Parkinson's Disease

Question 1

Characteristics of Parkinsons

Answer 1

Akinesia/Bradykinesia
Tremor
Rigidity
Postural Instability

Caused by degeneration of dopaminergic neurons of the pars compacta in the substantia nigra

Tremor not needed for diagnosis but bradykinesia is

Idiopathic PD refers to PD not secondary to drugs, vascular disease or PD plus disorder

Question 2

History of parkinsons

Answer 2

Family Hx

Prodromal pre-motor symptoms (can be the first 10 years)

• asomnia
• depression
• REM behavioural disorder
• Autonomic effects (hypotension, urinary incontinence, constipation)
• dementia, visual hallucinations
• restless leg syndrome
• Dribbling

Key motor features

• Usually symetrical onset
• slowness, stiffness, tremour
• freezing, dyskinesia, wearing off

Drugs
- current and past, concordance

ACP/EPOA - normally ends in significant dysphagia, autonomic dysfunction and psychiatric illness
Support
- Formal, informal including PD society

Question 3

Examination

Answer 3

Aim to demonstrate PD not PD plus disorder

General inspection

• masked facies
• flexed posture (can’t lie flat on pillow)
• Tremor
• Dribbling
• Speech - slow and monotone

Core features - TRAP
Tremor
- pill rolling increasing on distraction with movement of other hand and decrease on holding hands out flat
-Change of hand flap, intention tremor and postural tremor

Rigidity

• Cogwheel
• can distract by tapping opposite knee

Akinesia (bradykinesia)

• finger tapping slow
• decreased RAM, shuffle walk

Postural instability

• Ask to stand, walk and turn around
• Hesitancy, shuffling gait, loss of arm swing

EXTRA:
Glabellar tap - failure of attenuation blink
ocular movement - weakness of upwards gaze
Lying standing BP

FUNCTION:
write name and address - micrographia
undo a button

Question 4

Diagnosis

Answer 4

by a specialist
without medication
bradykinesia with one other clinical sx

Question 5

Differential Diagnosis

Answer 5

Parkinsons plus syndromes

1. Progressive supranuclear palsy - early postural instability, vertical gaze palsy, rigidity trunk>limbs, pseudo-bulbar palsy, symmetrical onset, unusual tremor
2. Multisystem atrophy - early autonomic features, rigidity>tremor
3. Cortico-basal degeneration - akinetic rigidity affecting one limb
4. Lewy body dementia - early dementia with fluctuating cognition and hallucination
5. Vascular parkinsonism - Legs>arms, prominent gait abnormality

Drug induced

1. Antipsychotics - haloperidol and lithium
2. dopamine receptor antagonists - prochlorperazine, metocloperamide

Toxins
1. copper (wilsons disease)

Question 6

Investigations

Answer 6

CT or MRI if no tremor to exclude brain lesion
Younger patients should have slit lamp for KF rings or serum copper
Olfactory testing

Question 7

Management - NP

Answer 7

Education
Exercise - PT
MDT - PD nurse, GP, respite care, SLT

Question 8

Management - P

Answer 8

treatment of non-motor symptoms

• Depression = SSRI
• Psychosis = quetiapine or olanzipine

Sinemet
- Levodopa + dopadecarboxylase inhibitor
- Initial response dramatic reducing in efficacy over time
SE: dyskinesia, painful dystonias, nausea, psychosis

Dopaimne agonists

• Ropinirole - used as monotherapy to delay levodopa
• Apomorphine - continuous infusion or emergency pen for freezing

Anticholinergics
- help with tremor
SE: confusion, dry mouth, dizziness, urinary retention

INVASIVE:
DBS
Surgical ablation of overactive basal ganglia