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Alasdair - Neurology > Parkinson's disease > Flashcards

Parkinson's disease Flashcards

1
Q

Signs of Parkinson’s disease on general inspection

A

Asymmetrical resting tremor: 5Hz - exacerbated by counting backwards
Hypomimia (reduced facial expression)
Extrapyramidal posture

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2
Q

Signs of Parkinson’s disease in the arms

A

Bradykinesia
Tone: cogwheel rigidity, may be enhanced by performing an action with the other limb
Normal power and reflexes
Coordination: abnormal if MSA

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3
Q

Signs of Parkinson’s disease in the eyes

A

Nystagmus: MSA
Vertical gaze palsy: PSP
Saccades: slow initiation and movement

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4
Q

Definition of cogwheel rigidity

A

Tremor superimposed on increased tone

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5
Q

Gait signs in Parkinson’s disease

A

Slow initiation
Shuffling (preceded by reduced stride length)
Hurrying = festination
Absent arm swing

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6
Q

Extra signs in Parkinson’s`

A

Glabellar tap (Myerson’s sign)
Write sentence and draw spiral (micrographia)
BP lying and standing

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7
Q

Completion of Parkinson’s exam

A

MMSE
Drug chart review
Abdominal examination: hepatomegaly + signs of CLD (DDx hepatic encephalopathy)

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8
Q

Causes of Parkinsonism

A 
Idiopathic PD
Parkinson Plus Syndromes:
Progressive Supranuclear Palsy (PSP)
Multiple system atrophy (MSA)
Lewy-body dementia
Corticobasilar degeneration
Multiple infarcts in the substantial nigra
Wilson's disease
Drugs: neuroleptics, metoclopramide
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9
Q

Specific history for Parkinsonism

A 
Symptoms: tremor, rigidity, akinesia
Autonomic: postural hypotension, urinary problems, constipation, hypersalivation
ADLs: 
Handwriting, buttons, shoelaces
Getting in and out of a car
Sleep:
Turning in bed, insomnia, daytime sleepiness
Complications: 
Depression
Drug SEs esp. motor fluctuation
Cause:
Sudden onset?
Eye or balance problems
Visual hallucinations, reduced memory
DHx
FHx
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10
Q

Investigations for Parkinsonism

A

Bloods: caerulopasmin (low in Wilson’s)
Imaging: CT/MRI to exclude vascular cause
DaTscan: ioflupane I123 injection binds to domapinergic neurones and allows visualisation of substantial nigra - can exclude other causes of tremor e.g. benign essential tremor.

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11
Q

General management of Parkinsonism

A

MDT
Assess disability e.g. using UPDRS (Unified Parkinson’s Disease Rating Scale)
Physiotherapy: postural exercises
Depression screen

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12
Q

Specific medical treatment of Parkinson’s

A

Choice of treatment depends on balance between improvement in motor symptoms and motor and psychiatric side-effects.
MAO-B: selegiline, rasagiline.
Oral/transdermal dopamine agonist: ropinirole, pramipexol.
Levodopa (most effective symptomatic drug)
For more advanced disease:
Apomorphine SC as a rescue agent for severe ‘off’ episodes.
Amantadine or an antimuscarinic e.g. procyclidine.
COMT inhibitors e.g. tolcapone.

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13
Q

Use of levodopa in Parkinson’s

A 
Given with a peripheral dopa-decarboxylase inhibitor. Preparations e.g. Sinemet.
Use lowest effective dose.
Long term use may cause weight loss. 
Side effects (N+V) are rare.
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14
Q

Use of dopamine agonists in Parkinson’s

A

Effective in controlling motor symptoms, used early in disease. Fewer motor side-effects and weaker effect cf long-term levodopa, therefore used more in younger patients. All eventually require levodopa.

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15
Q

Adjunct medications in Parkinson’s

A

Domperidone: nausea
Quetiapine: psychosis
Citalopram: depression

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16
Q

Epidemiology of idiopathic Parkinson’s disease

A

Mean onset 65 yoa

2% prevalence

17
Q

Pathophysiology of Parkinson’s disease

A

Destruction of dopaminergic neurones in pars compact and substantial nigra
Beta amyloid plaques
Neurofibrillary tangles: hyperphosphorylated tau

18
Q

Features of Parkinson’s disease

A

Asymmetric onset: side of onset remains worst
TRAPPS PD
Tremor (increased by stress, reduced by sleep)
Rigidity (lead pipe, cog-wheel)
Akinesia (slow initiation, difficulty with repetitive movement, micrographia, monotonous voice, mask-like face)
Postural instability (stooped gait, festination)
Postural hypotension (plus other autonomic dysfunction)
Sleep disorders (insomnia, excessive daytime sleepiness, obstructive sleep apnoea, RBD)
Psychosis esp visual hallucinations
Depression / Dementia / Drug SEs

19
Q

Sleep disorder in Parkinson’s Disease

A

Affects ~90% of PD patients
Insomnia + frequent waking leads to excessive daytime sleepiness (EDS)
Due to: inability to turn, restless legs, early morning dystonia (drugs wearing off), nocturne, obstructive sleep apnoea
REM Behavioural sleep Disorder (RBD): loss of muscle atone during REM sleep, violent enactment of dreams
Dopamine side effects: insomnia, drowsiness, EDS

20
Q

Autonomic dysfunction in Parkinson’s disease

A

Combined effects of drugs and neurodegeneration
Postural hypotension
Constipation
Hypersalivation (dribbling d/t reduced ability to swallow saliva)
Urgency, frequency, nocturne
Erectile dysfunction
Hyperhidrosis

21
Q

L-DOPA side-effects

A 
DOPAMINE
Dyskinesia
On-off phenomena = motor fluctuations
Psychosis
Autonomic BP problems (orthostatic hypotension)
Mouth dryness
Insomnia
N/V
Excessive daytime sleepiness
22
Q

Motor fluctuations with levodopa treatment

A

End-of-dose (wearing off): progressively decreased benefit

On-off effect: unpredictable fluctuations in motor performance unrelated to timing of dose

23
Q

Pathology of multi system atrophy

A

Papp-Lantos Bodies: alpha-synuclein inclusions in glial cells

24
Q

Features of multi system atrophy

A

Autonomic dysfunction: postural hypotension
Parkinsonism
Cerebellar ataxia

25
Q

Differentiating MSA from Parkinson’s

A

Main differentiating factor is in MSA parkinsonism does not improve with levodopa

26
Q

Name of MSA if autonomic features predominate

A

Shy Drager Syndrome

27
Q

Features of progressive supranuclear palsy (PSP)

A

Postural instability leading to falls
Vertical gaze palsy
Pseudobulbar palsy (speech and swallowing problems)
Parkinsonism (but: symmetrical onset, tremor is unusual)

28
Q

Features of corticobasilar degeneration

A

Unilateral parkinsonism, esp rigidity
Aphasia
Astereognosis: cortical sensory loss
Alien limb phenomenon: autonomous arm movements

29
Q

Pathology of Lewy-Body Dementia

A

Alpha synuclein and ubiquitin Lewy Bodies in brainstem and neocortex

30
Q

Features of Lewy-Body dementia

A

Fluctuating cognition
Visual hallucinations
Parkinsonism

31
Q

Features of Parkinsonism

A

Sudden onset
Parkinsonism worse in legs than arms
Pyramidal signs
Prominent gait abnormality

32
Q

Causes of tremor

A

Resting tremor: parkinsonism
Intention tremor: cerebellar
Postural tremor (worse with arms outstretched): Benign essential tremor, hyperthyroidism, alcohol withdrawal, beta agonists, anxiety.

33
Q

Features of benign essential tremor

A

Autosomal dominant
Occurs with movement and worse with anxiety, caffeine
Doesn’t occur during sleep
Better with EtOH

Alasdair - Neurology (16 decks)

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