Parkinsonism

Question 1

What is the cardinal triad of Parkinsonism?

Answer 1

Tremor - worse at rest, pill-rolling, 4-6 cycles/sec (slow)
Rigidity/increased tone - cogwheel rigidity
Bradykinesia/hypokinesia - slow to initiate movement, slow low amp excursions in repetitive actions (decr blink Tate, monotonous hypophonic speech) shuffling gait (festinance) with decr arm swing, expressionless face

Question 2

What are the causes of Parkinsonism?

Answer 2

Idiopathic PD
drugs - neuroleptics, metoclopramide, prochlorperazine
Trauma/boxing
Encephalopathy
Post ‘flu’
Manganese or copper toxicity (Wilson’s disease)
HIV
Parkinson-plus syndromes

Question 3

What is the typical presentation of idiopathic parkinson’s disease?

Answer 3

bradykinesia/hypokinesia plus one or more of:
tremor at rest
postural instability
muscular rigidity

subtle signs: sense of smell reduced, constipation, visual hallucinations, frequency/urgency, dribbling of saliva, depression and dementia

Question 4

What is the typical age of onset for idiopathic Parkinson’s disease

Answer 4

65 years

Question 5

What is the pathology of idiopathic parkinson’s disease?

Answer 5

mitochondrial DNA dysfunction causes degeneration of dopaminergic neurons in the substantia nigra pars compacta leading to a decrease in striatal dopamine levels

Question 6

What are the red flags that suggest a Parkinson’s-plus syndrome may be present in previously though Idiopathic parkinson’s disease?

Answer 6

VIVID
Vertical gaze palsy -> progressive supranuclear palsy
Impotence/incontinence -> multiple system atrophy
Visual hallucinations -> Lewy Body Dementia
Interfering (autonomous) activity by affected limb (alien limb phenomenon) -> cortico-basal degeneration
Diabetic/HTN pt who falls or has gait problems (eg ataxia, no festination) -> vascular parkinsonism

Question 7

What are some of the signs of progressive supranuclear palsy?

Answer 7

early postural instability and vertical gaze palsy +/- falls; rigidity of trunk > in limbs; symmetrical onset; speech and swallowing problems; little tremor

Question 8

What are some of the signs of multiple system atrophy?

Answer 8

Early autonomic features, postural hypotension, cerebellar and pyramidal signs, rigidity > tremor

Question 9

What are some of the signs of Lewy Body Dementia?

Answer 9

fluctuating cognition, vivid visual hallucinations and early dementia

Question 10

What are some of the signs of cortico-basal degeneration?

Answer 10

akinetic rigidity involving one limb, cortical sensory loss

Question 11

What are some of the signs of vascular parkinsonism?

Answer 11

pyramidal signs, often seen in diabetic/hypertensive patient who falls or has gait problems such as ataxia but with no festination

Question 12

What are the first line medication options for managing the motor and non-motor symptoms idiopathic parkinson’s disease?

Answer 12

motor: Levodopa first line, consider dopamine agonists or MAO-B inhibitors
adjuvant - Dopamine agonists, MAO-B inhibitors or COMT