Parkinson's disease 2 Flashcards
Epidemiology
1 in 500 adult population, 1% 65 year olds
Risk factors
- Advancing age
- Male (3:2)
- Caucasians > Asians and Africans
- Rural living and farmers (pesticides)
- Family history
- Previous head injury
- Idiopathic
Protective factors
Smoking and caffeine
Parkinsonism
Clinical syndrome comprising of bradykinesia (and one of..) Tremor, rigidity, postural instability
Biggest cause of parkinsonism?
Parkinson’s disease
How do you diagnose?
Pathology in brainstem and basal ganglia - Lewy bodies and neuronal degeneration (asymmetry, sustained response to levodopa)
Degenerative brain disorders caused by
Abnormal aggregation
Specifically in Parkinsons protein that aggregates is
Alpha-synuclein
Neurodegenerative causes of parkinsonism
Parkinson’s disease (PD), Lewy Body dementia (LBD), Progressive supra nuclear palsy (PSP), Multiple system atrophy (MSA)
2nd most common cause of Parkinsonism
Drug-induced
Drug-induced causes of parkinsonism
Dopamine antagonists (anti-psychotics, anti-emetics), Sodium valproate, MPTP
Other causes of parkinsonism
Vascular disease (stroke) and Metabolic (Wilson’s disease)
Wilson’s disease
Copper deposition in brain and liver
Bradykinesia
Slowed gait with shuffling steps, reduced facial express and blinking (hypomimia), reduced gesticulation, small handwriting (hypographia)
PD gait
Difficulty initiating, slowed pace, small steps, stooped flexed posture, festinating, several steps to turn, reduced arm swing, freezing, turn on block
Tremor
70%, begins in one hand, spreads bilaterally, rest tremor, reduces/disappears with action, leg and jaw tremors seen, ‘pill rolling’, distraction brings out tremor
Rigidity
Stiffness, ‘lead pipe’ rigidity, co-activation brings it out
Cogwheeling
Combination of rigidity and tremor
Other clinical features
Anosmia, sleep disturbances (REM behaviour disorder), hypophonia, dysphagia, dystonia, constipation and urinary disturbance, autonomic disturbance, depression and anxiety, dementia
Less dopamine leads to
Abnormal movements
Imaging
CT/MRI - normal
DaTscan (FP-CIT SPECT)
Nuclear medicine scan - inject tracer that binds to dopaminergic neurones (normal in central tremor and drug induced)
Problems with DaTscan
Expensive, Ionising radiation, cannot differentiated between PD and PD+ syndromes, (not specific), not widely available, takes a full day
DaTscan (FP-CIT SPECT)
Normal - comma
PD - full stop
Non-pharmacological treatment
Physio, OT, speech and language therapy
Dopamine agonist
Gets cells left to work harder (ropinerole, pramipexole, rotigotine, apomorphine)
L-Dopa
Pre-cursor of dopamine (Co-careldopa, Co-beneldopa, Duodopa (PEJ)
MAO-I
Rasagiline, selegiline
COMT-I
Entacapone, tolcapone
PD drugs
Increase dopaminergic stimulation to improve movements, tremor rigidity, increase ‘on’ periods and reduce ‘off’ periods
Too much dopaminergic stimulation
Abnormal movements (dyskinesia), confusion, hallucinations, impulse control disorders
Impulse control disorders
Hyper sexuality, gambling, excessive eating, failure to resist temptation, urge or impulse
Advance PD treatments
- Apomorphine (sb injection)
- Duodopa (L-dopa gel via PEJ tube)
- Deep brain stimulation (inhibits parts of basal ganglia)
Apomorphine
Potent dopamine agonist, skin nodules, similar adverse effects to other dopamine agonists, several months to find optimal dose (£10,000/year)
Duodena
16 hours a day straight into stomach (£30,000/year)
Deep brain stimulation
Risks 1% stroke, 2-4% infection
Prognosis
- Maintenance 5-10yr
- Complex 5 yr (swallowing)
- Palliative 3 yr (dementia, death)
What is commonest cause of death in PD?
Pneumonia
