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Geriatrics > Parkinsonism > Flashcards

Parkinsonism Flashcards

1
Q

What are the symptoms of Parkinsonisim

A

Bradykinesia +1 of
Rest tremor - may be present at other time / unilateral
Postural instability (poor balance / gait / falls )
Rigid - cog wheel

TRAP

  • Tremor
  • Rigid
  • Akinesia / bradykinesia
  • Postural instability
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2
Q

What is a test for bradykinesia

A

Finger tap test

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3
Q

What are degenerative causes (+Ve DAT)

A

Idiopathic Parkinson’s Disease
Lewy Body Dementia
Parkinson plus syndrome

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4
Q

What is typical Parkinson disease

A 
Chronic
Progressive
Asymmetrical
Gradual onset 
Levodopa responsive
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5
Q

What does Lewy Body present with

A

Psych symptoms first

Memory impairment <1 year before Parkinson’s signs

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6
Q

What are Parkinson PLus Syndrome and what are red flags to suggest

A

Progressive supranuclear palsy - ocular signs (vertical gaze palsy)
Multi-system atrophy - autonomic early, cerebellar, bulbar (swallowing)

Red flags
Early speech disturbance and falls common 
Early dementia 
Additional neurological signs 
Late signs of Parkinsons
Symmetrical findings 
LL most affected
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7
Q

What are secondary causes of Parkinsonism (-ve DAT)

Other causes

A

Vascular e.g. mini stroke hitting basal ganglia
Drug induced - dopamine antagonist (anti-psychotic / anti-emetics - metoclopramide)
Tend to be more bilateral

Other

  • Encephalitis
  • Wilson’s
  • CO poison = rare
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8
Q

What is common with vascular

A

Legs worse than arms
Step wise progression
Gait affected early + cognition

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9
Q

What drugs can cause Parkinsonism

A

Anti-psychotics
- Haloperidol = common

Anti-emetic

  • Metaclopomide - common in surgical
  • Bucazem (procloripirizine)

Amiodarone
Valproate

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10
Q

Why doesn’t domperiodone cause Parkinson’s

A

Doesn’t cross BBB but will meet VZV responsible for vomiting so useful as anti-emetic

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11
Q

What are typical of secondary causes / drug induced

A

Rapid onset
Bilateral
Rigid and rest tremor = uncommon
Poor levodopa response

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12
Q

How do you treat drug induced Parkinson’s

A

Anti-muscarinic to block cholinergic receptor
May not come back to premorbid state
Procyclidine for tremor

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13
Q

What are motor symptoms of Parkinson’s / what is gait like

A 
Bradykinesia 
Tremor 
Rigid 
Dystonia - part of disease or Rx 
Superimposed flexion so forward sense of gravity 
Balance problems 
Leg cramps 
Restless legs

Gait

  • Slow walking speed
  • Stooped posture
  • Short shuffling stride
  • Slow to turn
  • Reduced arm bilateral
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14
Q

What will bradykinesia cause (slowness of movement)

A

Masked expressionless face
Poverty of blinking
Reduced arm swing
Short shuffling gait
Difficulty initiating movement and turning
Stuck (particularly confined / busy spaces)
Micrographia - small compared to essential tremor
Hypophonia
Poor swallow / drool

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15
Q

What is typical of Parkinson’s tremor

A 
At rest
Slower than essential
Pin rolling - index and thumb common
Unilateral and distal first
Better with voluntary movement
Worse when distracted
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16
Q

What is rigidty

A

Increased tone across full range of movement
Not velocity dependent - spastic
Jerky ‘cogwheel’ due to superimposed tremor

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17
Q

What balance problems occur

A

Usually late on in disease
Marked postural instability
Beware of falls in 1st year as suggestive alternative Dx

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18
Q

What are non-motor symptoms

A

Bradyphrenia - memory / attention / executive function slow
Psychotic symptoms / impulse control - more due to SE of Rx (dopamine agonist)
REM Sleep disturbance
Autonomic dysfucntion
Constipation = very common
Anosmia
Psych - low mood, anxiety, REM sleep, dementia

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19
Q

What are autonomic dysfunction signs

A 
Incontinence
Postural hypo
- Common in Parkinson's not necessarily MSA 
Excessive sweating 
Impotence
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20
Q

What are the differential for tremor

A 
Essential
Hyperthyroid
Drug induced - salbutamol
Assocation with dystonia
Cerebellar disorder - not at rest, more on action / posture
Hepatic encephalopath
Anxiety
CO2 retention
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21
Q

What suggests essential tremor

A

Symmetrical
Occurs when maintaining a certain posture / action
Improves on rest
Head commonly involved
FH
Younger onset
Improves drinking small amounts of alcohol
Doesn’t progress as Parkinson’s - no mobility / speech / swallow

22
Q

How do you treat essential tremor

A

Propranolol

DBS if very severe`

23
Q

What excludes a diagnosis of Parkinson

A 
Rapid progression
No rest tremor
No response to Rx 
Early severe autonomic - postural hypo
Gaze palsy
Repeat head injury / stroke
Anti-psychotic drugs
Severe early dementia
24
Q

What is supporitve of IPD

A 
Unilateral
Rest tremor
Slowly progressive
Persistent asymmetry
Excellent response to Rx
Severe levodopa induced dyskinesia
Long term
25
Q

What is the underlying pathology of Parkinson’s

A

Neurodegeneratie
Unknown in 95%
Genetics in 5% - present younger
Deposition of Lewy Bodies (alpha synuclein)
Loss of dopamine neurones in SN of basal ganglia
CANNOT detect on image

26
Q

What are the stages of IPD

A 
Asymptomatic - degeneration starts
Symptom onset
Diagnosis 
Maintenance with Rx
Complex when motor complications begin - breathing / swallow
Palliative stage
Cognitive decline if survive
27
Q

How do you Dx Parkinson’s

A

Uncertain
Specialist for clinical Dx
Hx + exam
Can do DAT SPECT - aid Dx if unsure between essential + Parkinson

28
Q

What will reduced uptake in L side of brain suggest

A

R sided Parkinson symptoms

29
Q

How do you manage Parkinson’s

A

MDT- physio, OT, dietician, SLT, specialist nurse, psych

Medication when beginning to affect QOL

30
Q

What non-pharmacological measures can help

A

VIdeo / audtiory queues in freezing situation
Non-motor sympotms - anxiety / swallow / speech/ ADL
Sleep
Nutrition
Physio / OT
SALT
Deep brain stimulation

31
Q

WHen do you start medication

A

When Sx affecting QOL

32
Q

What responds best to medication

A

Motor symptoms

33
Q

WHat is the main stay of treatment

A

Levodopa with decarboxylase inhibitor (reduce SE as no conversion in peripheral tissue)
Can’t give dopamine as doesn’t cross BBB

34
Q

What are examples of Levodopa

A

Madopar
Co-carledopa
Co-beneldopa

35
Q

What are the benefits of Levodopa

A 
Quick response
Give regular doses
Improvement in symptoms
More motor SE
Less other adverse SE
36
Q

What are other SE of medication and when are they more likely but can occur on L-dopa

A 
Hallucination
Sleep 
Impulse control
Postural hypo 
GI 
Arrhythmia

More likely if

  • On dopamine agonist
  • Hx impulsivity
  • Hx of alcohol / smoking
37
Q

What are other medications

A

Dopamine agonist - Ropirinole / Pramipexole

  • Use in younger patients with midler symptoms
  • More adverse SE
  • Less effect on motor but double times to dyskinesia occurs

MOAB - stops breakdown of dopamine (Selegilline)

  • Less improvement in motor and ADL
  • Less motor SE
  • Less adverse SE

COMT (Entacapone)
- Use if still not controlled

38
Q

What is the main motor SE of treatment

A

Dyskinesia - occurs with even peak dose as disease progresses due to increased motor activity
- Dystonia - excessive contraction leads to abnormal movement
- Chorea - abnormal involuntary movement
- Athetosis - involuntary twitching
Motor fluctuations - on / off spells
Decreased effectiveness with time

39
Q

WHat can you give in advanced disease

A

Apomorphine (dopamine agonist) SC or syringe pump

Duodopa - gel form with PEG to bypass gut if poor absorption due to disease

40
Q

What is an acute admission for

A

Usually due to other medical issues e.g. delerium or swallow

41
Q

What should you be aware of

A

Neuroleptic Malignnat syndrome if stop medication suddenly or get at different time
Acute akinesia if med not taken

42
Q

What is neuroleptic malignant syndrome

A

Common with anti-psychotics or when dopamine medication stopped suddenly

43
Q

What are the signs of NMS

A 
Pyrexia
Tachycardia
Hypertension
Raised CK
AKI 2 to rhabdommyolysis if severe 
Rigid
Decreased reflex
44
Q

What do you do for NMS

A

Stop drug if anti-psychotic
Dopamine agonist
Dantrolene if severe (Ca antagonist)
IV fluid to prevent renal failure

45
Q

If suspect Parkinson in GP

A

Refer urgent to neurology / specialist

URGENT

46
Q

What vitamin should you supplement

A

Vit D

47
Q

If unable to take medication by mouth what do you do

A

Change to dopamine agonist patch to prevent acute dystonia

48
Q

If stop medication suddenly what are patients at risk of

A

NMS

Acute dystonia

49
Q

What are serious risk of dopamine agonist (Ergots)

A

Pulmonary, retroperitoneal and cardiac fibrosis

50
Q

What do you do before starting

A

U+E + ESR
CXR
ECHO

51
Q

What is amantadine used for

A

Relieve fatigue

52
Q

What are SE

A 
Ataxia
Slurred speech
Confusion
Dizzy
Lived reticularis

Geriatrics (8 decks)

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