Parkinson's disease

Question 1

What is the classic triad of signs with parkinsonism?

Answer 1

Tremor

Rigidity

Bradykinesia/hypokinesia

Question 2

Is parkinsonism the same as Parkinson’s disease?

Answer 2

No

There are multiple causes of parkinsonism, of which Parkinson’s disease is only one

Question 3

Is the tremor of parkinsonism worse with action or at rest?

Answer 3

At rest

Question 4

Is the tremor of parkinsonism faster or slower than a cerebellar tremor?

Answer 4

Slower

4-6 Hz

Question 5

What is the characteristic tremor that those with parkinsonism display?

Answer 5

‘Pill-rolling’ movement of thumb over fingers

Question 6

How does the gait change in parkinsonism?

Answer 6

Reduced arm swinging

Festinance (short, shuffling steps with flexed trunk as if forever a step behind one’s centre of gravity)

Freezing at obstacles and doors

Question 7

Describe the bradykinesia associated with parkinsonism

Answer 7

Slowness of movement initiation with progressive reduction in speed and amplitude of repetitive actions

Paucity of movement (expressionless face, decreased blink rate, scanning speech, micrographia)

Question 8

What are some causes of parkinsonism?

Answer 8

Idiopathic

Parkinson’s-plus syndromes (PSP, SA, CBD, lewy-body dementia)

Trauma (pugilistic encephalopathy)

Drug induced (prochlorperazine, neuroleptics, metoclopramide)

Question 9

What is the definition of Parkinson’s disease?

Answer 9

Sbradykinesia/hypokinesia bradykinesiaen dromedaryhypokinesia plus at least one of rest tremor, postural instability without other cause, or muscular rigidity

Question 10

What is the pathophysiology of Parkinson’s disease?

Answer 10

Degeneration of dopamine rich neurons in the substantial night pars compact causing decreased striated dopamine levels

Question 11

What is thought to be the reason for the degeneration seen in Parkinson’s disease?

Answer 11

Thought to be related to mitochondrial DNA dysfunction

Question 12

What are some non-motor features of Parkinson’s disease?

Answer 12

Anosmia, depression, dementia, REM behavioural sleep disorder, L-Dopa side effects

Question 13

What is the mean age of onset of Parkinson’s disease?

Answer 13

65 years

Question 14

What is the key decision in the management of Parkinson’s disease and why?

Answer 14

When to start L-Dopa administration

Because of end-of-dose wearing off, and dopamine-induced dyskinesias

Question 15

Over what timeframe will patients develop dopamine-induced dyskinesias?

Answer 15

5-10 years

Question 16

When should you start a patient on L-Dopa?

Answer 16

Over the age of 80

Or when Parkinson’s disease interferes with ADLs

Question 17

What alternative treatments can you use in Parkinson’s disease to delay the use of L-Dopa?

Answer 17

Dopamine agonists and MAO-B inhibitors

Question 18

What surgical options are available in the treatment of Parkinson’s disease?

Answer 18

DBS (deep brain stimulation) in the substantia nigra

Question 19

When is DBS used in Parkinson’s disease?

Answer 19

When a patient is dopamine responsive but remains poorly controlled

Question 20

Dopamine agonists can be used to delay commencement of a Parkinson’s patient on L-Dopa, but which agonists are currently used?

Answer 20

Ropinirole and pramipexole

Apomorphine is a potent DA used subcut for end-of-dose effects but ulceration at injection-site can be severe

Question 21

What MAO-B inhibitors can be used as an alternative to dopamine agonists in early Parkinson’s disease?

Answer 21

rasagiline

Selegiline

Question 22

What are some side effects of MAO-B inhibitors?

Answer 22

Postural hypotension

AF

Question 23

Why are the dopamine agonists bromocriptine and cabergoline no longer used in the treatment of Parkinson’s disease?

Answer 23

Because they may cause cardiac valvulopathies and serosal fibrosis

Question 24

What is a future drup therapy for Parkinson’s disease?

Answer 24

Istradefylline

An adenosine A2A receptor blocker, potentiates response to L-Dopa allowing lower doses