Parkinsonism

Question 1

What is parkinsonism an extrapyramidal triad of?

Answer 1

Hypertonia
Tremor
Bradykinesia

Question 2

Describe the tremor in parkinsonism

Answer 2

Worse at rest, often pill rolling of thumb over finger

Question 3

Describe hypertonia in parkinsonism

Answer 3

Rigidity and tremor gives cogwheel rigidity felt by the examiner during rapid pronation/supination

Question 4

Describe bradykinesia in parkinsonism

Answer 4

Slow to initiate movement
Actions slow and decrease in amplitude with repetition
Gait is festinant
Expressionless face

Question 5

Describe festinant gait

Answer 5

Shuffling
Pitched forward
Decreased arm swing
Freezing at obstacles and doors due to poor simultaneous motor and cognitive function

Question 6

What are the causes of parkinsonism

Answer 6

Parkinson's disease
Parkinson's plus syndromes
Vascular parkinsonism
Drugs
Toxins
Wilsons disease
Trauma
Encephalitis
Neurosyphilis

Question 7

Describe the pathophysiology of Parkinson’s disease

Answer 7

Loss of dopaminergic neurons in the substantia nigra, associated with lewy bodies in the basal ganglia, brainstem and cortex

Question 8

Is Parkinson’s disease a genetic disease

Answer 8

Most cases are sporadic however genetic loci have been implicated in familial cases

Question 9

What is the mean age at onset of Parkinson’s disease

Answer 9

60yo

Question 10

What does prevalence of Parkinson’s disease increase with?

Answer 10

Age

Question 11

Describe the clinical features of Parkinson’s disease

Answer 11

Parkinsonism triad

Plus non motor symptoms

Question 12

What non-motor symptoms are present in Parkinson’s disease

Answer 12

Autonomic dysfunction - postural hypotension, constipation, urinary frequency/urgency, dribbling of saliva
Sleep disturbance
Reduced sense of smell
Neuropsychiatric complications such as dementia, depression and psychosis

Question 13

Describe how the diagnosis of Parkinson’s disease is made

Answer 13

Clinical diagnosis based on the core features of bradykinesia with resting tremor and/or hypertonia

Clinical response to dopaminergic therapy is supportive

Question 14

Which diagnoses should be excluded when considering Parkinson’s disease

Answer 14

Cerebellar disease and frontotemporal dementia

Question 15

Describe the location of symptoms in Parkinson’s disease

Answer 15

Unilateral - worse on one side

Question 16

What imaging can be considered in Parkinson’s disease to support the diagnosis and exclude other causes

Answer 16

MRI - exclude structural problems
DaT scan - functional neuroimaging
PET scan - functional neuroimaging

Question 17

Describe the focus of Parkinson’s disease treatment

Answer 17

Symptom control

Does not slow disease progression

Question 18

List some non-pharmacological treatments of Parkinson’s disease

Answer 18

Deep brain stimulation

Surgical ablation of overactive basal ganglia circuits

Question 19

Give examples of some Parkinson’s plus symptoms

Answer 19

Progressive supranuclear palsy
Multiple systems atrophy
Cortico-basal degeneration
Lewy body dementia

Question 20

Describe progressive supranuclear palsy

Answer 20

Early postural instability 
Vertical gaze palsy 
Falls
Rigidity of trunk > limbs
Symmetrical onset 
Speech and swallowing problems 
Little tremor

Question 21

Describe multiple systems atrophy

Answer 21

Early autonomic features - incontinence/impotence
Postural hypotension
Cerebellar and pyramidal signs
Rigidity>tremor

Question 22

Describe cortico-basal degeneration

Answer 22

Akinetic rigidity involving one limb
Cortical sensory loss
Apraxia

Question 23

Describe vascular Parkinson’s

Answer 23

Postural instability and falls rather than tremor, bradykinesia and festination

Question 24

Which patients is vascular Parkinson’s common in?

Answer 24

Diabetics and hypertensives

Question 25

Which drugs commonly cause secondary Parkinsons

Answer 25

Neuroleptics Metoclopramide Prochlorperazine

Question 26

Which toxins cause secondary Parkinson's

Answer 26

Manganese

Question 27

What is Parkinson's disease caused by trauma called?

Answer 27

Dementia pugilistica

Question 28

Describe the management of Parkinson's disease

Answer 28

``` MDT input Assess disability and cognition objectively and regularly Monitor mood for depression Involve palliative care services early Offer respite care for the carers ```

Question 29

What happens to the efficacy of levodopa over time?

Answer 29

Decreases - requires larger doses and more frequent dosing and worsening of SEs and response fluctuations

Question 30

When should levodopa be started?

Answer 30

Age > 70yo or when PD seriously interferes with life Discuss pros and cons with the patient

Question 31

What might happen if you withdraw Parkinson's disease medications too early ?

Answer 31

Acute akinesia | Neuroleptic malignant syndrome

Question 32

What is levodopa?

Answer 32

Dopamine precursor, given combined with a dopa-decarboxylase inhibitor in co-beneldopa and co-careldopa

Question 33

List the side effects of levodopa

Answer 33

Dyskinesia Painful dystonia Non motor SEs - psychosis, visual hallucinations, nausea and vomiting

Question 34

Which anti-emetic should be given to treat nausea in people with Parkinson's disease?

Answer 34

Domperidone

Question 35

List some dopamine agonists

Answer 35

``` Ropinirole Pramipexole Rotigotine Bromocriptine Pergolide Cabergoline ```

Question 36

What is the role of dopamine agonists

Answer 36

Can delay starting levodopa and also allows for decreased doses of levodopa

Question 37

What are the side effects of dopamine agonists

Answer 37

Nausea Drowsiness Hallucinations Compulsive behaviour - gambling, hypersexuality

Question 38

What is the problem with ergot derived dopamine agonists

Answer 38

Fibrotic reactions

Question 39

Which weak dopamine agonist is used for drug-induced dyskinesias

Answer 39

Amantadine

Question 40

What is apomorphine, how is it given and what is it used for?

Answer 40

Potent dopamine agonist used with continuous SC infusion to even out end of dose effects or as a rescue pen for sudden off freezing

Question 41

What is a side effect of apomorphine

Answer 41

Injection site ulcers

Question 42

What class of drug can be given as an alternative to dopamine agonists in early Parkinson's disease

Answer 42

Monoamine oxidase inhibitors

Question 43

List some side effects of Monoamine oxidase inhibitors

Answer 43

Postural hypotension | Atrial fibrillation

Question 44

What is the role of COMT inhibitors

Answer 44

May help with motor complications in late disease | Lessen the off time in those with end dose wearing off

Question 45

What is the complication and monitoring in the use of tolcapone

Answer 45

Hepatic complications | Requires close monitoring of LFT

Question 46

Give 2 examples of COMT inhibitor

Answer 46

Entacapone | Tolcapone