Parkinson’s Disease (2)

Question 1

What is it the most common type of?
→ What is this characterised by?

What is its pathophysiology?

Answer 1

➊ Parkinsonian Syndrome
→ Bradykinesia + 1 of rigidity, tremor or postural instability

➋ Loss of dopaminergic neurons in substantia nigra

Question 2

What are the motor symptoms it presents with?

What are the features of a Parkinsonian gait?

What are the non-motor symptoms most present with?
→ What does very prominent autonomic dysfunction point towards?

Answer 2

➊ Parkinsonian Triad:
• Bradykinesia - Actions slow and decrease in amplitude with repetition, e.g. parkinsonian gait, blink rate, micrographia, hypomimia
• Resting tremor - often ‘pill-rolling’ of thumb over fingers
• Rigidity

➋ Shuffling, forward tilt, stooped posture with reduced arm swing and asymmetric tremor – There is also, festination (tendency to pick up speed)

➌ • Autonomic dysfunction – constipation, postural hypotension, sweating, impotence, nausea, sexual dysfunction
• REMS disorder
• Loss of smell
• Cognitive impairment – affects most in the end
• Psychiatric features – depression, anxiety, hallucinations
→ MSA

Question 3

How does a Parkinson’s tremor differ from a Benign Essential tremor?

Answer 3

Parkinson’s tremor:
• Asymmetrical
• Present at rest
• Goes with intention
• Other PD features
• No change with alcohol

Benign Essential Tremor:
• Symmetrical
• Not present at rest
• Postural - Worse with intention
• No other PD features
• Improves with alcohol

Question 4

How is it investigated?

Answer 4

DAT scan

Question 5

Management:
What will these pts have with medication?
→ Why is this important to take into account?

What is the best drug for it?
→ What is the main SE? When does it occur?

What are other drug options?

What will occur as the disease progresses?

Answer 5

➊ On and off periods, which become more common as the drug decreases in efficacy over time
→ So you know when to start pharmacological management – May be better to start late (e.g. when 70+) or when PD seriously interferes with life

➋ Levodopa - Best drug for symptoms but becomes less effective over time, therefore is often kept for when other options are no longer effective
→ Dyskinesia, which occurs when the dose is too high – Dystonia, Chorea, Athetosis (writhing movements)

➌ DA, COMT-I, MAOB-I, NMDA R Antagonists

➍ • End-of-dose effects – Motor activity declines as the previous dose wears off
• On-off phenomena – Random fluctuations in drug effect

Question 6

Parkinson-plus Syndromes:
What are the different types? How does each present?

Answer 6

• Progressive Supranuclear Palsy (PSP) – Parkinsonism and Vertical gaze palsy, rigidity of trunk >limbs; symmetrical onset, bulbar symptoms, little tremor
• Multiple System Atrophy – Degeneration of neurones of multiple systems in brain, affecting basal ganglia – Parkinsonism and early autonomic dysfunction (postural hypotension, constipation, sexual dysfunction)
• Lewy Body Dementia – Cognitive impairment and visual hallucinations before Parkinsonism
• Corticobasal Degeneration – Parkinsonism and spontaneous activity or akinetic rigidity of a limb