Parkinsonism Flashcards
What are the symptoms of Parkinsonism?
- tremor
- rigidity
- bradykinesia
- postural instability or gait dysfunction
What are the possible causes of Parkinsonism?
1) Parkinson’s disease
2) Atypical Parkinsonism disorders
3) Drug induced
4) Vascular
What is the pathophysiology of Parkinsons disease?
premature degeneration of Substantia Nigra cells, cells produce dopamine so degeneration leads to a reduction in dopamine
How is Parkinsons diagnosed?
Queen’s Square Brain Bank criteria
1) Bradykinesia (essential)
+ one of: muscular rigidity, tremor, Gait dysfunction
What is bradykinesia?
slowness of initiation of voluntary movement & progressive reduction of repetitive movement
How do people often present with bradykinesia?
difficulty doing buttons, less swinging of arms, hard to brush teeth, reduced blinking, can be interpreted as weakness
What kind of tremor is seen in Parkinsons?
postural re-emergent tremor
What are the possible differential diagnosis of Parkinson’s?
Tremor
- essential tremor (no bradykinesia or gait changes)
- dystonic tremor
How does gait change in Parkinsons?
- stooped posture
- shuffling
- arms flexed and shaking
- festination
- reduced arm swinging
- reduced foot-lift, stride length and cadence
- loss of fluency when turning
- narrow-based gait
What extra test can help diagnose Parkinson?
pull test gently pull back on shoulders from behind (struggle to maintain upright posture and fall unless caught)
What are the types of atypical Parkinson syndrome
1) multiple system atrophy
2) progressive supranuclear palsy
3) corticobasal degeneration
What history findings would suggest a non-degenerative cause of Parkinsonism?
- repeated strokes
- head injury
- history of encephalitis
- neuroleptic drug exposure (**)
What are the red flags to suggest symptoms are not caused by Parkinson’s disease?
- poor response to levodopa
- early recurrent falls
- prominent early speech or swallowing difficulty
- early cognitive decline
- should have no cognitive symptoms on presentation
- shoudnt have autonomic dysfunction
- wheelchair dependant (should remain ambulant for several years)
How can Parkinsons and supranuclear palsy be differentiated?
get supra nuclear gaze palsy and inability to stop repetitive movements in supranuclear palsy
How can MSA (multiple system atrophy) and Parkinsons be differentiated?
- MSA get high pitched and quivering voice changes
- in MSA get jerky postural tremor unlike parkisnsons
What investigations are used to diagnose Parkinsonism?
MRI
Dopamine transporter scan - shows whether dopamine pathways are intact (abnormal scan is circular appearance)
When will the DAT scan be abnormal?
degenerative Parkinsonism (any type)
What are the supportive criteria for Parkinsons disease?
- unilateral onset
- persistant asymmetry
- rest tremor
- progressive
- excellent response to levodopa
- get dyskinesia as side effect of levodopa
- visual hallucinations
- clinical course of over 10y (slow degeneration)
What are the treatments for Parkinsons?
1) Dopaminergic medication: !Levodopa and dopamine agonists!
2) Dopamine degradation inhibitors: MAO b inhibitors and COMT inhibitors
What are the advantages of Levodopa?
most effective at alleviating Parkinsonism, least non-dyskinesia side effects
What are the advantages of dopamine agonists?
less dyskinesia side effects
What are the first line drugs for Parkinsonism?
- no first line different dependant on case
In which group of people is impulse control disorder most common when on Parkinson medication?
young males, with history of bipolar, alcohol abuse or risk taking behaviours
What are the non-oral advanced treatment options?
- apomorphine subcut infusion
- Duodopa (levodopa intrajejunal infusion)
- deep brain stimulation
What is dopamine dysregulation syndrome?
- patient get addicted to PD medication (usually levodopa)
- behaviour similar to substance abuse
What are some of the non-motor PD symptoms?
- neuropsychiatric (depression, anxiety and dementia)
- Sleep disorder (REM sleep behaviour)
- Autonomic (urinary symptoms & sexual dysfunction)
- GI (constipation and nausea)
- Sensory (pain and olfactory disturbance)
- fatigue and weight changes
What are the symptoms of PD drug withdrawal?
- fever
- rigidity
- confusion
- sweating
- raised CK
- autonomic instability
What drugs can interact with PD medication?
opioids antipsychotics metoclopramide prochlorperazine phenergan calcium channel antagonist
What are the motor feature of Parkinsonism?
- manual dexterity problems
- slowing down
- loss of movement
- loss of arm swing
- difficulty with repetitive movements
- dragging of leg
- micrographia
- difficulty turning in bed
- reduced facial expression
- reduced blinking
- drooling overnight
- hypophonia
