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Neurology > Parkinsonism > Flashcards

Parkinsonism Flashcards

1
Q

What is Parkinson’s Disease?

A

Chronic progressive neurological disorder characterised by motor symptoms of resting tremor, rigidity, bradykinesia, postural instability.

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2
Q

What is the mean age of onset of PD?

A

70 years

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3
Q

What are the key RFx for PD?

A
  • Increasing age,
  • familial PD and
  • MPTP exposure.
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4
Q

What are the key diagnostic factors of PD?

A

Resting tremor, bradykinesia, rigidity, postural instability, RFx.
Criteria: two or more of the first 3.

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5
Q

What initial tests should be ordered in PD?

A

Dopaminergic agent trial -> positive if improvement in symptoms.

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6
Q

What DDx should be excluded in patients presenting with PD like symptoms?

A

Wilson’s disease; exclude in all patients

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7
Q

What is the initial treatment for mild parkinsonism?

A

MAO-B inhibitor, dopaminergic agent, amantidine + physical activity.

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8
Q

What are the long term complications of PD?

A

levodopa induced dyskinesias, akathisia (restlessness), motor fluctuations, dementia, psychosis, depression, impulse control disorder.

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9
Q

What is the pathophysiology of PD?

A

Degeneration of dopaminergic neurons in the substantial nigra pars compacta in the basal ganglia; thus decreased dopamine in striatum leading to disinhibition of the indirect pathway and decreased activation of the direct pathway (causes increased inhibition of cortical motor areas)

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10
Q

Hx features of PD?

A

Onset usually asymmetric, with eventual spread to other body parts.
Many patients will report restlessness/sleepwalking.
Some notice hyponosmia.

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11
Q

What are the symptoms of PD?

A

Resting tremor, reduction in dexterity, bradykinesia, masked facies, sleep disturbances, autonomic dysfunction, bradyphrenia, dementia.

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12
Q

How does a resting tremor appear?

A

Pill rolling tremor.

Like rolling a marble/pill in fingers.

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13
Q

What are the signs of PD?

A
  • Resting tremor
  • Cogwheel rigidity
  • Signs reflective of bradykinesia (decreased speed of movement, micrographic, masked facies, softer voice)
  • Festinating gait
  • Freezing
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14
Q

When should neuroimaging be conducted in suspected PD?

A

CT or MRI only indicated if patient is younger than 55 or if the pt has additional sx not associated w/ Parkinson’s.

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15
Q

What are the Ddx for PD?

A
  • 1) Parkinson plus syndrome;
  • 2) normal pressure hydrocephalus;
  • 3) essential tremor;
  • 4) Huntington’s disease;
  • 5) Wilson’s disease;
  • 6) post encephalic parkinsonism;
  • 7) adverse effects of neuroleptics.
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16
Q

What are the major Parkinson Plus syndrome?

A

Shy Drager syndrome, Progressive supranuclear palsy; Lewy body dementia.

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17
Q

What is normal pressure hydrocephalus?

A

Wet, wobbly, wacky (urinary incontinence, gait disturbance, dementia)
Get CT, sx resolve with LP drainage.

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18
Q

What is essential tremor?

A

Tremor only resolves w/ alcohol consumption or w/ trial of propranolol.

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19
Q

What are the features of Huntington’s disease?

A 
Personality changes, anhedonia, ballismus; chorea.
Autosomal dominant (runs in families)
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20
Q

What are the features of Wilson’s disease?

A

Psychiatric disturbances, liver failure, KF rings, autosomal recessive.

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21
Q

Which therapies should be instituted in a higher functioning patient?

A

Withhold dopaminergics termporarily.

60yo: amantadine (anti-chol AEx bad in elderly)

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22
Q

Which therapies should be instituted in lower functioning patients?

A 
Commence dopaminergics.
Levodopa/carbidopa commenced in all pts at this point.
Adjunctive therapy (inc effect): DA agonist (pramipexole, bromocriptine).
23
Q

What should be instituted when the patient’s response to dopaminergics begins to decline?

A

MAO-B inhibitors.

Selegiline or rasagiline.

24
Q

What is the role of COMT inhibitors?

A

Reduce fluctuations and AEx.

Do not help Parkinson sx themselves. Only regulate dopamine levels in blood.

25
Q

How should nausea be managed in PD?

A

Domperidone

Avoid anti-cholinergic, anti-histamine based anti-emetics.

26
Q

What is O/P PD management?

A
  • Referral to neurology
  • Screen for depression, mood disorders, psychosis
  • Exercise and speech therapy (QoL)
27
Q

What is progressive supra nuclear palsy?

A

Parkinonian Sx + vertical gaze palsy.

Tremor may not be as prominent.

28
Q

What is Shy-Drager syndrome?

A

Parkinsonian sx + severe autonomic instability, gait issues.

  • Strong sx autonomic dysfunction: orthostatic hTN,
  • UMN sx: hyperreflexia, primitive reflexes,
  • Cereberllar sx, nystagmus.
  • Imaging shows atrophy of brainstem, cerebellum.
29
Q

What is Lewy body dementia?

A

Parkinsonian sx + prominent dementia coinciding near onset of sx.

30
Q

Parkinson’s male or female more?

A

M:F 3:2

31
Q

Questions for bradykinesia?

A

If walking with someone of your age do they have to slow to keep up with you?
Are fine movements difficult?
Can you use cutlery/do buttons etc?
Can you turn over in bed?

32
Q

What is a common description of rigidity?

A

End of dose dystonia

Pain occurring as drugs wearing off.

33
Q

Describe the gait of PD

A

Reduced speed and step length; narrow base of support; forward trunk flexion; reduced arm swing; short, shuffling steps.
Freezing, festination, difficulty turning.

34
Q

What is the Pull test?

A

Positive if patient staggers backwards multiple steps when pulled - retropulsion

35
Q

Dyskinesia?

A

Abnormal involuntary movements (choreic, dystonic, ballistic, myotonic)

36
Q

What is dystonia?

A

Involuntary muscle contraction involving abnormal movements and postures.
More sustained abnormal posture than dyskinesia.

37
Q

How can PD dyskinesia be treated?

A

Usually reversible levodopa induced motor complication.

Treat by adjusting levodopa dosing.

38
Q

How can dystonia in PD be treated?

A

Can be an undertreated PD motor symptom or a complication of levodopa treatment.

39
Q

What is madopar?

A

Combination benzerazide-levodopa

40
Q

What is levodopa?

A

Replacement of dopamine via prodrug (levodopa)

41
Q

What is levodopa most effective in treating?

A

Hypokinetic motor symptoms, also tremor and rigidity.

Less effective for postural instability

42
Q

What is levodopa always combined with?

A

Peripheral decarboxylase inhibitor to minimise peripheral conversion to dopamine (–> AEx).

43
Q

What is Sinemet?

A

Levodopa/carbidopa

44
Q

What are the AEx of levodopa?

A 
Dyskinesia
Nausea, abdo cramps
Somnolence
Dizziness and headache
Confusion/hallucination/delusions/psychosis
Orthostatic hTN
45
Q

What are levodopa related complications?

A 
Motor fluctuations:
Wearing off
On-off syndrome
Failure to turn on (no response)
Acute akinesia/dyskinesia
46
Q

What are the dopamine agonists?

A

Pramiprexole
Rotisotine
Apomorphine (S/C)
All highly emetic

47
Q

How can ‘wearing off’ be reduced?

A

1) Change levodopa routine

2) Add second drug (COMT-i, MAO-I, dopamine agoist)

48
Q

What is entacapone?

A

COMT-I

49
Q

What are the side effects of DA?

A

N/V, somnolence, orthostatic hTN, confusion, hallucinations, impulse control disorders, cutaenous rxns, CP/ang.

50
Q

What precautions prior to commencing DA?

A
  • Orthostatic hTN

- Antiemetic prior to dose

51
Q

What is quetiapine?

A

Anti-DA agent

Can be used to counter DA induced hallucinations.

52
Q

How should orthostatic hTN be Mx?

A

Non pharm: profiling stategies, avoid sudden changes, elevate head of bed, avoid excessive alcohol and large meals.
Pharm: salt supplements, fludocortisone.

53
Q

Gender distribution PD?

A

3M:2F

54
Q

Cardinal features of PD?

A 
TRAP
Tremor
Rigidity
Akinesia/BRADYkinesia
Postrual instability

Neurology (38 decks)

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