Parkinson's Disease Flashcards
What is PD
UMN Progressive disease
Define Parkinsonism
Clinical syndrome characterized by a variable combo of motor signs
- Tremor
- Bradykinesia
- Rigidity
- Decreased postural control
- Gait difficulties
Define syndrome
A group of symptoms that occur together
Define Idiopathic Parkinson’s Disease
Chronic, progressive neurodegenerative condition characterized by degenration of dopaminergic neurons, leading to both motor and non-motor impairments
What is the 2nd most common neurodegenerative disorder
Idiopathic Parkinson’s Disease
By 2040, how many people will have PD (estimate)
13 million people
How many people each year are diagnosed with PD in the US
60,000
What percent of US pop over 65 has PD
1.6%
T or F: More females have PD
F - more men
What decade of life does a diagnosis usually occur?
5th and 6th decade of life
What percent of people show symptoms < 45 yo
5-10% of people
What does dopamine depletion in PD lead to
Abnormal habitual learning and loss of motor control
What is loss of automaticity
Inability to perform movements without attention directed towards the movement
What occurs with loss of automaticity
Habitual behaviour decrease/problems
Flexibility of motor behaviour is reduced
Dual tasking decreased
Exaggerated dependence on external motor drive
What does loss of automaticity contribute to
Micrographia Decreased: - arm swing - stride length - facial expression
What gets damaged in PD
Sensorimotor striatum of the BG - SNc
What is the etiology of PD?
- Unknown but combo of: genetic toxic infectious other/unkown
How is a diagnosis Made
ABSENSE of a specific marker or diagnostic test (It’s a diagnosis of exclusion)
What is a DaTSCAN
- Specialized imaging technique captures detailed pictures of the dopamine neurons that is able to determine whether there is a REDUCTION OF DOPAMINE CELLS, which usually occurs w/PD
How is a clinical Dx made
Med Hx, presentation of symptoms (unilat onset, resting termor, levodopa response, LT comp. of levadopa treatment), exam findings, response to meds, and disease course
What is a method used to classify the degree of pathology in PD?
Braak Stages of PD
Presentation of Braak Stages 1 & 2
Impaired olfaction and constipation, possible presence of lewy bodies
When in the Braak stages are ___ displayed?
a) Sleep
b) Motor
c) Emotional
d) Cognitive
a) Mid-stage (3&4)
b) Mid-stage (3&4)
c) Later braak stages (5&6)
d) Later braak stages (5&6)
What occurs in the brain in Braak 3&4
Lewy bodies move to midbrain and frontal cortex
What occurs in the brain in Braak 5&6
Lewy bodies move to frontal cortex and sensorimotor cortex
What is a method used to measure the degree of disease in PD?
Modified Hoehn and Yahr Staging
What is Stage 0 of Modified Hoehn and Yahr Staging
No signs of disease
What is Stage 1 of Modified Hoehn and Yahr Staging
Unilateral disease
What is Stage 1.5 of Modified Hoehn and Yahr Staging
Unilat + axial
What is Stage 2 of Modified Hoehn and Yahr Staging
Bil disease w/o impairment of balance
What is Stage 2.5 of Modified Hoehn and Yahr Staging
Mild bil disease with recovery on pull test
What is Stage 3 of Modified Hoehn and Yahr Staging
Mild to moderate bil disease; some postural instability; physically independent
What is Stage 4 of Modified Hoehn and Yahr Staging
Severe disability; still able to walk or stand unassisted
What is Stage 5 of Modified Hoehn and Yahr Staging
WC bound or bedridden unless aided
What are some premanifest symptoms of PD
Hyposmia (decreased olfaction) Constipation Depression & Anxiety REM sleep behaviour disorder Dec. Arm swing Mild motor fun. changes
What are some early symptoms of PD
Unilat tremor Rigidity Mild gait hypokinesia Micrographia Reduced speech volume
What are some middle symptoms of PD
Bil bradykinesia, axial and limb rigidty
Bal and gait dficits/falls
Speech impairments
May need ass toward end
What are some late symptoms of PD
Severe voluntary mvmt impairments
Pulm fun & swallowing
Dependence in mobility, self-care, and ADLs
What are the clinical features of PD
Tremor
Rigidity
Bradykinesia
Loss of postural control
What is the first sign in 70% of people w/PD
Tremor
T or F: Tremor is a fast frequency
False, it is slow, low (4-6 Hz)
List and define the two types of rigidity
Cogwheel: Jerky resistance to passive mvmt
Leadpipe: Sustained resistance to passive movement
What mm group is more affected w/Rigidity
Flexors –> stooped posture
Proximal earlier
What is rigidity characterized by
Characterized by increased resistance to passive movement that affects proximal mm early
What is the most disabling of the early PD symptoms?
Bradykinesia
Define bradykinesia
Slowness of voluntary mvmt
Define Hypokinesia
Reduction in mvmt amplitude - primary cause of dec gait speed and step length
Define akinesia
Freezing episodes
T or F: Individuals w/PD have perfect kinesthetic perception
False - it is impaired
What is true of postural control
It worsens with disease progression and:
- Dec. limits of stability, mag. of postural responses
- Impaired postural adaptations
- Altered anticipatory postural adjustments
What % of PD Pts have fallen in the previous year
70% of PD Pts
What are some secondary motor symptoms
Motor performance
Gait
Dual Tasking
What gait disturbances are present w/PD
Slower, shorter step lengths w/Inc. variability and dec. trunk rot.
What is true of dual tasking in PD
It will lead to dec. gait speed and inc. gait variability and manifests as difficulties prioritizing attention in complex environments
What is hypokinetic dysarthria
Reduced speech volume, monotone speech, mumbled and imprecise articulation, variable speaking rates
What is Hypomimia
Reduced facial mvmts/expression, slowed eye mvmts/blinking,
What is micrographia a form of
Hypokinesia
List some nonmotor symptom categories of PD
Autonomic dysfunction
Cognitive and emotional dysfunction
Sensory
Sleep disorders
What is important about nonmotor symptoms
THEY ARE TREATABLE
What is postprandial hypotension
BP drops after meals
What are some Autonomic Dysfunctions that can occur w/PD
CV Dysfunction Thermoregulatory Dysfunction (hyperhydrosis) Fatigue Respiratory Dysfunction
What are some examples of CV Dysfunction
Orthostatic hypotension and post prandial hypotension
What are some respiratory dysfunctions w/PD
Difficulty with getting air out
What are some Cog/Emo/Behav. Changes
Apathy and OC Behaviour
What sensory changes w/PD
Olfactory - 70-90% Pts
Visual - “tired eyes”
What can be a treatment of OH
Immediately: Drink 12-16 oz of ice water
Chronic: Inc. fluid and salt, elevate head of bed, abd binder, pressure stockings
What is a good treatment for fatigue in PD
EXERCISE !!!
What is a good treatment of Respiratory Dysfunction
Inspiratory and expiratory mm strength training
What percept of PD Pts develop:
Major depression
Anxiety
30-45 dep
25-49 anx.
What are the goals of medicine
1) Provide symptomatic relief for motor and non symptoms
2) Min. motor fluctuations and max “ON” Periods
3) Increase amount of dopamine available in BG
List the medications for motor symptoms
- L-Dopa
- Dopamine agonist
- COMT Inhibitors
- MAO-B Inhibitors
- Antiviral
- Anticholinergics
When was L-dopa first introduced
Late 60s
What is the most effective treatment of motor symptoms of PD
Carbidopa + Levodopa to prevent L-DOPA being converted into dopamine in the bloodstream and reduce risk of side effects
When should L-dopa be taken for max absorption
1/2 hour prior to mean and 1 hr after a meal
What is a myth about L-dopa and what is the truth regarding it
Over time L-dopa stops working - False, overt the therapeutic window narrows as the efficacy threshold rises, and the dyskinesia threshold lowers
What are the L-dopa risk factors for motor compications
Younger age at onsent of PD
Disease severity
Higher daily L-dopa dosage
Longer disease duration
What is a dopamine agonist
A drug that mimics dopamine by stimulating postsynaptic dopamine receptors directly that works to treat the 4 primary clinical PD symptoms
What is COMT
An enzyme involved in the peripheral degradation of L-dopa/dopamine
What is a COMT inhibitor
Blocks the COMT enzyme to increase the availability of dopamine and effectively allow more time for L-dopa to be absorbed in the brain
What is MAO
An enzyme in the cells of the body that breaks down neurotransmitters, w/B being mainly in the brain
What is a MAO-B inhibitor
A drug that blocks the action of MAO-B to provide the brain more time to absorb and potentially boost the effectiveness of levadopa
What antiviral drugs are used for PD and why
Amantadine to increase release of DA and then blocks ACh receptors -> can decrease dyskinesia
What is the role of Anticholinergics in the treatment of PD?
To treat tremors by blocking ACh receptors to inhibit dopamine reuptake
List the 2 types of Sx Procedures that can be done for PD
Lesioning procedures
DBS
What are some types of lesioning
Both rarely performed today
Pallidotomy (GP destroyed)
Subthalamotomy (subthalamic nuc. destroyed)
What is done in DBS
Electrode into brain and attaching it to computerized pulse generator which is implanted under the skin in the chest
What are the 3 DBS targets for PD
STN (Subthalamic nucleus)
GPi (Globus Pallidus Interna)
Thalamus
T or F: DBS increases the amount of dopamine in the brain
FALSE!! It paces the nuclei (STN and GPi) w/a constant steady-frequency to compensate for the excessive and abnormally patterned electrical dc in the GPI or STN
1) DBS candidate
2) DBS non-candidate
1) Pt w/PD that is dopamine responsive, age 20-75
2) Non PD Parkinson symptoms, severe cognitive/depressive symptoms, inability to have sx, poor compliance or poor social support systems
Which are some benefits of DBS
dec.: dyskinesia, dystonia, tremor, brady/hypokinesia, stiffness
Improve sleep
What are some risks of DBS
2-3% risk of stroke, dec. in verbal fluency, changes in modd/apathy
Define capacity
What you measure in the clinic
Define performance
Measured in real life
What is true about people w/PD and exercise?
Although Pts know the importance of exercise, they are not meeting the recommendations
T or F: Once Pts reach moderate PD, it is too late for them to start exercising
FALSE!!! Exercise will make improvements in dopamine loss at any point in the disease
What are the key elements of PT Intervention?
- Early referral
- Promote an active lifestyle
- Rx of exercise [aerobic, strength, flexibility, and balance]
- task specific training
