Parkinsonism

Question 1

What are the symptoms of Parkinsonism?

Answer 1

• tremor
• rigidity
• bradykinesia
• postural instability or gait dysfunction

Question 2

What are the possible causes of Parkinsonism?

Answer 2

1) Parkinson’s disease
2) Atypical Parkinsonism disorders
3) Drug induced
4) Vascular

Question 3

What is the pathophysiology of Parkinsons disease?

Answer 3

premature degeneration of Substantia Nigra cells, cells produce dopamine so degeneration leads to a reduction in dopamine

Question 4

How is Parkinsons diagnosed?

Answer 4

Queen’s Square Brain Bank criteria
1) Bradykinesia (essential)
+ one of: muscular rigidity, tremor, Gait dysfunction

Question 5

What is bradykinesia?

Answer 5

slowness of initiation of voluntary movement & progressive reduction of repetitive movement

Question 6

How do people often present with bradykinesia?

Answer 6

difficulty doing buttons, less swinging of arms, hard to brush teeth, reduced blinking, can be interpreted as weakness

Question 7

What kind of tremor is seen in Parkinsons?

Answer 7

postural re-emergent tremor

Question 8

What are the possible differential diagnosis of Parkinson’s?

Answer 8

Tremor

• essential tremor (no bradykinesia or gait changes)
• dystonic tremor

Question 9

How does gait change in Parkinsons?

Answer 9

• 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

Question 10

What extra test can help diagnose Parkinson?

Answer 10

pull test gently pull back on shoulders from behind (struggle to maintain upright posture and fall unless caught)

Question 11

What are the types of atypical Parkinson syndrome

Answer 11

1) multiple system atrophy
2) progressive supranuclear palsy
3) corticobasal degeneration

Question 12

What history findings would suggest a non-degenerative cause of Parkinsonism?

Answer 12

• repeated strokes
• head injury
• history of encephalitis
• neuroleptic drug exposure (**)

Question 13

What are the red flags to suggest symptoms are not caused by Parkinson’s disease?

Answer 13

• 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)

Question 14

How can Parkinsons and supranuclear palsy be differentiated?

Answer 14

get supra nuclear gaze palsy and inability to stop repetitive movements in supranuclear palsy

Question 15

How can MSA (multiple system atrophy) and Parkinsons be differentiated?

Answer 15

• MSA get high pitched and quivering voice changes

- in MSA get jerky postural tremor unlike parkisnsons

Question 16

What investigations are used to diagnose Parkinsonism?

Answer 16

MRI

Dopamine transporter scan - shows whether dopamine pathways are intact (abnormal scan is circular appearance)

Question 17

When will the DAT scan be abnormal?

Answer 17

degenerative Parkinsonism (any type)

Question 18

What are the supportive criteria for Parkinsons disease?

Answer 18

• 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)

Question 19

What are the treatments for Parkinsons?

Answer 19

1) Dopaminergic medication: !Levodopa and dopamine agonists!

2) Dopamine degradation inhibitors: MAO b inhibitors and COMT inhibitors

Question 20

What are the advantages of Levodopa?

Answer 20

most effective at alleviating Parkinsonism, least non-dyskinesia side effects

Question 21

What are the advantages of dopamine agonists?

Answer 21

less dyskinesia side effects

Question 22

What are the first line drugs for Parkinsonism?

Answer 22

• no first line different dependant on case

Question 23

In which group of people is impulse control disorder most common when on Parkinson medication?

Answer 23

young males, with history of bipolar, alcohol abuse or risk taking behaviours

Question 24

What are the non-oral advanced treatment options?

Answer 24

• apomorphine subcut infusion
• Duodopa (levodopa intrajejunal infusion)
• deep brain stimulation

Question 25

What is dopamine dysregulation syndrome?

Answer 25

• patient get addicted to PD medication (usually levodopa)

- behaviour similar to substance abuse

Question 26

What are some of the non-motor PD symptoms?

Answer 26

• 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

Question 27

What are the symptoms of PD drug withdrawal?

Answer 27

• fever
• rigidity
• confusion
• sweating
• raised CK
• autonomic instability

Question 28

What drugs can interact with PD medication?

Answer 28

opioids 
antipsychotics 
metoclopramide 
prochlorperazine 
phenergan
calcium channel antagonist

Question 29

What are the motor feature of Parkinsonism?

Answer 29

• 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