Parkinsonism Flashcards by Eilidh Seaton

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

How well did you know this?

Not at all

Perfectly

What is a test for bradykinesia

Finger tap test

How well did you know this?

Not at all

Perfectly

What are degenerative causes (+Ve DAT)

Idiopathic Parkinson’s Disease
Lewy Body Dementia
Parkinson plus syndrome

How well did you know this?

Not at all

Perfectly

What is typical Parkinson disease

Chronic
Progressive
Asymmetrical
Gradual onset 
Levodopa responsive

How well did you know this?

Not at all

Perfectly

What does Lewy Body present with

Psych symptoms first

Memory impairment <1 year before Parkinson’s signs

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

What is common with vascular

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

How well did you know this?

Not at all

Perfectly

What drugs can cause Parkinsonism

Anti-psychotics
- Haloperidol = common

Anti-emetic

Metaclopomide - common in surgical
Bucazem (procloripirizine)

Amiodarone
Valproate

How well did you know this?

Not at all

Perfectly

Why doesn’t domperiodone cause Parkinson’s

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

How well did you know this?

Not at all

Perfectly

What are typical of secondary causes / drug induced

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

How well did you know this?

Not at all

Perfectly

How do you treat drug induced Parkinson’s

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

What is rigidty

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

How well did you know this?

Not at all

Perfectly

What balance problems occur

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

What are autonomic dysfunction signs

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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 ```