Parkinson's Disease

Question 1

Define Parkinson’s disease.

Answer 1

Progressive disease of the nervous system marked by tremor, muscular rigidity and slow, imprecise movements

Question 2

What is Parkinson’s disease caused by? (3)

Answer 2

Genetics (e.g. PARK1-15 genes)
Degenerative
Secondary

Question 3

List 4 examples of degenerative disorders which can cause Parkinson’s disease.

Answer 3

Dementia with Lewy bodies
Progressive supranuclear palsy
Multiple system atrophy
Corticobasal degeneration

Question 4

List 4 causes of secondary Parkinson’s disease.

Answer 4

Drug-induced (e.g. dopamine antagonists)
Cerebrovascular disease
Toxins (e.g. CO, organophosphates, MPTP)
Infections

Question 5

Describe the pathophysiology of Parkinson’s disease.

Answer 5

1. Loss of dopaminergic neurons within the substantia nigra
   a. Clinical presentation begins when 50% of dopaminergic neurons are lost
2. Surviving neurons contain Lewy bodies (extracellular alpha synuclein/ubiquitin accumulation)
   a. Caused by factors such as oxidative stress, excitotoxicity etc.
   b. This disrupts normal neuron function
   c. This causes further dysfunction in the motor loop

Question 6

Describe the 6 stages of Parkinson’s progression.

For each one, consider areas of the brain affected and corresponding clinical features.

HINT: there are 6 stages, but they are grouped into 3 categories.

Answer 6

Stages 1-2:
Areas affected:
-Medulla
-Pons
-Olfactory nucleus
Clinical features:
-Pre-symptomatic
-Loss of smell

STAGES 3-4:
Areas affected:
-Midbrain
-Substantia nigra compacta
Clinical features:
-Parkinsonian features

STAGES 5-6:
Areas affected:
-Substantia nigra
-Neocortex
Clinical features:
-Development of dementia (on top of existing Parkinson's symptoms)

Question 7

What are the main categories of Parkinson’s symptoms? (5)

Answer 7

Motor symptoms
Neuropsychiatric symptoms
Autonomic symptoms
Sleep disturbance
Other symptoms

Question 8

Describe motor symptoms in Parkinson’s. (7)

Answer 8

Bradykinesia
Resting tremor
Muscular rigidity (cogwheel)
Postural instability
Gait disturbances, e.g.
-Reduced arm swing
-Shuffling gait

Question 9

Describe neuropsychiatric symptoms in Parkinson’s. (3)

Answer 9

Dementia
Depression
Anxiety

Question 10

Describe autonomic symptoms in Parkinson’s. (6)

Answer 10

Constipation
Urinary urgency/nocturia
Erectile dysfunction
Excessive salivation/sweating
Postural hypotension
Dysphagia

Question 11

Describe sleep disturbances in Parkinson’s. (3)

Answer 11

REM sleep behaviour disorder
Restless leg syndrome
Daytime sleepiness

Question 12

List 3 other symptoms in Parkinson’s.

Answer 12

Reduced olfactory function
Fatigue
Pain/other sensory symptoms

Question 13

Which 2 features of a neurological exam would be NORMAL in Parkinson’s?

Answer 13

Normal strength

Normal reflexes

Question 14

What investigations would you do for Parkinson’s disease? (3)

Answer 14

Bloods:

• Exclude other causes of tremor
• Thyroid function tests
• Copper/caeruloplasmin levels

CT/MRI scan:

• Normal in Parkinson’s
• Exclude vascular Parkinson’s/other causes

DAT SPECT:
-Measures pre-synaptic dopamine function

Question 15

List 4 types of drugs you would you to treat Parkinson’s.

Answer 15

Dopamine precursors
Dopamine agonists
MAO-B inhibitors
COMT inhibitors

Question 16

Give 2 examples of combination drugs containing L-dopa.

What are the combinations?

Answer 16

Sinemet (L-dopa plus carbidopa)

Madopar (L-dopa plus benserazide)

Question 17

List 3 examples of dopamine agonists.

Which ones are non-selective, and which ones selective?

Answer 17

Bromocriptine
Pramipexole (selective: D3)
Apomorphine (non-selective)

Question 18

List 2 examples of MAO-B inhibitors.

Answer 18

Selegiline

Rasagiline

Question 19

Give 1 example of a COMT inhibitor.

Answer 19

Entacapone

Question 20

Give 1 example of a combination drug containing a COMT inhibitor.

What is the combination?

Answer 20

Stalevo (COMT inhibitor plus L-dopa)

Question 21

Describe the MDT for Parkinson’s. (9)

Answer 21

GP
Neurologist
Parkinson's nurse specialist
Speech and language therapist
Psychiatrist
Psychologist 
Occupational therapist
Palliative care team
Neurosurgeon