Parkinson's Disease Lecture Powerpoint

Question 1

Parkinsonism vs parkinson disease (what is a defining characteristic that makes parkinson’s disease stand out)

Answer 1

Parkinsonism is the clinical syndrome presenting with any combo of bradykinesia, rest tremor, rigidity, and postural instability with the most common cause being parkinson’s disease but there are many others, vs parkinson’s disease is a chronic progressive disorder caused by degenerative loss of dopaminergic neurons in the brain characterized clinically by aysmmetric parkinsonism (defining trait) and a clear dramatic benefit from dopaminergic therapy

Question 2

TRAP acronym for parkinsonism

Answer 2

rest Tremor
Rigidity
brady or Akinesia
Postural instability

Question 3

Differential diagnosis of parkinsonism (4)

Answer 3

• Parkinson disease (most common)
• Dementia with lewy bodies
• Multiple system atrophy
• Huntington disease

Question 4

Dementia with Lewy bodies

Answer 4

-Second most common form of degenerative dementia characterized by early psychotic symptoms (unlike parkinsons which that is late stage), see fluctuations in attention or level of arousal and protein aggregate buildups called lewy bodies in neurons and REM sleep disorder behavior disorder (act out dreams)

Question 5

Multiple system atrophy (what is its one unique characteristic)

Answer 5

A slightly more common parkinsonism disease in men than women that causes autonomic dysfunction, cerebellar signs, and parkinsonism that is poorly responsive to levodopa therapy with a median survival rate of 6-9 years but is always bilateral (not asymmetric), lacks rest tremor or cortical sensory loss.
-Characteristic finding is stimulus sensitive myoclonic jerk

Question 6

3 subtypes of multiple system atrophy

Answer 6

Shy drager syndrome, striatonigral degeneration, olivapontocerebellar atrophy

Question 7

Multiple system atrophy treatment (1)

Answer 7

-palliative symptomatic treatment

Question 8

Progressive supranuclear palsy

Answer 8

A rare form of parkinsonism characterized by early instability with falls, failure to respond to levodopa therapy, and marked slowing of vertical gaze (especially downward) with a median survival rate of 5-9 years but is always bilateral, lacks rest tremor or cortical sensory loss

Question 9

Corticol basal degeneration

Answer 9

Form of parkinsonism with insidious onset and progression of ASYMMETRIC cortical and basal ganglionic features, speech impairment, cortical dysfunction, and abnormal slow horizontal saccades (slow moving compared to nystagmus)

Question 10

Essential tremor

Answer 10

Most common neurologic of an action tremor that usually affects hands and arms but also head, chin, trunk, and legs. Not commonly isolated tremor, and often becomes readily apparent when arms arms outstretched or engaged in activities such as writing

Question 11

Depression and Parkinsonism

Answer 11

Often may see overlap in symptoms such as flat affect, bradykinesia, decreased appetite making it hard to differentiate source

Question 12

Idiopathic and familial basal ganglia calcification/fahr disease

Answer 12

A type of parkinsonism that is due to accumulation of calcium in the basal ganglia (but not other parts of body) that then results in early age onset (as early as 20) parkinsonism

Question 13

Common causes of secondary parkinsonism (7)

Answer 13

• Antipsychotropic agents (can take a while to develop effects, remit after cessation)
• toxins (cyanide poisoning can mimick)
• head trauma
• lesions
• metabolic disorders
• infection (toxoplasmosis in cat poop)
• CVD

Question 14

Pseudohypoparathyroidism

Answer 14

A secondary cause of parkinsonism from high parathyroid hormones but low blood Ca2+ due to resistance in response of the body in the pathway to increase levels

Question 15

Vascular parkinsonism

Answer 15

A type of parkinsonism caused by its primary risk factor CVD, do NOT see rest tremor but do see prominent instability and gait disorder

Question 16

Normal pressure hydrocephalus

Answer 16

Syndrome of urinary incontinence, gait dysfunction, urinary incontinence, and cognitive impairment that may mimic symptoms of parkinsonism but can be differentiated by seeing ventricular enlargement on CT/MRI and improvement upon shunting treatment

Question 17

rabbit syndrome

Answer 17

Type of drug induced parkinsonism that is an adverse effect of antipsychotic meds for which perioral tremors that spare the tongue occur that resemble a rabbit’s nose

Question 18

Huntington’s disease

Answer 18

Genetic anomaly that causes chorea type movements in early stage but can mimic parkinsons in end stage

Question 19

Restless leg syndrome

Answer 19

Occurs in up to 15% of population, sleep related disorder causing unpleasant or uncomfortable urge to move legs that is relieved upon motion, makes it hard to sleep and can cause periodic movement during sleep, suspected to be related to low iron stores and is dopamine related to some degree, treatment with dopamine agonist but try to avoid benzos or opioids

Question 20

Malignant neuroleptic syndrome definition, clinical symptoms, and treatment

Answer 20

• Life threatening neurologic emergency associated with use of antipsychotic agents that leads to systemic complications
• clinical symptoms see rigidity, fever, mental status changes, and believed to be from dopamine receptor blockade.
• Treated thru cessation of offending agent

Question 21

Domperidone

Answer 21

Non approved US medication that is an antiemetic that requires closely monitoring to prevent progression to neuroleptic malignant syndrome but is used to treat gastroparesis

Question 22

Distinguishing features of parkinsonism from parkinson disease (5)

Answer 22

• Falls at presentation and early disease course unlikely to be PD
• poor response to levodopa
• symmetry of onset
• rapid progression
• lack of tremor

Question 23

Parkinson disease epidemiology

Answer 23

1% of population by age 65, 5% by age 85, most common neurodegenerative movement disorder

Question 24

Parkinson disease pathophysiology

Answer 24

• Brought on by degeneration of dopaminergic neurons in the substantia nigra par compacta of the midbrain resulting in intracytoplasmic inclusions known as lewy bodies and deposition of a-synuclein that then spreads out to rest of brain in chronic progressive disease, asymptomatic until 60% of neurons have been lost
• precise mech not understood but likely a complex interaction of genetic abnormalities and oxidative stress, etc.

Question 25

Substantia nigra

Answer 25

Part of brainstem midbrain that is a dark streak composed of pars compacta and pars reticulata, with pars compacta having a dense conc. of dopamine neurons and pars reticulata having GABA neurons. These motor pathways play a significant role in motor function and thus is significantly damaged in disease states like parkinsons

Question 26

Clinical presentation of parkinson’s disesase (9)

Answer 26

• Resting tremor 3-7 Hz
• pill rolling motion
• tremor stops upon intention and returns upon distraction
• tremor unilateral initially then becomes bilateral
• distal to proximal bradykinesia
• cogwheel rigidity on the same side as the tremor
• micrographia
• shuffling gait that gets progressivley faster
• anosmia in early early onset***

Question 27

Diagnosis of parkinson’s disease (1)

Answer 27

Clinical diagnosis, MRI and dopamine tag scanning are useful for ruling out but none are diagnostic

Question 28

Parkinson disease treatment options

Answer 28

-PT/OT/speech therapy

-

Question 29

Delayed therapy of parkinson’s treatment

Answer 29

Debate if it is worth to start early med because no evidence if it improves any outcome and has bad side effects so must weigh better or worse

Question 30

Therapeutic options for Parkinson’s disease (4)

Answer 30

• Levodopa/carbidopa (replaces dopa in brain, on off fluctuations are complications and bad other side effects, gold standard most effective/carbidopa prevents conversion of dopa to dopamine in periphery)
• anticholinergics (assist with tremor)
• MAOB inhibitors (delays breakdown of dopamine allowing it to be in receptors longer)
• Catechol o methyl transferase inhibitors (prevents transferase from degrading neurotransmitters)