of PD or adjunct to L-dopa (delay levo by 9 mo)

  • improves wearing off
  • DI: meperidine, DM, sympathomimetic amines, SSRI

(MAO-Bi)

25
Q

What are MAO-Bi known for?

A

worsening dyskinesias

26
Q

Rasagaline

A
  • mono or adjunct to levo
  • improves wearing off
  • treat motor complication of random-off

CI: cyclobenzaprine, mirtazapine, St. John’s wort, meperidine, methadone, tramadol, DM, sympathomimetic amines

27
Q

Safinamide

A

adjunct tx of wearing off (without worsening dyskinesias)
- no dietary restriction of tyramine

CI: MAOi, opioids, DM, SNRI, TCA, Cyclobenzaprine, methylphenidate, amphetamines, St. Johns wort

28
Q

Amantadine

A

EARLY PD
* benefit w/i a couple of days

improve dyskinesias & may alleviate tremor!

CAUTION: geriatric

SE: livedo reticularis (reddish mottling of skin), ankle edema, hallucinations

(+) decr. severity of dopa induced dyskinesias (antiglutamatergic)

(-) tolerance may develop, cognitive SE, withdrawal potential

29
Q

Anticholinergics

A

(benztropine, trihexyphenidyl)

  • tremor = not relieved by agonist or l-dopa
  • combo c other meds for PD
  • improve bladder dysfunction (female) & drooling
  • not in pt > 70 yo
30
Q

Anticholinergic AE

A
  • forgetfulness/ decr. ST memory
  • hallucinations, psychosis
  • dry mouth
  • blurred vision
  • constipation
  • trouble with urination (worsens BPH)
31
Q

What do we use in mod-severe disease?

A
  1. DA agonists
  2. Levodopa/carbidopa
  3. Combo tx
32
Q

Peripheral AE of DA agonists

A
  • N/V

- ortho HoTN

33
Q

Central AE of DA agonists

A
  • motor changes
  • dyskinesias
  • psychiatric disturbances
  • pedal edema
  • pleuropulmonary (ergots)
34
Q

Are DA agonists or L-dopa more likely to cause dyskinesias?

A

L-dopa

35
Q

DA agonists

A

(+) antiparkinsonian effects, decr. risk for l-dopa related motor complications

(-) neuropsych SE, erythromelagia, pedal edema, sedative SE

  • 4-6 wks before you can see improvements
36
Q

L-dopa counseling points

A
  • avoid giving WM to improve absorption in severe disease

AE:

  • dopaminergic
  • peripheral (usually controlled by adding carbidopa)
  • central
  • at least 3 days bw dose adjustments
  • 2-3 wks for therapeutic response (quicker than DA agonists)
37
Q

L-dopa advantages & disadvantages

A

(+) best anti-parkinsonian drug, works with most pts, maybe improve mortality?

(-) SE, dyskinesias/dystonias, motor changes, neuropsych sx, sedation

38
Q

Initial tx: levodopa/carbidopa

  1. age
  2. funct
  3. AE
A
  1. all pt
  2. sustained tx benefits
  3. dyskinesias/ motor fluctuations
39
Q

Initial tx: DA agonists

  1. age
  2. funct
  3. AE
A
  1. immediate tx response NOT needed (< 65 yo)
  2. decr. risk of dyskineasias/motor complications
  3. incr. risk for impulse control disorder
40
Q

What agents are adjunct tx?

A
  • COMTi
  • apomorphine
  • istradflylline (adenosine a2 blocker)
41
Q

Catachol-O-methyl-transferase (COMT)

A
  • extend levodopa effect = decrease “off” time

- may incr. dyskinesias –> DECR. L-dopa dose

42
Q

COMTi AE

A
  • diarrhea
  • central & peripheral DA SE
  • liver toxicity (tolcapone)
43
Q

COMT (+) & (-)

A

(+) decr. “off” time, enhanced motor responses in pts with L-dopa motor fluctuation, improved ADL scores if stable L-dopa responders
* better if at onset of L-dopa tx

(-) DA SE (dyskinesias), discoloration of urine,
- tolcapone: explosive diarrhea, liver tox

44
Q

Apomorphine

A
  • acute, intermittent tx of hypomobility “off” episodes

CI: 5HT3 & COMTi

AE:

  • severe N/V (coadmin w/ trimethobenzamide)
  • angina
  • cardiac arrest
  • HoTN & ortho HoTN
  • MI
  • syncope
45
Q

Istradeflylline

A
  • for “off” periods as adjunct to carbi/levo

special dosing for:

  • smoking > 20 cig/d = 40 mg
  • on CYP3A4i = 20 mg
  • CYP3A4 inD = DO NOT USE
46
Q

Istradeflylline AE:

A
  • dyskinesias
  • dizziness
  • constipation
  • N
  • hallucinations
  • insomnia
47
Q

What happens with DA excess?

A
  • dyskinesias
  • hallucinations
  • delusions
48
Q

What happens with DA deficiency?

A

worsening PD symptoms

49
Q

What do we do abt: Random off?

A

sx unrelated to med dosing time

  1. entacapone and rasagiline
  2. pergolide, pramipexole, ropinirole, tolcapone
  3. apomorphine, cabergoline, selegiline
50
Q

What do we do abt: wearing off?

A

sx @ the end of dosing interval (plasma levels decr.)

  • incr. dose frequency
  • CR carb/levo
  • DA agonist
  • selegiline, rasagiline
  • COMTi
  • amantadine
51
Q

What do we do abt: dyskinesias?

A

involuntary movements during PEAK plasma levels

  • amantadine
  • smaller/ more frequent doses
52
Q

What do we do abt: dystonias?

A

sustained muscle contractions/ abnorm postures (distal lower extremeties)

  • HS SR carbido/levod
  • DA agonists
  • baclofen
  • botulinum toxin
53
Q

What can we use for depression in PD pts?

A
  • SSRI, SNRI, bupropion
  • TCADs (amitriptyline, nortriptyline, desimpramine)
  • caution c worse cognition, ortho HoTN –> fall risk

(pramipexole with motor & mood sx are targeted

54
Q

What can we use for psychosis with PD?

A
  • Quetiapine
  • Pimavanserin
  • Clozapine
55
Q

What about PD + mild cognitive impairment?

A
  • atomoxetine
56
Q

What about dementia + PD?

A
  • donepezil

- rivastigmine

57
Q

What if pt experiences ortho HoTN?

A
  1. incr. fluids + Na consumption, elevate head of bed, compression stockings (non-pharm)
  2. fludrocortisone
  3. midodrine
58
Q

What is Sialorrhea?

How do we treat?

A

excess drooling

  1. glycopyrrolate/scopolamine transderm
  2. botulinum tox
  3. atropine drops

CNS Module: Exam 2 (8 decks)

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