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Parkinson's disease and movement disorders Flashcards

1
Q

What is Parkinson’s disease?

A

A degenerative, progressive movement disorder caused by a reduction in dopamine in the substantia nigra with characteristic motor symptoms of tremor, bradykinesia, and postural instability

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2
Q

What is the difference between parkinsonism and Parkinson’s disease?

A

Parkinsonism is a collection of symptoms that are similar to those of Parkinson’s without the degenerative changes of Parkinson’s

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3
Q

How common is Parkinson’s?

A

Increasing prevalence with age
Peak age of onset 55-65
More common in men

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4
Q

What can cause Parkinson’s disease?

A

Idiopathic
Combination of…
- Environmental factors - pesticides, methylphenyl tetrahydropyridine found in illegal opiates
- Parkinson genes - mutation in Parkins gene and alpha synuclein gene
- Oxidative stress and mitochondrial dysfunction

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5
Q

What can cause Parkinsonism?

A

Drugs - neuroleptics, anti-emetics
Normal pressure hydrocephalus
Vascular Parkinsonism
Parkinson’s plus eg multiple system atrophy

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6
Q

What can increase your risk of Parkinson’s disease?

A

Male
Increasing age
FHx
Non-smoker

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7
Q

What is the pathology of Parkinson’s disease?

A

Mitochondrial dysfunction and oxidative stress
Results from progressive degeneration of dopaminergic neurons from pars compacta of SN in midbrain that projects to striatum of basal ganglia
Reduced striatal dopamine levels due to loss of dopaminergic neurons
Less dopamine so thalamus inhibited decreasing movement
Neuronal inclusions - Lewy bodies present in Parkinson’s and becomes gradually more widespread as disease progresses, spreading from lower brainstem to midbrain and then cortex
Degeneration in other basal ganglia nuclei

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8
Q

What makes up the basal ganglia?

A

Striatum
Globus pallidus
Substantia nigra
Subthalamic nucleus

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9
Q

What makes up the striatum?

A

Putamen and caudate nucleus

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10
Q

What makes up the globus pallidus?

A

External and internal

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11
Q

How does dopaminergic cell loss correlate to degree of akinesia?

A

Increased cell loss = increased akinesia

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12
Q

What is akinesia?

A

Muscle rigidity
Stiffness
Lack of responsiveness

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13
Q

How does Parkinson’s present (motor symptoms)?

A

Onset gradual and often presents with impaired dexterity
Asymmetrical
Tremor 70% (4Hz slow resting pill rolling)
Rigidity - cogwheel
Bradykinesia/hypokinesia
Gait problems - festinance, freezing, reduced arm swing)
Expressionless face (hypomimesis)
Cramping
Difficulty with fine movements eg problems doing up buttons
Micrographa

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14
Q

What pre-symptomatic symptoms can you get with Parkinson’s?

A 
Anosmia
Depression/anxiety
Aches and pains
REM sleep disorders
Urinary urgency
Hypotension
Constipation
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15
Q

What is tremor in Parkinson’s like?

A

Worse at rest
Asymmetrical
Most obvious in hands
Improved with voluntary movements and made worse by anxiety
4-6 cycles/sec
Issue with repetitive hand movements with worsening rhythm longer attempted

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16
Q

What is rigidity like in Parkinson’s?

A

Increased tone in limbs and trunk
Limbs resist passive extension throughout movement
Rigidity over entire radius of joint movement
Can cause pain and problems with turning in bed

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17
Q

What does bradykinesia look like in Parkinson’s?

A

Slow to imitate movements
Reduced blink rate, monotonous hypophonic speech
Micrographia

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18
Q

What does gait look like in Parkinson’s?

A

Reduced asymmetrical arm swing
Narrow gait
Narrow base
Stooped posture and small steps
Festinance - shuffling steps, maybe dragging foot with flexed trunk
Difficulty initiating movement and turning
Poor balance

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19
Q

How does Parkinson’s present (non-motor symptoms)?

A 
Drooling of saliva and swallowing difficulty late feature (aspiration pneumonia as a terminal event)
Mood disturbance - depression 40%
Sleep disturbance
Cognitive disorders
Pain 
Impulse control disorders
Autonomic dysfunction
Anxiety
Psychotic symptoms
Dopamine dysregulation syndrome
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20
Q

What sleep disturbance might you get in Parkinson’s?

A 
REM sleep behaviour disturbance
Insomnia (due to one/more of lack of muscle and mental relaxation, stiffness, restlessness, difficulty moving into comfortable positions, tremor bothersome, medications wearing off, driving/work implications)
Daytime sleepiness
Sleep disruptions
Restless leg syndrome
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21
Q

What autonomic dysfunction might you get in Parkinson’s?

A 
Orthostatic hypotension
Constipation
Heat intolerance
Urinary frequency and incontinence and urgency
Nocturia
Sweating
Hypersalivation
Drooling 
Sexual dysfunction
N&V
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22
Q

What are the phases of Parkinson’s treatment?

A

Early honeymoon period - quite easy to treat, still have buffer of axons in SN - medication seems to last for longer as dopamine released in brain in response to medication
Middle period wearing off - medication doesn’t last as long, loss of buffer
Later period dyskinesia’s (drug induced chorea), fluctuations between chorea and stiffness, cognitive impairment

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23
Q

What is a differential diagnosis for Parkinson’s?

A 
Benign essential tremor - worse on movement and rare whilst at rest
Multiple cerebral infarcts
Lewy-body dementia
Drug-induced
Wilson's disease
Trauma
All dopamine antagonists
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24
Q

How is Parkinson’s diagnosed?

A

Clinical - based on Hx and examination
Confirmed by response to L-dopa
MRI head - initially normal but slowly atrophies, used to exclude tumours or normal pressure hydrocephalus
Lack of - incontinence, symmetry, early falls
U&E, LFT, TFT, Ca (rule out differentials)
Diagnose using UK PD society brain bank criteria - cannot diagnose without bradykinesia
Review diagnosis every 6-12 months
Document discussion of risk impulse control disorder, sleep attacks, hallucinations
Consider DAT scan in atypical tremors
PET and SPECT - look at metabolic activity of dopamine transporters in basal ganglia measured with PET and SPECT

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25
How might normal pressure hydrocephalus present?
Forget how to walk Enlarged ventricles Dementia
26
How benign essential tremor treated?
50% respond to medication | Treat with propranolol, primidone, gabapentin
27
How does benign essential tremor present?
Intention tremor
28
What is the role of the GP in Parkinson's diagnosis?
Refer to specialist untreated | Refer to specialist if any problems arise
29
What do you need to put in place for a patient with Parkinson's?
``` Oral and written communication to patient and family Care plan Point of contact to specialist services Access to PT, OT, SALT, and dietician Advise vit D supplementation ```
30
What medication can you prescribe in Parkinson's?
Co-careldopa/co-beneldopa - controlled release/dispersible for resuce/morning COMT - catechol-O-methyltransferase inhibitor - prevents breakdown of levodopa in brain and periphery Dopamine agonists - non-ergot/ergot MAO inhibitors Apomorphine Amantadine New - safinamide, opicapone
31
Name a non-ergot dopamine agonist
Ropinirole Pramipexole Rotigontine
32
Name an ergot dopamine agonist
Bromocriptine Pergolide Cabergoline
33
Name a disadvantage of ergot dopamine agonists
Can cause fibrosis all around body
34
Name an advantage of dopamine agonists
Less dyskinesia than levo-dopa | Longer acting
35
Name a disadvantage of dopamine agonists
``` Risk of hallucinations Compulsive behaviour Postural hypotension Daytime sleepiness S/E ```
36
Name a MAO inhibitor
Selegiline | Rasagiline
37
How can you prescribe selegiline?
5-10mg PO | 1.25mg sublingual
38
How can you prescribe rasagiline?
1mg OD
39
What is possibly special about rasagiline?
Possibly neuroprotective
40
What should you be careful with when prescribing MAO inhibitors?
Prescribing with SSRIs/tricyclics - serotonin syndrome CI - tramadol, pethidine Rasagiline SSRI best avoided - citalopram relatively safe, tricyclics - nortryptilline Selegiline - avoid antidepressants
41
What is apomorphine?
Water soluble dopamine agonist Rescue treatment in pen form/continuous daytime infusion Helps smooth out motor fluctuations, less hallucinogenic than other dopamine agonists
42
What is amatadine used for?
Dyskinesia
43
How can you treat cognitive disorders in Parkinson's?
Cholinesterase inhibitors | Memantine if cholinesterase inhibitors not tolerated
44
How do you treat orthostatic hypotension?
Stop any medications that may be causing it - anti-hypertensives, midodrine, fludrocortisone, ephedrine
45
How can you treat urinary symptoms?
Anticholinergics | Tropsium
46
How can you treat hypersalivation?
Glycopyrrolate | Botulinum
47
How can you treat N&V?
Anti-emetics
48
How can you treat depression and anxiety?
Treat as non-PD
49
How do you treat psychotic symptoms?
Refer onto neurologists | Low dose anti-psychotics - quetiapine or clozapine
50
What motor effects can you get with long term L-dopa usage?
Reduced efficacy over time even if dose increased On-dyskinesias Off-dykinesias Freezing Doesn't alter disease progression, just offers symptoms relief
51
What else can you do to treat Parkinson's?
Deep brain stimulation | If not dopamine responsive
52
When should you refer someone with a tremor?
All new tremors that aren't essential If diagnostic uncertainty Essential tremor requiring further management Tremor with other neurological symptom - ataxia, cerebellar signs, Parkinsonism
53
What is Huntington's disease?
An inherited neurodegenerative disease characterised by chorea, dystonia, incoordination, cognitive decline and behavioural difficulties
54
What is chorea?
Continuous flow of jerky, semi-purposeful movements, flitting from one part of the body to another, may interfere with voluntary movements, cease during sleep
55
What is the inheritance pattern of Huntington's disease?
Autosomal dominant condition with full penetrance - all gene carriers with develop disease
56
How common is Huntington's disease?
Very rare | Prevalence worldwide 5 per 100,000
57
What causes Huntington's disease?
Mutation on chromosome 4 resulting in repeated expression of CAG sequence - encodes huntingtin protein CAG trinucleotide repeat expansion accumulates in brain cells causing damage
58
What is the risk of a child of a someone with Huntington's also having Huntington's?
50%
59
What is the pathology of Huntington's disease?
Repeated expression of CAG sequence leads to translation of expanded polyglutamine repeated sequence in huntingtin gene expressed throughout body Protein gene product function is unclear but thought to be toxic gain of function mutation The more CAG repeats present the earlier symptoms onset - Most adult onset 36-55 repeats - Early onset from childhood over 60 repeats Progressive cerebral atrophy with marked loss of neurons in caudate nucleus and putamen of basal ganglia - specifically loss of corpus striatum gaba-nergic and cholinergic neurons Results in decreased Ach and GABA synthesis in striatum GABA main inhibitory neurotransmitter, loss of this will result in decreased inhibition of dopamine release and therefore results in excessive thalamic stimulation and thus excessive movements - chorea
60
What is the course of Huntington's disease?
Initially tends to present in middle age with prodromal phase of mild symptoms then progressing to psychiatric and cognitive symptoms
61
What are the symptoms of the prodromal phase in Huntington's disease?
Mild psychotic and behavioural symptoms
62
What is chorea like?
Relentlessly progressive, jerky, explosive, rigidity, involuntary movements - cease with sleep Can't sit still May begin as general restlessness, unintentionally initiated movements and lack of co-ordination
63
What symptoms might you get in Huntington's disease?
``` Chorea Dysarthria Dysphagia Abnormal eye movements Psychiatric problems Dementia - impaired cognitive abilities and memory Associated with seizures Eventually death ```
64
What psychiatric problems can you get with Huntington's?
Behavioural change - aggression, addictive behaviour, apathy, self-neglect Depression/anxiety
65
What could be a differential diagnosis of Huntington's disease?
``` Sydenham's chorea (rheumatic fever) Creutzfeldt-Jacob disease (prion) Wilson's disease SLE Stroke of basal ganglia ```
66
How is Huntington's diagnosed?
Mainly clinical diagnosis Genetic testing/DNA analysis - extensive genetic counselling required due to impact positive diagnosis will have - inevitable terrible death CT/MRI - shows caudate nucleus atrophy and increased size of frontal horns of lateral ventricles (signs of brain matter destruction)
67
How is Huntington's disease treated?
No disease-modifying treatment available Treatment for symptoms Counselling to patient and family, genetic counselling to any children of patients Symptomatic management of chorea - Benzodiazepines - Sulpiride - neuroleptic - depresses nerve function - Tetradenzaine - dopamine depleting agent Anti-depressants such as SSRI Antipsychotic medications Aggression treatment - risperidone
68
What is the prognosis of Huntington's disease?
Death within 15-20 years of diagnosis

Neuro and geriatrics (21 decks)

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