Parkinson's Disease Flashcards
What are the two motor systems in the body?
Pyramidal and Extrapyramidal
Parkinson’s disease is a dysfunction of the midbrain?
Extrapyramidal
What are the three parts of basal ganglia?
Corpus Striatum, Amygdala, Claustrum
What are the structures that compose the corpus striatum?
Caudate nucleus, Putamen, Globus Pallidus
What composes the Lentiform nucleus?
Putamen, Globus Pallidus
What composes the Neostrium?
Caudate Nucleus, Putamen
What supplies neostriatum?
Lenticulostriate, MCA
What supplies globus pallidus?
Recurrent artery of Heubner, ACA
What are the two primary efferents of the extrapyramidal system?
Substantia Nigra Pars Reticulata and Globus Pallidus Interna
What is the primary afferent of the direct pathway?
Striatum
What is the primary afferent of the indirect pathway?
Subthalamus
What is the inhibitory NT of the brain?
GABA
What is the excitatory NT of the brain?
Glutamate
NT: Dopamine in the indirect pathway
Inhibitory
NT: Dopamine in the direct pathway
Excitatory
NT: ACH in the indirect pathway
Excitatory
NT: ACH in the direct pathway
Inhibitory
To be able to do its function, what should be the level of ACH and Dopamine in the striatum?
Equal
Group of disorders with disturbances in the dopamine system of the basal ganglia
Parkinsonism
Three types of parkinsonism
Primary PD, Secondary PD, Parkinson’s plus syndrome
What is the diagnostic tool for PD?
Apomorphine Test
Two other names of PD
Shaking palsy and paralysis agitans
It is a very slowly progressive disorder on CNS with motor and non-motor symptoms
Parkinson’s Disease
What gender is predominantly affected by PD?
M>F
What is the average onset of PD?
40-60 years
What is the onset of Young-onset?
21-40 years
What is the onset of Juvenile-onset?
<21 years
The progressive loss of dopaminergic cells that produces dopamine in substantia nigra
Primary PD
What are the two etiology of Primary PD?
Idiopathic and Genetic
The 3 genes affected in Primary PD
PPL: Pink 1, Park 1, Lark 2
Primary PD may be secondary to what?
Hyperactivity of cholinergic cells in the striatum
What diagnostic tool used in Primary PD?
MRI
What do you see in MRI to confirm Primary PD?
Paleness of SN
What is the kind of symptoms first to occur in primary PD?
Non-motor > Motor
Motor symptoms in primary PD occur in what percentage of destruction?
30-60%
What protein is absent in the BG that causes the appearance of Lewy bodies?
Synuclein protein
“Von economo’s disease”
Post-infectious PD
What is the other name of Post-infectious PD?
Encephalitis Lethargica
What is the route of Post-infectious PD?
Viral
Post-traumatic PD is secondary to what MOI?
Repetitive Trauma
What occupation is predisposed to Post-traumatic PD?
Boxers
What is the other name of Post-traumatic PD?
Dementia Pugilistica
What toxin is the most common cause of toxic PD?
Manganese
What heroine is associated with Toxic PD?
1-methyl-4-phenyl-1236-tetrahydropyridine (MPTP)
What are the other 4 toxins associated with Toxic PD?
PCCM: Pesticides, Cyanide, Carbon Disulfide, Methanol
“Wilson’s Disease”
Metabolic PD
What causes metabolic PD?
Hepatolenticular degeneration
What chromosome is affected by metabolic PD?
Chromosome 13
What is the genetic route of metabolic PD?
Autosomal Recessive
What causes metabolic PD?
Overaccumulation of Copper
Three areas where coppers go?
Eyes, Liver, BG
What manifestation can be seen in the eyes if there is an overaccumulation of copper?
Kayser-fleischer ring
Where specific area of BG is affected in metabolic PD?
Lentiform nucleus
What manifestation can be seen in the liver if there is an overaccumulation of copper?
It becoms firm and large
What are the three drugs associated with Drug-induced PD?
Anti-depressant, anti-hypertension, anti-psychotic
What PD is resulted in the lesion of blood supply?
Vascular PD
What are the 6 types of secondary PD?
Post-infectious, Post-traumatic, Toxic, Metabolic, Drug-induced, Vascular
What is the most common presenting symptom of PD?
Resting Tremor
5 sites of resting tremor
Hand, FA, Postural tremor, Jaw & Tongue, LE
It is the rapid extension-flexion of the index finger and thumb
Pill-rolling
What are the 3 frequencies of Pill-rolling?
3-5 Hz, 4-6 Hz, 4-7 Hz
What type of tremor is seen in advanced stage PD?
Action tremor
What is induces resting tremor?
Stress
When does the resting tremor disappear?
During sleep
Velocity-independent resistance to passive movement
Rigidity
Two types of rigidity
Lead pipe and Cogwheel
Type of rigidity that is uniform, sustained, resistance
Lead Pipe
Type of rigidity that is intermittent, jerky-racthet like resistance
Cogwheel
What is the other name of lead pipe?
Plastic
Cogwheel is secondary to what?
Superimposed tremors
Most disabling symptom of PD
Bradykinesia
(+) delayed initiation
Akinesia
(+) decrease amplitude of movement
Hypokinesia
Masked face
Hypomimia
(+) small handwriting
Micrographia
(+) slowness of movement
Bradykinesia
(+) decrease thought process
Bradyphrenia
What is the symptom that is last to occur in PD?
Postural Instability
Postural Instability is indicative of what stage of PD?
Advanced stage
Patients with Postural Instability have a risk for ____?
Falls
What posture is predominant in flexor muscles?
Simian Posture
6 components of simian posture
Forward head, Protracted shoulder, shoulder ADIR, elbow flexion, hip flexion, knee flexion
3 components of a striatal hand
FA pronation, wrist & MCP flexion, IP extension
3 components of a striatal foot
DIB: DF, Inversion, Big toe extension
What is the cardinal sign of PD?
TRAP: Tremor, Rigidity, Akinesia, Postural Instability
Four gait difficulty is seen in PD patients
Shuffling, Festinating, Freezing, Fear of Falling
Typical gait pattern in PD
Shuffling gait
Gait with small steps with increased speed
Festinating Gait
Gait due to the start of an off-state phenomenon
Freezing gait
Cautious gait
Fear of falling
Features of shuffling gait
Decrease step length, stride length, BOS, velocity
Festinating gait is secondary to what factors?
Displaced COG and Advance stage PD
What are the 6 other manifestations of PD?
PBSACB: Pain, Bulbar dysfunction, Sleep disorder, Autonomic Dysfunction, Cognitive Impairments, Behavioral changes
What is the most common source of pain in PD?
Limb rigidity
What are the two syndrome causes of pain in PD?
Postural stress and Restless leg
What is the CN affected in PD?
CN 3, 7, 9, 1
Excessive drooling
Sialorrhea
What is the most common speech problem in PD?
Hypokinetic dysarthria
What is the most common speech problem in advanced-stage PD?
Mutism
Three features of sleep disorder in PD
Insomnia, Excessive day time sleeping, REM sleep behavior disorder
Six features of Automatic dysfunction in PD
Erectile dysfunction, urinary incontinence, excessive sweating, seborrhea, OH, constipation
What are the two cognitive and behavioral changes were seen in PD?
Dementia and Depression
Three positive prognosticating factors of PD
Tremor, Rigidity, Family History
Six negative prognosticating factors of PD
Bradykinesia, Akinesia, Gait difficulty, Cognitive impairments, Postural instability, Late age onset
Modified HY: Unilateral disability
1
Modified HY: Confined to bed or wheelchair
5
Modified HY: Bilateral disability with a balance problem
3
Modified HY: Unilateral disability + axial involvement
1.5
Modified HY: Bilateral disability
2
Modified HY: All s/sx is present and severe
4
Modified HY: Bilateral disability with the recovery of pull-test
2.5
Modified HY: Unsteadiness but the patient can live independently
3
Modified HY: Standing and walking are only possible with assistance
4
Three consideration with pharmacologic therapy in PD
Time, Low Protein Diet, and Peak Dose
Time consideration: PD medications take effect
1 hr before or after a meal
Why do PD patients should have a low protein diet?
High protein level inhibits the absorption of levodopa
What is the time effective to conduct a rehab for PD patients?
1 hour after taking levodopa
The precursor of dopamine
Levodopa
The drug that prevents the early conversion of levodopa
Carbidopa
The gold standard drug for PD
Sinemet
Two phases of pharmacologic therapy in PD
Honeymoon period and Wearing off phase
The phase where optimal effects of medication occur
Honeymoon period
The phase where effects of medication start to wear off
Wearing off phase
How long does the Honeymoon period last?
7-8 years
What do physicians prescribe when the patient is already experiencing the wearing-off phase?
Increase dosage of levodopa
9 adverse effect of increased dosage of levodopa
VPDMDNDMO: Visual hallucination, Peak dose dyskinesia, Dystonia, Motor fluctuations, Dysuria, Nausea, Dryness of mouth, Mood/sleep disorders, OH
What is the most common adverse effect experienced by patients?
Visual hallucination
What are the two involuntary movements seen experienced by patients?
Grimacing of face and limb choreoathetosis
What is the most common site of dystonia in PD?
Foot = clawing of toes
What is the most common site of dystonia in the body?
Neck
Feeling of restlessness
Akathisia
Motor fluctuations are caused by?
End dose deterioration, On-off phenomenon
Difficulty in urination
Dysuria
What are the two medications administered together with Sinemet to prevent adverse effects?
Dopamine agonist and anticholinergic
7 dopamine agonist
Bromocriptine, premipexole, ropinerole, pergolide, cabergolide, amantadine, apomorphine
2 anticholinergic
Trihexyphenidyl, Bentropine
What substance inhibits NT in the brain including dopamine?
MAO: Mono-amine oxidase
2 MAO-inhibitors
Rasagiline, Selegiline
Four types of Parkinson plus syndrome
Progressive Supranuclear palsy, Corticobasal ganglionic degeneration, Multi-system Atrophy, PD with early dementia
Parkinson plus syndrome due to (-) tau protein in the midbrain
Progressive Supranuclear palsy
Parkinson plus syndrome due to (-) tau protein in the cortex
Corticobasal ganglionic degeneration
Parkinson plus syndrome due to (-) synuclein protein
Multi-system Atrophy
What are the PD-like symptoms seen in Progressive Supranuclear palsy?
Shuffling gait and Difficulty in performing vertical gaze
What are the PD-like symptoms seen in Corticobasal ganglionic degeneration?
Asymmetric, akinetic rigid syndrome; Apraxia; Alien hand syndrome
Sites affected in Multi-system Atrophy
Basal ganglia, cerebellum, autonomic system
Another name of Multi-system Atrophy - Basal ganglia
Striatonigral degeneration (MSA-P)
Another name of Multi-system Atrophy - Cerebellum
Olivopontocerebellar Atrophy (MSA-C)
Another name of Multi-system Atrophy - Autonomic system
Shy-dager syndrome (MSA-A)
What is the most common cause of dementia?
Alzheimer’s disease
Dementia due to cycad seed toxicity
Guamanian ALS
Dementia due to (-) synuclein protein
Diffuse cortico lewy bodies