Parkinson's disease Flashcards
describe PD
a chronic, progressive neuro disorder characterized by tremor, bradykinesia, rigidity, and postural instability
what are some genetic factors that could lead to PD
parkin gene
alpha synuclein
what are some toxin exposures that could lead to PD
exogenous: well waste, farming, heavy metals
endogenous: free radicals, infection, iron
what factors increase risk of PD
age
rural residence, farming, pesticides
frequent consumption of dairy
what are protective factors of PD
cigarette smoking
coffee, tea, caffeine
possibly: diet, hormones, vascular, meds
drugs that can cause secondary parkinsonism include
dopamine blockers: AP, metoclopramide
dopamine depletors: methyldopa, reserpine
medical causes of secondary parkinsonism
normal pressure hydrocephalus (NPH)
infarction
infection
trauma
any lesions/ neoplasms to substantia nigra
which of the following is false about parkinson’s
1. affects race equally if in same community
2. hallmark features include resting tremor, rigidity, bradycardia, postural instability
3. smoking decreases risk
4. frequent dairy consumption increases risk
2- bradykinesia
what are the hallmark features of parkinson’s
resting tremor
bradykinesia
rigidity
postural instability
should PK pts take vit e or CoQ10 for neuroprotection
no
T or F: dopaminergic tx are neuroprotective
F
what is often the first sign of PK dx
olfactoy changes- may lose some sense of smell
is the LD challenge recommended for PK screening
no because it can change movement in normal people
PK dx must have
bradykinesia + at least 1 of tremor or rigidity + 2 supportive criteria (olfactory loss, dramatic response to dopaminergic tx)
what is the exclusion criteria + red flags for PK dx (give 2 examples)
exclusion: restricted to lower limbs, tx with dopamine blocker at onset
red flags: rapid progression, absence of nonmotor features at 5yrs
most patients with PK will die from
infections + complications from immobility
the prognosis for PK pt dx at midlife is
15-20yrs
what is stage 1 of PK
unilateral involvement only
what is stage 5 of PK
wheelchir bound/ bedridden unless assisted
list 3 outcomes of importance in PK tx
imaging techniques
time to change in management (time to start LD, amount of increase/ decrease in (LD dose)
time to clinical event (first dopaminergic complications, time to motor fluctuations)
caregiver burden
changes in clinical scales
HRQL (PD specific instruments)
economics
what is the difference between ADL and IADL
ADL = basic functions you do every day like eating, dressing, washing
IADL = not daily, but still essential like banking, laundry, cleaning
what are some nonpharm PD tx
rehab (PT, OT, SLP)
tech (computer based, VR, AI)
3 guidelines for PD rehab
refer to dietician for advise
advise to take vit D supplement
advise not to take OTC dietary supplements without first consulting HCP
give the 3 guidelines for early pharm tx in PD
LD may be started at lowest dose possible for sx in early PD
DA may be titrated to effective dose in early PD
MAO-Bi may be used as sx tx for early PD
adjunct may be added to LD if pt develops _____ or _______ despite optimal LD tx
dyskinesias or motor fluctuations
what is the preferred initial PD tx
LD
DA may be used for early PD in
<60yrs + high risk of dyskinesias
when to avoid DA in PD
> 70yrs, Hx ICD, preexisting cog impairment, excessive daytime sleepiness, hallucinations
MO-B inhibitors may be prescribed as initial dopaminergic tx for ___________ in pts with early PD
mild motor sx
which has more motor benefits? LD or MOBi
LD
which 2 MAOi are irreversible
selegiline, rasagiline
selegiline and rasagiline may be used as
initial monotx or as an adjunct to LD
safinamide may be used as
adjunct to LD
which MAOi’s active metabolites are amphetamines
selegiline
which MAObi should be avoided in older adults
selegiline
DA indications
used in early disease to minimize use of LD
used in late disease as adjunct to LD
characteristics of older DA agents include (4)
less receptor sensitivity
low cost
high ADR
adjunct
characteristics of newer DA agents include (4)
receptor specificity (D2-4)
high cose
lwoer ADR
adjunct or monotx
how to titrate DA dose
titrate slowly q1-2wks to effective dose
how should you decrease LD dose once a DA is added
decrease up to 25%
list 3 DA SEs
N/V
orthostasis
psychiatric conditions (2x LD) + hallucintions
syncope, excessive daytime sleepiness, insomnia, dyskinesias, addiction disorders
DA benefits are usually clinically significant for
1yr
which is more expensive, DA or LD
DA
which form of LD is used for PD
L form
starting, max, and usual ceiling dose of LD
start = 100/25 TID
max = 1500mg LD/d
usual ceiling dose = 800mg LD/d
what is the min dose of carbidopa to be used with LD? why is it added?
75mg/d
to prevent LD breakdown in periphery = allows same effect at lower doses = less vomiting potential
list the 4 LD products
sinemet
prolopa
stalevo
duodopa
sinemet IR and CR onset
IR = 30min
CR = 2h
pros of IR sinemet
rapid, immediate effect
ca nbe crushed, chewed
lower cost
CR sinemet pros
controls late stage complications
lower peaks
can be split
cons of IR sinemet
multiple doses/ day
dependence on burst
peak related dyskinesias
more fluctuations in sx
cons of CR sinemet
expensive
higher dose required
not chewed/ crushed
does not provide burst
clinicians should initially prescribe ____ levodopa rather than ___ levodopa or levodopa/ carbidopa/ entacapone in pts with early PD
IR rather than CR
dopamine metabolism produces
free radicles
characteristics of LD tx in early PD
smooth, extended duration of target clinical response
low incidence of dyskinesias
characteristics of LD in late PD
short duration of target clinical response
on time associated with dyskinesias
which COMTi is emergency release
tolcapone
what is entacapone
peripheral enzyme inhibitor (COMTi)
dosed with each LD dose
COMTi can reduce LD by ____ on average
25%
COMTi suggested early use wit hLD to ___________
decrease oxidative stress by lowering LD dose
SE of COMTi
excessive LD
COMTi intx
AD
drugs metabolized by COMT- dobutamine, epinephrine, methyldopa, isoproterenol
T or F; LD has disease modifying effects
F
T or F: there is no reason to delay LD tx
T
rank the following based on how often they are stopped (lowest to highest): LD, MAOi, DA
LD < DA <MAOi
LD vs DA
___ is better tolerated
____ has higher rates of SEs
_____ more likely to be stopped
____ has better sx control
____ have fewer motor complications
LD, DA, DA, LD, DA
which has fewer LT complications, but is less efficacious
1. LD
2. DA
2
which is better tolerated, better efficacy, but has higher motor complications
1. LD
2. DA
1
dopaminergic EDS counselling
is present in 50% of drivers = warm pts, may have to stop driving for at least 1mth
waht is the EDS
epworth sleep scale
impulse control disorders in PD are due to
dopamine increases from meds in the striatum
6 RF for ICD
young onset of PD, male, personality, unmarried Hx (fam, SU, psych), use of a DA
how to manage ICD
less aggressive DA use, slower titration
DBS may be considered
anti- ACh in PD
1. is a first line tx
2. is now rarely used
3. is useful in tremor or dystonia in older pts
4. may be used early in disease as adjuncts
2
anticholinergics in PD is useful in
tremor or dystonia in younger pts
amantadine was traditionally used in
influenza
amantadine use in
young pts, early tx
amantadine itnx
additive eff with anticholinergics
which NHPs contain Ldopa
ashwaganda
NHPs in PD
1. avoid all NHPs
2. overall weak evidence
3. must add on dietary restrictions
4. may use in place of DA tx
2- can still try but ask first
what is wearing off phenomenon
LD effect not lasting
what is on off phenomenon
changes in absorption, intx
dyskinesias on PD tx is due to
sensitization of receptors
dystonias in PD tx is due to
acute lack of dopamine
wearing off phenomenon onset
delayed (years)
on off phenomenon onset
delayed
dyskinesias onset from PD tx
early or delayed
dystonias onset from PD tx
early or delayed
what is a surgical intervention to PD
deep brain stimulation
thalamotomy
medial pallidotomy
fecal transplantation
challenges to DBS
not complete resolution of PD sx
complications like depression, behaviours, cog impirmenet
