Parkinsonism Flashcards
What is parkinsonism an extrapyramidal triad of?
Hypertonia
Tremor
Bradykinesia
Describe the tremor in parkinsonism
Worse at rest, often pill rolling of thumb over finger
Describe hypertonia in parkinsonism
Rigidity and tremor gives cogwheel rigidity felt by the examiner during rapid pronation/supination
Describe bradykinesia in parkinsonism
Slow to initiate movement
Actions slow and decrease in amplitude with repetition
Gait is festinant
Expressionless face
Describe festinant gait
Shuffling
Pitched forward
Decreased arm swing
Freezing at obstacles and doors due to poor simultaneous motor and cognitive function
What are the causes of parkinsonism
Parkinson's disease Parkinson's plus syndromes Vascular parkinsonism Drugs Toxins Wilsons disease Trauma Encephalitis Neurosyphilis
Describe the pathophysiology of Parkinson’s disease
Loss of dopaminergic neurons in the substantia nigra, associated with lewy bodies in the basal ganglia, brainstem and cortex
Is Parkinson’s disease a genetic disease
Most cases are sporadic however genetic loci have been implicated in familial cases
What is the mean age at onset of Parkinson’s disease
60yo
What does prevalence of Parkinson’s disease increase with?
Age
Describe the clinical features of Parkinson’s disease
Parkinsonism triad
Plus non motor symptoms
What non-motor symptoms are present in Parkinson’s disease
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
Describe how the diagnosis of Parkinson’s disease is made
Clinical diagnosis based on the core features of bradykinesia with resting tremor and/or hypertonia
Clinical response to dopaminergic therapy is supportive
Which diagnoses should be excluded when considering Parkinson’s disease
Cerebellar disease and frontotemporal dementia
Describe the location of symptoms in Parkinson’s disease
Unilateral - worse on one side
What imaging can be considered in Parkinson’s disease to support the diagnosis and exclude other causes
MRI - exclude structural problems
DaT scan - functional neuroimaging
PET scan - functional neuroimaging
Describe the focus of Parkinson’s disease treatment
Symptom control
Does not slow disease progression
List some non-pharmacological treatments of Parkinson’s disease
Deep brain stimulation
Surgical ablation of overactive basal ganglia circuits
Give examples of some Parkinson’s plus symptoms
Progressive supranuclear palsy
Multiple systems atrophy
Cortico-basal degeneration
Lewy body dementia
Describe progressive supranuclear palsy
Early postural instability Vertical gaze palsy Falls Rigidity of trunk > limbs Symmetrical onset Speech and swallowing problems Little tremor
Describe multiple systems atrophy
Early autonomic features - incontinence/impotence
Postural hypotension
Cerebellar and pyramidal signs
Rigidity>tremor
Describe cortico-basal degeneration
Akinetic rigidity involving one limb
Cortical sensory loss
Apraxia
Describe vascular Parkinson’s
Postural instability and falls rather than tremor, bradykinesia and festination
Which patients is vascular Parkinson’s common in?
Diabetics and hypertensives
Which drugs commonly cause secondary Parkinsons
Neuroleptics
Metoclopramide
Prochlorperazine
Which toxins cause secondary Parkinson’s
Manganese
What is Parkinson’s disease caused by trauma called?
Dementia pugilistica
Describe the management of Parkinson’s disease
MDT input Assess disability and cognition objectively and regularly Monitor mood for depression Involve palliative care services early Offer respite care for the carers
What happens to the efficacy of levodopa over time?
Decreases - requires larger doses and more frequent dosing and worsening of SEs and response fluctuations
When should levodopa be started?
Age > 70yo
or when PD seriously interferes with life
Discuss pros and cons with the patient
What might happen if you withdraw Parkinson’s disease medications too early ?
Acute akinesia
Neuroleptic malignant syndrome
What is levodopa?
Dopamine precursor, given combined with a dopa-decarboxylase inhibitor in co-beneldopa and co-careldopa
List the side effects of levodopa
Dyskinesia
Painful dystonia
Non motor SEs - psychosis, visual hallucinations, nausea and vomiting
Which anti-emetic should be given to treat nausea in people with Parkinson’s disease?
Domperidone
List some dopamine agonists
Ropinirole Pramipexole Rotigotine Bromocriptine Pergolide Cabergoline
What is the role of dopamine agonists
Can delay starting levodopa and also allows for decreased doses of levodopa
What are the side effects of dopamine agonists
Nausea
Drowsiness
Hallucinations
Compulsive behaviour - gambling, hypersexuality
What is the problem with ergot derived dopamine agonists
Fibrotic reactions
Which weak dopamine agonist is used for drug-induced dyskinesias
Amantadine
What is apomorphine, how is it given and what is it used for?
Potent dopamine agonist used with continuous SC infusion to even out end of dose effects or as a rescue pen for sudden off freezing
What is a side effect of apomorphine
Injection site ulcers
What class of drug can be given as an alternative to dopamine agonists in early Parkinson’s disease
Monoamine oxidase inhibitors
List some side effects of Monoamine oxidase inhibitors
Postural hypotension
Atrial fibrillation
What is the role of COMT inhibitors
May help with motor complications in late disease
Lessen the off time in those with end dose wearing off
What is the complication and monitoring in the use of tolcapone
Hepatic complications
Requires close monitoring of LFT
Give 2 examples of COMT inhibitor
Entacapone
Tolcapone
