Parkinsonism Flashcards
Parkinsonism Signs
Tremor Rigidity Bradykinesia Postural instability Gait dysfunction
Parkinson’s differential diagnosis
Degenerative : Parkinson’s , Atypical Parkinsonism disorders ( multiple system atrophy , progressive supra nuclear palsy, corticobasal degeneration )
Non-degenerative : Drug induced, vascular ,structural , toxins , infections , metabolic
Physiological affects of Parkinsonism
Mostly idiopathic , some are genetic.
Reduced dopamine levels due to degeneration of dopamine producing nerve cells
How is Parkinson’s diagnosed
Clinical Diagnosis : Bradykinesia + at least 1 other symptom
1- Bradykinesia : must be present for there to be clinical Parkinsonism
2- Other symptoms: muscular rigidity , 4-6Hz rest tremor , postural instability
What is Bradykinesia and how might a patient present with it
Slowness of initiation of voluntary movement with progressive reduction in speed and amplitude with repetitive movements.
Ex: difficulty buttoning shirts , general slowness , difficult brushing teeth , dragging leg , loss of arm swing , change in handwriting ( micrographic ) , difficulty turning in bed , reduced facial expression , reduced blinking , drooling overnight , hypophonia ( quieter speech )
Describe Parkinsonism tremor
Postural re-emergent tremor ( almost always point to Parkinsonism ).
Tremor starts a few seconds after movement is done , or at rest.
Not necessary to be present for clinical diagnosis of Parkinson’s
Explain Essential tremor
Flexion-extension, distal , symmetrical hand tremor : with action
- sometimes a head tremor
- no bradykinesia or Parkinsonism gait features , rigidity
- voice tremor
- usually have a family history of it & alcohol response
Describe Parkinsonism rigidity
Increased resistance to passive movement
- flexion & extension at wrist and elbow
- co-activation via Froment’s manoeuvre
- Asymmetric
- different than spasticity
Describe Parkinsonism Gait
Stooped posture, shuffling , arms flexed & shaking , destination = further along disease
Initially Presents as : reduced arm-swing ( asymmetrical & tremor ) , reduced foot-lift , reduced stride length , reduced cadence , loss of fluency when turning ( clock face/ en-bloc turning ) , narrow-based gait
Describe Parkinsonism Postural instability
Impairment of normal reflexes that maintain upright posture, leads to balance problems and vulnerability to falls.
Assessed via Pull test: from behind the patient you pull their shoulders back , patient with Parkinsonism will lose postural reflexes, take multiple steps backwards, can’t regain upright posture and would fall if Doctor is not there to catch them. Parkinsonism if person takes more than 3-4 steps
What are the causes of Parkinsonism
Degenerative : Parkinson’s most common
Non-degerative causes: drug induced and vascular
Features of non-degerative or secondary causes of Parkinsonism
1- repeated strokes / head injury
2- history of encephalitis
3- neuroleptic drug exposure : Antipsychotics, metoclopramide , prochlorperazine , lithium , sodium valproate , calcium channel blockers
Features of degenerative Atypical Parkinsonism disorders that would point away from Parkinson’s Disease
1- poor or un-sustained levodopa response : patient doesn’t improve when given levodopa
2- early recurrent falls ( in beginning of disease onset )
3- early cognitive decline ( ex: early dementia starting at disease onset or within 1 year )
4- prominent early speech or swallowing difficulties ( dysarthria and high pitch/quivering )
5- cerebellar , pyramidal signs , dyspraxia or supranuclear gaze palsy
6- prominent & early autonomic dysfunctions ( urinary symptoms )
7- wheelchair dependent in less than 3 years
8- absence of rest tremor or dyskinesia
Progressive supra nuclear palsy in MRI
Midbrain atrophy that resembles humming bird chase , or Mickey Mouse in axial section
Multiple system atrophy in MRI
Midbrain cross atrophy ( hotbun cross )
DAT scan
Dopamine transporter Scan. Shows that dopamine producing neurones from substantia Niagara to basal ganglia affected, shows up as Dots on scan.
Abnormal DAT can indicate what
1- Parkinson's disease 2- MSA 3 PSP 4- Dementia with LBs 5- cud 6- Wilson's disease 7- Spinocerebellar ataxia 2,3
Supportive criteria for Parkinson’s disease
1- Unilateral onset 2- persistent asymmetry 3- rest tremor 4- progressive 5- excellent levodopa response 6- levodopa induced dyskinesia 7- sustained response to levodopa for at least 5 years 8- visual hallucinations 9- clinical course generally greater than 10 years ( not as progressive as atypical Parkinsonism disorders )
Parkinson’s disease Treatment
1- Dopaminergic medications ( 1st line) : levodopa or dopamine agonists
2- Dopamine degradation inhibitors : MAO b inhibitors , COMT inhbitors
Give examples of Levodopa
Madopar, sinemet , stalevo
Give examples of Dopamine agonists
Ropinirole , pramipexole , rotigotine, apomorphine
What must be given with COMT inhibitors
Levodopa
What is the most affective Parkinson’s treatment but what is it’s disadvantages
Levodopa
Disadvatages : short half life ( needs to be taken multiple times a day ) , more dyskinesia , less likely to cause psychotic symptoms , competes for absorption from other amino acids, absorbed in gut ( delayed gastric emptying will affect )
Give examples of MAO b inhibitors
Azilect, selegiline
Give examples of COMT inhibitors
Entacapone , stalevo, tolcapone
Describe Parkinson’s disease progression
As disease progressive there’s more degeneration of dopaminergic neurons = more exogenous dopamine is required
changes in dopamine receptor sensitivity = lower threshold for levodopa induced dyskinesia and narrowing of treatment window
Strategies to consider if patient has problematic motor fluctuations
1- Levodopa fractionation / dose increase
2- Dopamine agonist for prolonged release
3- COMT / MAOi
4- Amantadine
5- Anti-cholinergics
What might cause unpredictable motor fluctuations
May be due to erratic gastric emptying which is unlikely to be helped with oral medications. Start on Non-oral treatment options
What are the Non-oral treatment options for Parkinson’s disease with unpredictable motor fluctuations
1- Deep Brian stimulation : can’t have cognitive difficulties , depression or psychotic symptoms
2- Apomorphine subcutaneous injection pen
3- Apomorphine subcutaneous infusion : avoid if Hx of dementia or prominent psychotic symptoms
4- Duodopa ( intrajejunal levodopa infusion ) : useful if patient is susceptible to psychotic effects of Das
What disorder is a common side affect for Parkinson’s medications
Impulse Control Disorders - changes in behaviour
Most common : gambling, excessive shopping , binge eating , hyper sexuality
Which medications will most likely cause Impulse Control Disorders & what are the risk factors
Reported with all Dopaminergic PD medications : most strongly associated with dopamine agonists ( dose related )
Risk factors : young males, history or FMH of alcohol abuse , risk taking behaviour , prominent dyskinesia , FMH of bipolar disorder
What is Dopamine Dysregulation Syndrome
Addictive relationship with PD medications : usually levodopa or S/C apomorphine
- behaviour analogous to substance misuse
- seeks medication when not required from motor perspective
- development of cyclical mood disorder : hypomania & risky behaviour vs anhedonia & anxiety
Important Non-motor PD symtoms
Depression , REM sleep behaviour disorder , constipation , olfactory disturbance , erectile dysfunction , anxiety
PD medication with modest antidepressant effect
Dopamine agonists
Treatment for Depression with PD
Setraline , Mirtazepine ( if insomnia ) , venlafaxine , amitriptyline titrating
Acute confusion or psychosis with PD
Exclude infection , electrolyte disturbance or medication errors.
Consider PD medication dose reduction. DO not abruptly withdraw
Rivastigmine or memantine for chronic hallucinations
PD drug withdrawal symptoms
DAWS ( DA withdrawal syndrome ) : agitation , autonomic overactivity , depression , anxiety , psychosis
What is Parkinson’s hyperpyrexia syndrome
Due to PD withdrawal
Symtpms : fever, rigidity , sweating , raised CK , confusion , drowsiness , autonomic instability
Postural light headedness with PD
Due to non-pharmacological measures ( fluid intake, salt , ) or PD meds contributing
Treatment : Domperidone , fludrocortisone
For refractory cases : midodrine or ephedrine
Constipation with PD patients
Common in most PD patients. has an influence on motor function
Treatment can improve motor function. Try macrogols. treatment
Swallowing difficulties with PD
usually only a problem in advanced PD
- not responsive to Dopaminergic meds
- if PD medications can’t be swallowed then consider madopar dispersible / NG tube
REM sleep behaviour disorder treatment with PD
Clonazepam
Erectile dysfunction treatment with PD
Sildenafil
Anxiety treatment with PD
Mirtazepine , Sertraline
Medications to avoid with PD
1- Opioids : constipation , confusion , psychosis 2- Antipsychotics : exacerbate PD 3- Metoclopramide 4- prochlorperazine 5- phenergan 6- calcium channel antagonists
Which antipsychotics are preferred in patients with PD
Quetiapine & Clozapine
Common causes of sudden deterioration in PD
1- Constipations 2- Illness / infections 3- stress related episodes 4- dehydrations 5- withdrawal/ change in meds 6- use of neuroleptics or contraindicated drugs 7- depression 8- chronic/acute pain 9- anxiety / panic attacks 10- poor sleep
