Parkinsonism Flashcards
What is this a presentation of?
Tremor (worst at rest, pill-rolling), hypertonia (cogwheel rigidity), bradykinesia (actions slow with repetition), shuffling gait, expressionless face.
Parkinsonism
What is the difference in tremor between cerebellar disease and Parkinsonism?
- Cerebellar disease - intention (on action)
2. Parkinsonism - resting
What are the causes of Parkinsonism?
- Primary Parkinson’s disease
- Parkinson’s plus syndromes - PSP, MSA, Lewy body dementia
- Vascular Parkinsonism
- Secondary to drugs
- Wilson’s
What is the pathophysiology of Parkinson’s disease and what is the mean age of onset?
- Loss of dopaminergic neurones in the substantia nigra (par compacta)
- 60 years
What are the clinical motor features of Parkinson’s disease?
Tremor, hypertonia, bradykinesia.
What are the clinical non-motor features of Parkinson’s disease?
Postural hypotension, constipation, depression, daytime sleepiness, anosmia, cognitive dysfunction later on.
How is Parkinson’s disease diagnosed?
- Clinical based on core symptoms
- Symptoms should be unilateral or worse on one side
- Clinical response to dopaminergic therapy is supportive
- If unsure - MRI to rule out structural pathology and consider DaT scan
What is this a presentation of?
Early postural instability (many falls), broad bear-like gait, vertical gaze palsy, rigidity of trunk > limbs, symmetrical in onset, little tremor.
Progressive supranuclear palsy (Parkinson’s plus)
What is this a presentation of?
Early autonomic features (impotence, incontinence, postural hypotension), rigidity > tremor.
Multiple system atrophy (Parkinson’s plus)
Which drugs are responsible for secondary parkinsonism and how is it treated?
- 1st generation antipsychotics, metoclopramide (especially in the young)
- Treat with anti-cholinergic (procyclidine)
How is the cause of parkinsonism investigated?
- Wilson’s should be excluded in those under 40 years old
- If atypical features - acute onset, asymmetrical, early cognitive features, rapidly progressive disease - MRI
- Definitive diagnosis made post-mortem
When should you start L-DOPA in parkinsonism and why should it not be stopped suddenly?
- Only if patient is limited by symptoms (because it needs larger and larger doses with large fluctuations between on/off time)
- Risk of acute akinesia and neuroleptic malignant syndrome
What is the first line treatment for parkinsonism and what are the side effects?
- L-DOPA TDS
2. Dyskinesia (involuntary movements), visual hallucinations, nausea and vomiting.
What is added to a treatment regime for parkinsonism if a patient is already on optimal L-DOPA?
- Dopamine agonists (ropinirole)
- MAO-Bi (rasagiline, selegiline)
- CMOTi (entacapone, tolcapone)
- Amantadine - for drug-induced dyskinesia
- SC apomorphine - for ‘frozen’ patients
- Deep brain stimulation
What is this describing?
An oscillatory, typically rhythmic and regular movement affecting one or more body parts.
Tremor
What is this describing?
Sustained, twisting and frequently repetitive movement with prolonged abnormal postures. Repeatedly involve same group of muscles.
Dystonia
What is this describing?
Involuntary, irregular, purposeless, non-rhythmic, abrupt, rapid, unsustained movements that seem to flow from one body part to another.
Chorea
What is this describing?
Sudden, brief, shock-like involuntary movements caused by muscular contractions or inhibitions (asterixis).
Myoclonus
What is this describing?
Abrupt sudden isolated movements or sounds.
Tics
