Parkinson's disease Flashcards
Parkinson’s disease criteria
Gradual onset progressive:
1) Bradykinesia: slow initiation with reduced speed and amplitude of repetitive actions eg. finger or foot tapping
2) Or hypokinesia: poverty of movement:
- reduced facial expression, arm swing, blinking
- difficulty with fine movements - doing buttons, jars, micrographia.
- slow, shufflingg gait, freezing gait or difficulty turning in bed
+ >1:
1) Stiffness or rigidity: led pipe/cogwheel (if with tremor)
2) Rest tremor: improves on moving/concentrating/during sleep. Can be pill-rolling or affect wrist, leg, lips, jaw, head
3) Balance problems/gait disorder:: stooped, pull test - falls backwards
Non-motor:
1) Depression. anxiety
2) Anosmia
3) Cognitive impairment
4) Sleep disturbance
5) Constipation
Drug induced Parkinsonism
Typically rapid onset, bilateral and without rigidity, possibly action tremor.
1) Antipsychotics (within 10 weeks): 1st generation (haloperidol, chlorpromazine, penthixols) > 2nd generation (amisulprode, aripiprazole, olanxapine, quetiapine, risperidone)
2) Anti-emetics: prochlorperazine, metoclopramide
Less commonly: SSRI, CCB, amiodarone, lithium, donepezil, memantime, sodium valproate, methyldopa
Progressive supra nuclear palsy
Early dysphagia, gaze palsy, recurrent falls
Multiple system atrophy
Severe autonomic involvement eg. postural hypotension or cerebellar ataxia
Wilson’s disease
Kayser-Fleischer rings, tremor, ataxia, dystonia, liver disease
Essential tremor
Bilateral, symmetrical
Worsens with stress, caffeine, sleep deprivation
Improves with alcohol and BB
Use SPECT if can’t differentiate essential tremor from tremor in PD
Driving in Parkinson’s disease
Must notify DVLA
G1: may drive if safe
G2: may drive if safe, review annually
Medical management of Parkinson’s disease - motor symptoms
1) Levodopa + co-beneldopa/careldopa to prevent peripheral metabolism of LD and reduce SE
- LD improves motor symptoms, but can cause motor complications eg. dyskinesias
2) MAO-B inhibtitors (selegiling, rasagiline, safinamide)
- less improvement in motor fumnction, but less motor complications
3) Oral dopamine agonists (praipexole, ropinirole, rotigotine)
- less improvement in motor symptoms, less motor complications, more adverse effects (sleepiness/halls/impulse control)
4) Ergot derived dopamine agonists (cabergoline, pergolide)
- risk of cardiac fibrosis with long-term use therefore not used 1st line
Adjuvant treatments:
1) COMT inhibitor (entacapone, opicapone) - with levodopa if develops dyskinesia or motor fluctuations despite optimal LDopa therapy
2) Amantadine - for dyskinesia
3) S/C apomorphine - for freezing episodes on optimal treatment
4) DBS
Nausea & vomiting in PD
If medication related should settle, take with food.
Avoid metoclopramide or prochlorperazine
Consider low dose domeridone (increased risk of VT and also QT prolongation with apomorphine)
Specialists may increase proportion of co-careldopa to L-Dopa
Which PD medication is best for motor symptoms?
Levodopa
Which PD medication is best for ADLs?
Levodopa
Which PD medication has most motor complications?
Levodopa
Which PD medication has most adverse events - excessive sleepiness, hallucinations, impulse control disorders
Dopamine agonists (pramipexole, ropinirole, rotigotine). Increased risk if history of alcohol/smoking or impulsive behaviours
Impulse control disorders - gambling, hyper sexuality, binge eating, obsessive shopping - can offer CBT if modifying DA therapy not effective
First line treatment in early PD if motor symptoms impact on QoL?
Levodopa
First line treatment in early PD where motor symptoms do not impact on QoL?
Choice of levodopa, DA agonists, MAO-B inhibitors
Which medication is not offered first line in PD?
Ergot-derived DA agonists (bromocriptine, pergolide, cabergoline)
Managing day-time sleepiness in PD
1) Inform DVLA, stop driving
2) Modafinil (CI in pregnancy)
Managing REM sleep behaviour disorder (?+ restless leg syndrome) in PD
Cloazepam or melatonin
Managing noturnal akinesia in PD
Levodopa or DA agonists
Consider rotigotine patch if levodopa and/or PO DA agonists not effective
Managing orthostatic hypotension in PD
Causes: anti-HTN, dopaminergic, anticholinergics, antidepressants
Consider midodrine (monitor for supine HTN)
If midrodrine CI/not tolerated - consider fludrocortisone
Managing hallucinations and delusions in PD
If not tolerated by patient and family consider quetiapine if no cognitive impariemt
If not effective, offer clozapine
Lower doses of quetiapine and clozapine are needed in PD
Do not offer olanzapine
Phenothiazines and butyrophenones can worsen motor features
Managing PD dementia
Offer cholinesterase inhibitor in mild-moderate dementia (consider in severe dementia)
Rivastigmine capsules are the only one authorised.
can use donepezol, galantamine and rivastigmine off-label
If cholinesterase inhibitors not tolerated /CI consider memantine
Managing drooling of saliva in PD
1) SALT
2) If SALT not effective consider glycopyronium bromide
3) If GB not effective or CI (cognitive impairment, hallucinations, delusions, adverse reaction to anticholinergics) - consider Botox
PD and physical activity
1) early physio
2) disease specific physio
3) Alexander Technique if balance/motor function problems
