Parkinsonism

Question 1

What are the cardinal features of PD?

Answer 1

Postural instability
Bradykinesia
Tremor - high amplitude and low frequency pill rolling
Cogwheel rigidity

Question 2

What are the different types of PD?

Answer 2

Idiopathic PD
Vascular PD
Drug-induced PD
Lewy body PD
Progressive supra nuclear palsy 
Multi-system atrophy

Question 3

What are the suggestive features of idiopathic PD?

Answer 3

Unilateral onset
Upper limb predominance
Treatment responsive
Presenting bradykinesia

Question 4

What are the suggestive features of vascular PD?

Answer 4

lower limb predominance
bilateral onset
presentation with falls and gait problems

Question 5

What are the suggestive features of drug induced PD?

Answer 5

history of typical or atypical antipsychotic prescribing

Question 6

What are the suggestive features of lewy body dementia?

Answer 6

prominent cognitive impairment presenting at the same time as parkinsonism or within a few months
prominent hallucinations
fluctuations in level of consciousness

Question 7

What are the suggestive features of progressive supra nuclear palsy?

Answer 7

eye sign-vertical gaze palsy
cognitive impairment with frontal disinhibition
not responsive to dopaminergic treatment

Question 8

What are the suggestive features of multi-system atrophy?

Answer 8

Prominent autonomic features-orthostatic hypotension, incontinence, impotence, difficulty regulating body temperature-early in presentation
Cerebellar signs
Not responsive to treatment

Question 9

What is the characteristic gait and posture of a PD patient?

Answer 9

head held forward
drooping eyelids, open mouth, salivary drooling
tremor of hands
slow shuffling gait, short steps

Question 10

Describe the TW for parkinson treatment

Answer 10

the TW narrows over time and around the 10-15 year mark the proportion of the day “on” or “off” may begin to exceed the portion of the day where the therapy is effective

Question 11

What is bradykinesia and how is it detected?

Answer 11

slow movements detected using the finger-thumb test

Question 12

What is rigidity in parkinson’s?

Answer 12

detected as increased tone on movements

the superimposed tremor causes - cogwheeling

Question 13

Describe the tremor in PD

Answer 13

resting
high amplitude
low frequency (pill rolling)

may be unmasked by mental arithmetic or moving the contralateral limb

Question 14

How is postural instability detected?

Answer 14

detected using shoulder-tug test

Question 15

What are the other additional features of parkinson’s?

Answer 15

micrographia - small writing

abnormal gait - slow to initiate, shuffling, short steps, gets faster with momentum

Question 16

How is a PD diagnosis made?

Answer 16

• predominantly clinical
• CT brain to look for for signs of generalised cerebral ischaemia in patients with suspected vascular dementia
• SPECT scan
• dopaminergic treatment to establish whether idiopathic PD is present

Question 17

How is treatment monitored for effectiveness?

Answer 17

an appropriate baseline measurement of physical functioning e.g. lindop score, should be taken before treatment, with follow up to measure objective improvements

Question 18

Which type of parkinsons is treatment for motor symptoms effective?

Answer 18

Idiopathic parkinsons disease

Question 19

What are the treatment options in PD?

Answer 19

anticholinergic agents
dopamine agonists
monoamine oxidase B inhibitors (MAOBs)

Question 20

Why should anticholinergic agents not be used in older patients?

Answer 20

they almost always induce confusion

Question 21

What is the problem when using dopamine agonists?

Answer 21

useful when commenced early, may result in problems with therapeutic window later on

Question 22

What is the best treatment for older patients or those with a cognitive impairment?

Answer 22

levodopa with a decarboxylase inhibitor

Cobeneldopa cocareldopa - first line agent

Question 23

What adjuncts are used in addition to dopaminergic therapy?

Answer 23

Catechol-O-methyl transferase (COMT) inhibitors

Amantidine

Question 24

Why are COMT inhibitors used?

Answer 24

inhibit the breakdown of levodopa and increase its elimination half-life which helps with end of dose deteriorations

Question 25

When is amantadine used?

Answer 25

in patients with prominent dyskinesias

Question 26

Which advanced therapies are used in role of later disease?

Answer 26

direct duodenal infusion therapy (duodena)
apomorphine
deep-brain stimulation

Question 27

What are the non motor symptoms for idiopathic parkinson’s?

may be made worse by drug therapy

Answer 27

depression 
constipation 
dribbling of saliva
change in taste and smell 
urinary incontinence 
insomnia and sleep disturbance 
unexplained pain

Question 28

How are these non motor symptoms identified?

Answer 28

non moter symptoms (NMS)
parkinson disease quality of life questionnaire (PDQ)

some are responsive to dopamine therapy