Parkinsonism Flashcards
What are the symptoms of Parkinsonisim
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
What is a test for bradykinesia
Finger tap test
What are degenerative causes (+Ve DAT)
Idiopathic Parkinson’s Disease
Lewy Body Dementia
Parkinson plus syndrome
What is typical Parkinson disease
Chronic Progressive Asymmetrical Gradual onset Levodopa responsive
What does Lewy Body present with
Psych symptoms first
Memory impairment <1 year before Parkinson’s signs
What are Parkinson PLus Syndrome and what are red flags to suggest
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
What are secondary causes of Parkinsonism (-ve DAT)
Other causes
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
What is common with vascular
Legs worse than arms
Step wise progression
Gait affected early + cognition
What drugs can cause Parkinsonism
Anti-psychotics
- Haloperidol = common
Anti-emetic
- Metaclopomide - common in surgical
- Bucazem (procloripirizine)
Amiodarone
Valproate
Why doesn’t domperiodone cause Parkinson’s
Doesn’t cross BBB but will meet VZV responsible for vomiting so useful as anti-emetic
What are typical of secondary causes / drug induced
Rapid onset
Bilateral
Rigid and rest tremor = uncommon
Poor levodopa response
How do you treat drug induced Parkinson’s
Anti-muscarinic to block cholinergic receptor
May not come back to premorbid state
Procyclidine for tremor
What are motor symptoms of Parkinson’s / what is gait like
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
What will bradykinesia cause (slowness of movement)
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
What is typical of Parkinson’s tremor
At rest Slower than essential Pin rolling - index and thumb common Unilateral and distal first Better with voluntary movement Worse when distracted
What is rigidty
Increased tone across full range of movement
Not velocity dependent - spastic
Jerky ‘cogwheel’ due to superimposed tremor
What balance problems occur
Usually late on in disease
Marked postural instability
Beware of falls in 1st year as suggestive alternative Dx
What are non-motor symptoms
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
What are autonomic dysfunction signs
Incontinence Postural hypo - Common in Parkinson's not necessarily MSA Excessive sweating Impotence
What are the differential for tremor
Essential Hyperthyroid Drug induced - salbutamol Assocation with dystonia Cerebellar disorder - not at rest, more on action / posture Hepatic encephalopath Anxiety CO2 retention
What suggests essential tremor
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
How do you treat essential tremor
Propranolol
DBS if very severe`
What excludes a diagnosis of Parkinson
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
What is supporitve of IPD
Unilateral Rest tremor Slowly progressive Persistent asymmetry Excellent response to Rx Severe levodopa induced dyskinesia Long term
What is the underlying pathology of Parkinson’s
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
What are the stages of IPD
Asymptomatic - degeneration starts Symptom onset Diagnosis Maintenance with Rx Complex when motor complications begin - breathing / swallow Palliative stage Cognitive decline if survive
How do you Dx Parkinson’s
Uncertain
Specialist for clinical Dx
Hx + exam
Can do DAT SPECT - aid Dx if unsure between essential + Parkinson
What will reduced uptake in L side of brain suggest
R sided Parkinson symptoms
How do you manage Parkinson’s
MDT- physio, OT, dietician, SLT, specialist nurse, psych
Medication when beginning to affect QOL
What non-pharmacological measures can help
VIdeo / audtiory queues in freezing situation
Non-motor sympotms - anxiety / swallow / speech/ ADL
Sleep
Nutrition
Physio / OT
SALT
Deep brain stimulation
WHen do you start medication
When Sx affecting QOL
What responds best to medication
Motor symptoms
WHat is the main stay of treatment
Levodopa with decarboxylase inhibitor (reduce SE as no conversion in peripheral tissue)
Can’t give dopamine as doesn’t cross BBB
What are examples of Levodopa
Madopar
Co-carledopa
Co-beneldopa
What are the benefits of Levodopa
Quick response Give regular doses Improvement in symptoms More motor SE Less other adverse SE
What are other SE of medication and when are they more likely but can occur on L-dopa
Hallucination Sleep Impulse control Postural hypo GI Arrhythmia
More likely if
- On dopamine agonist
- Hx impulsivity
- Hx of alcohol / smoking
What are other medications
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
What is the main motor SE of treatment
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
WHat can you give in advanced disease
Apomorphine (dopamine agonist) SC or syringe pump
Duodopa - gel form with PEG to bypass gut if poor absorption due to disease
What is an acute admission for
Usually due to other medical issues e.g. delerium or swallow
What should you be aware of
Neuroleptic Malignnat syndrome if stop medication suddenly or get at different time
Acute akinesia if med not taken
What is neuroleptic malignant syndrome
Common with anti-psychotics or when dopamine medication stopped suddenly
What are the signs of NMS
Pyrexia Tachycardia Hypertension Raised CK AKI 2 to rhabdommyolysis if severe Rigid Decreased reflex
What do you do for NMS
Stop drug if anti-psychotic
Dopamine agonist
Dantrolene if severe (Ca antagonist)
IV fluid to prevent renal failure
If suspect Parkinson in GP
Refer urgent to neurology / specialist
URGENT
What vitamin should you supplement
Vit D
If unable to take medication by mouth what do you do
Change to dopamine agonist patch to prevent acute dystonia
If stop medication suddenly what are patients at risk of
NMS
Acute dystonia
What are serious risk of dopamine agonist (Ergots)
Pulmonary, retroperitoneal and cardiac fibrosis
What do you do before starting
U+E + ESR
CXR
ECHO
What is amantadine used for
Relieve fatigue
What are SE
Ataxia Slurred speech Confusion Dizzy Lived reticularis
