Parkinson's and MS

Question 1

What is the diagnostic criteria for Parkinson’s NCD

Answer 1

• established parkinson’s disease
• insidious or gradual onset
• not better explained by other NCD

diagnose if :

1. no mixed aetiology
2. parkinson’s clearly preceeded onset of NCD

Question 2

what are the four cardinal motor features of parkinsons

Answer 2

 Bradykinesia (slow and small movements). Reduced blink, face expression, and gesturing. Soft voice. Difficulty getting out of chair, shuffling steps, reduced arm swing, freezing
 Tremor (usually resting) “pill rolling”, often involves thumb
 Rigidity (different from spasticity)
 Postural changes. Imbalance, falls; stooped flexed posture

pyramidal movements are intact but extrapyramidal is not

crab writing

Question 3

what are parkinsonisms

Answer 3

 Parkinson disease (idiopathic or genetic)

 Parkinson-plus degenerations (dementia with Lewy bodies, progressive supranuclear palsy, corticobasal degeneration, multiple system atrophy)

 Drug-induced parkinsonism (anti-dopaminergics)

 Rare but treatable in young people: Wilson disease
and Dopa-responsive dystonia

 Other: “vascular” parkinsonism, brain trauma, CNS infection

Question 4

Describe drug-induced parkinsonism

Answer 4

 Drugs that reduce dopamine transmission

 Antipsychotics / antiemetics: Risperidone, haloperidol, metoclopramide, promethazine, prochlorperazine, etc.

 Can be indistinguishable from PD

 Clozapine does not seem to cause it; quetiapine appears to have low rates

 Management: reduce or discontinue offending agent. Can take months to resolve!

Question 5

early complaints in PD?

Answer 5

 Resting tremor
 Writing smaller; harder to do buttons
 Slowness, “weakness”, limb not working well
 Stiff or achy limb
 Stoop, shuffle-walk, “dragging” leg(s)
 Trouble getting out of chairs or turning in bed
 Low or soft voice
 Non-motor: anosmia, dream enactment, constipation, anxiety, depression, “passiveness”

Question 6

pharmacotherapy for PD?

Answer 6

L-dopa (with carbidopa) is most effective and usually best tolerated

Dopamine agonists (ropinirole, pramipexole)

Others have only modest benefits (MAO- B inhibitors, anticholinergics, amantadine)

Question 7

When taking medicatio for PD, describe the fluctuation in . motor complaints

Answer 7

Fluctuations. Medication wears off before next dose. OFF periods worse as disease progresses.

 Dyskinesias (usually at the peak of ON) – more movement, chorea.

Need larger and/or more frequent med
doses, or combinations of drugs.

 Deep brain stimulation an option for some patients with medically refractory motor complications.

Question 8

What are some motor symptoms that may not respond to med adjustments?

Answer 8

Postural instability and falls
Freezing of gait
 Fatigue
Dysarthria, dysphagia 
Some tremor (!)

Question 9

hallucinations in pD?

Answer 9

• visual (not auditory like in SCZ)
• benign
• Main contributors are disease progression (brain pathologic changes), age, and meds
• Older patients much more at risk

Question 10

what is cogwheel rigidity

Answer 10

like a cog, if your rigidity occurs in the context of a tremor, you get some movement as the tremor happens, like a cog wheel.

opposite is lead pipe rigidity

Question 11

Describe PD dementia

Answer 11

 PDD is a cognitive, and neuropsychiatric disorder that occurs in patients with Parkinson’s disease
 Core of diagnosis is Idiopathic Parkinson’s disease
 PDD follows a PD diagnosis
Cognitive decline at least 1 yr. after PD

Question 12

What does the cognitive PD profile look like?

Answer 12

 Impaired memory (retrieval > amnestic pattern)
Benefit from external cues
Preserved recognition
 Executive dysfunction
Concepts, problem solving, set shifting
Internally cued behaviour
 Attentional impairment
Reaction times and vigilance
Fluctuations
 Visuospatial deficit
Visuospatial analysis and orientation
Tasks that require planning and sequencing
 Bradyphrenia - slowness of thought

• personality changes
• depressive synmptoms
• REM sleep disorder
• hallucinations

Question 13

What are some limitations of the current therapies for PD

Answer 13

 Dopaminergic therapy
Exacerbating/ triggering psychotic symptoms

 Neuroleptics (atypical)
Hypersensitivity to neuroleptics
Complications of antipsychotics in elderly (mortality rates)
 Worsening cognitive function
 Worsening motor problems