Parkinson's Disease Lecture Powerpoint Flashcards
Parkinsonism vs parkinson disease (what is a defining characteristic that makes parkinson’s disease stand out)
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
TRAP acronym for parkinsonism
rest Tremor
Rigidity
brady or Akinesia
Postural instability
Differential diagnosis of parkinsonism (4)
- Parkinson disease (most common)
- Dementia with lewy bodies
- Multiple system atrophy
- Huntington disease
Dementia with Lewy bodies
-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)
Multiple system atrophy (what is its one unique characteristic)
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
3 subtypes of multiple system atrophy
Shy drager syndrome, striatonigral degeneration, olivapontocerebellar atrophy
Multiple system atrophy treatment (1)
-palliative symptomatic treatment
Progressive supranuclear palsy
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
Corticol basal degeneration
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)
Essential tremor
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
Depression and Parkinsonism
Often may see overlap in symptoms such as flat affect, bradykinesia, decreased appetite making it hard to differentiate source
Idiopathic and familial basal ganglia calcification/fahr disease
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
Common causes of secondary parkinsonism (7)
- 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
Pseudohypoparathyroidism
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
Vascular parkinsonism
A type of parkinsonism caused by its primary risk factor CVD, do NOT see rest tremor but do see prominent instability and gait disorder
Normal pressure hydrocephalus
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
rabbit syndrome
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
Huntington’s disease
Genetic anomaly that causes chorea type movements in early stage but can mimic parkinsons in end stage
Restless leg syndrome
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
Malignant neuroleptic syndrome definition, clinical symptoms, and treatment
- 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
Domperidone
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
Distinguishing features of parkinsonism from parkinson disease (5)
- Falls at presentation and early disease course unlikely to be PD
- poor response to levodopa
- symmetry of onset
- rapid progression
- lack of tremor
Parkinson disease epidemiology
1% of population by age 65, 5% by age 85, most common neurodegenerative movement disorder
Parkinson disease pathophysiology
- 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.
Substantia nigra
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
Clinical presentation of parkinson’s disesase (9)
- 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***
Diagnosis of parkinson’s disease (1)
Clinical diagnosis, MRI and dopamine tag scanning are useful for ruling out but none are diagnostic
Parkinson disease treatment options
-PT/OT/speech therapy
-
Delayed therapy of parkinson’s treatment
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
Therapeutic options for Parkinson’s disease (4)
- 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)
