Parkinsonism Flashcards
What is Parkinsonism?
Tremor: resting, pill rolling 3-5Hz, worse when tired
Hypertonia: rigidity - lead pipe - cogwheel due to superimposed tremor
Bradykinesia: slow to imitate movement, actions slow and decrease in amplitude with repetition,
Gait is shuffling with reduced arm swing and freezing at obstacles/doors
Masked facies
What are other features of Parkinson’s disease
Masked facies Flexed, stooped posture Micrographia Drooling of saliva Depression, dementia, psychosis Impaired olfaction REM sleep behaviour disorder Fatigue Postural hypotension Constipation
What is the pathology in PD?
Progressive neurodegeneration of dopaminergic neurones in the substantiated nivea of the basal ganglia, associated with alpha synuclein deposition and Lewy body formation in the basal ganglia, brainstem and cortex.
What are causes of Parkinsonism?
PD Drug induced parkinsonism - antipsychotics, metaclopramide (domperidone does not cross BBB) Progressive supra nuclear palsy Multiple system atrophy Wilson's disease Post-encephalitis Dementia pugilistica (secondary to head trauma) Toxins: Carbon monoxide Corticobasal degeneration Lewy body dementia
What are the features of drug induced parkinsonism?
Motor symptoms are generally rapid onset and bilateral
Rigidity and rest tremor are uncommon
What drugs cause Parkinsonism
Dopamine receptor antagonists Chlorpromaxine Haloperidol Metoclopramide Prochlorperazine
(domperidone does not cross the BBB
Describe diagnosis of PD
Clinical: Bradykinesia Rigidity Resting tremor Postural instability
Exclude cerebellar disease and frontotemporal dementia
Clinical response to dopamine therapy is supportive
Signs are worse on one side - if symmetrical look for other causes
MRI to rule out structural pathology
DAT scan
What is progressive supra nuclear palsy?
PSP
Steele-Richardson-Olszewski sydnrome
Early postural instability Vertical gaze palsy - patients may complain of difficulty reading or descending stairs Falls Rigidity of trunk > limbs Symmetrical onset Speech and swallowing problem Cognitive impairment
Poor response to L-dopa
What is multiple system atrophy?
MSA
Shy Drager syndrome
Early autonomic features e.g. erectile dysfunction, incontinence, postural hypotension
Cerebellar + pyramidal signs
Rigidity > tremor
MSA-P - predominant parkinsonism features
MSA-C - predominant cerebellar features
What is corticobasal degeneration?
Akinetic rigidity involving one limb
Cortical sensory loss
Apraxia (even autonomous interfering activity by affected limb
What is Lewy body dementia? Features?
Alpha synuclein cytoplasmic inclusions in the substantia nivea, paralimbic and neocortical areas
Can be seen on SPECT scan
Fluctuating cognitive impairment
Detailed visual hallucinations
Later on, parkinsonism
What should you avoid in Lewy body dementia?
Avoid using neuroleptics as patients are extremely sensitive and may develop irreversible parkinsonism
What is management for Lewy body dementia?
Acetylcholinesterase inhibitors (donezepil, rivastigmine) and NMDA antagonist memantine can be used
What is first line treatment of PD if motor symptoms are affecting patients QOL
Levodopa
What is first line treatment of PD if motor symptoms are not affecting patients QOL?
Dopamine agonist
Levodopa
MAO-B inhibitor
