Parkinson's Disease

Question 1

Patients with parkinson’s disease classically present with motor-symptoms. List the most common symptoms (5)

Answer 1

1. Hypokinesia
2. Bradykinesia
3. Rigidity
4. Rest tremor
5. Postural instability

Question 2

Parkinson’s disease is a progressive neurodegenerative condition resulting from the death of which cells in the brain?

Answer 2

dompamnergic cells of the substantia nigra

Question 3

list the Non-motor symptoms associated with parkinsons disease (7)

Answer 3

1) Dementia
2) Depression
3) Sleep disturbances
4) Bladder and bowel dysfunction
5) Speech and language changes
6) Swallowing problems
7) Weight loss

Question 4

Outline the non-drug treatment options for the management of parkinsons disease (4)

Answer 4

1) Physiotherapy for balance or motor function problems
2) SALT for communication, swallowing or saliva problems
3) Occupational therapy - difficulties with daily activities
4) Possibly dietitian

Question 5

What is the first line treatment in the early stages of Parkinson’s disease, for patients whose motor symptoms decrease their QOL?

Answer 5

levodopa combined with carbidopa (co-careldopa) or benserazide (co-beneldopa)

Question 6

How often should a person with parkinsons be reviewed by their specialist?

Answer 6

Every 6 to 12 months

Question 7

when diagnosed with PD, who should the patient inform?

Answer 7

The DVLA and their car insurer

Question 8

What is the first line treatment for PD patients whose motor symptoms do not affect their QOL? (3)

Answer 8

A choice of:

1. levodopa
2. Non- ergot-derived dopamine- receptor agonists (praipexole, ropinirole or rotigotine)
3. monoamine-oxidase-B inhibitors (rasagiline or selegiline)

Question 9

What should be discussed before chosing a treatment option?

Answer 9

1. individual circumstances including symptoms, comorbidities and preferances
2. potential benefits and harms from the different drugs available.

Question 10

Patients should be informed about the risk of adverse reactions from antiparkinsonian drugs. Summarise some of the common adverse effects caused by these drugs (3)

Answer 10

1) Psychotic symptoms
2) Excessive sleepiness and sudden onset of sleep with dopamine-receptor agonists
3) Impulse control disorders with all dopaminergic therapy (especially dopamine-receptor agonists)

Question 11

Summarise some of the complications associated with levedopa treatment

Answer 11

1. Motor complications, including response fluctuations and dyskinesias.
   - response fluctuations were there are large variations in motor performance. Normal function durng ‘on’ period and weakness and restriction during ‘off’ period.
2. ‘End of dose’ deterioration- with progressively shorter duration of benefit possibly.

Question 12

Summarise the negatives associated with dopamine- receptor agonists

Answer 12

1. overall improvement in motor performance more noticable than with levodopa than dopamine- receptor agonists
2. excessive sleepiness , hallucinations and impulse control disorders are more likely to occur

Question 13

why must antiparkinsons drug concentrations not be allowed to fall suddenly from poor absorption or abrupt withdrawal.

Answer 13

• acute akinesia

- neuroleptic malignant syndrome

Question 14

Patients who develop dyskinesia or motor fluctuations despite optimal levodopa therapy should be offered which drugs as an adjunct to levodopa? (3)

Answer 14

Choice of one of the following:

1) Non-ergotic dopamine-receptor agonists E.g. Pramipexole, ropinirole, rotigotine
2) Or monoamine oxidase B inhibitors e.g. rasagiline or selegiline
3) Or a COMT inhibitor e.g. entacapone or tolcapone

Question 15

when should a ergot-derived dopamine-receptor agonist e.g. bromocriptine, cabergoline or pergolide be considered in the management of parkinsons?

Answer 15

An adjunct to levodopa if symptoms are not adequately controlled with a non-ergot-derived dopamine-receptor agonist

Question 16

when would amantadine be considered in parkinsons?

Answer 16

If dyskinesia is not adequately managed by modifying existing therapy

Question 17

what drug should be given to patients who experience daytime sleepiness or sudden onset of sleep once reversiblle pharmacological and physical causes have been excluded

Answer 17

Modafinil

Question 18

what should be the first line treatment for nocturnal akinesia?

Answer 18

levodopa or dopamine-receptor agonists and rotigotine as second line if both first line treatments ineffective.

Question 19

what is the drug therapy for patients who develop postual hypotension

Answer 19

first line: midodrine 
and fludrocortisone (unlicenced) as an alernative

Question 20

what drugs can be used to treat psychotic symptoms eg hallucinations and delusions in PD patients with no cognitive impairment

Answer 20

quetaipine (unlicenced)

or else clozapine

Question 21

what drugs can be used to treat rapid eye movement sleep behaviour disorder

Answer 21

• clonazepam (unlicenced)

- melatonin

Question 22

what is the treatment of drooling of saliva?

Answer 22

drug treatment should only be considered if non drug treatment e.g SALT is ineffective
following this use glycopyrronium bromide or botox

Question 23

what drugs can be used to treat PD dementia?

Answer 23

acetylcholinesterase inhibitors should be offered to pts with mild-moderate PD dementia. If acetylcholinesterase inhibitors c/i consider memantine