Parkinsonism and Movement disorders

Question 1

What are the core symptoms of Parkinson’s Disease?

Answer 1

1. Rigidity (Increased tone)
2. Resting Tremor (4-6Hz) accentuated by distraction, usually unilateral
3. Upper Body Bradykinesia (slowed initiation of movement + impaired fine movements)
4. Postural Instability (Later) - postural righting reflexes impaired and high risk of falls late in disease. shown in shoulder tug test.

Question 2

What is Multi-System Atrophy?

Answer 2

Side to side nystagmus

Cerebellar signs

Question 3

What is PSP Progressive Supranuclear Palsy?

Answer 3

parkinsonism with rigidity in extension rather than flexion

supranuclear paralysis of eye movement in downward direction.

Question 4

What is the aetiology of PD?

Answer 4

1. Genetics (doubled lifetime risk if first degree relative has PD) often associated with atypical onset.
2. Environmental toxins: pesticides, drinking well water
3. head injury
4. post-infectious

• • possible start point in gut. Bacterial overgrowth common in PD, h pylori eradication associated w PD
    protective: cig smoking, caffeine,

Question 5

What are some of the non-motor symptoms of Parkinson’s Disease?

Answer 5

hypomimia
drooling
dementia
micrographia (small handwriting)
Hypophonia (quiet)
Dysphagia (later)
Hallucinations
Executive dysfunction
Insomnia
Postural hypotension
Anxiety
Fatigue
Pain / sensory disturbance
Restless legs
Detrusor instability
Apathy 
Delirium
Many are not tx by dopaminergic therapy

Question 6

What is the pathophys of Parkinson’s Disease?

Answer 6

1. Lewy Bodies (alpha synuclein inclusions in Nigral cells) leading to cell death
2. Depletion of pigmented Dopaminergic neurones in Substantia Nigra
3. Atrophy of Substantia Nigra
4. Reduced neuromelanin
   Reduced DA from SN–> Globus Pallidus, Reduced inhibition of Subthalamic Nucleus, get increased inhibition of the Cortex resulting in Bradykinesia.
   50% neurones lost when first PD symptom presents but 80% of total DA lost
   Thought to start in olfactory region and lower brainstem before spreading to substantia nigra

Complex motor sequences - especially when internally driven - rely on the basal ganglia
Allow learned motor sequences [walking, dressing, speaking] to be carried out while attention is directed elsewhere.

Question 7

What are some of the examination findings in a patient with PD?

Answer 7

1. thumb to second finger: Bradykinesia + Basal Ganglia dysfunction- lack of amplitude and gets smaller + slower as patient fatigues
2. Gait: shuffling, stooped posture, reduced arm swing (due to increased tone), hesitant due to bradykinesia and diff turning, festinating gait (gets faster and faster to stop falling over), unsteady
3. Lead Pipe Rigidity (increased tone) (cog wheel- tone + tremor): often accentuated by distraction with other arm
4. Resting tremor (improves on finger nose test)

Question 8

How is Parkinson’s Disease managed?

Answer 8

PHARMA
1. Levodopa(DA precursor that neurones can convert to DA) + Dopa Decarboxylase Inhibitor (e.g. Carbidopa)
{first line if PD symptoms impact on their life}
2. Other Meds: DA Agonist (combo with 1. or monoT) less potent than L-dopa, reduced motor SE but worse hallucinations + delusions, excessive sleepiness, postural hypotension, n, impulse control disorders; MAO-B Inhibitors
{any of these are first line in patients who’s PD does not impact on their life}
3. ADD DA Agonist; MAO-B Inhibitor; COMT Inhibitor to Levodopa if developed dyskinesia or motor fluctuations despite optimal levodopa therapy.

• – Meds should never be withdrawn suddenly due to risk of Neuroleptic Malignant Syndrome
  2. PT: exercises particularly for posture and rigidity, cueing
  3. OT: anxiety management, routine management, aids and appliances, CBT,
  4. SLT: think “louder”
  5. Pally care
  6. Carer support
  7. PD Nurse Specialist: Education and support
  8. Vitamin D and high protein diet

Consider meds for non-motor e.g. hallucinations, drooling, depression, daytime sleepiness, orthostatic hypotension if other things have failed e.g. reduce dose of meds/ med review. Tx PD Dementia cholinesterase inhibitor for all cases.

Question 9

What are the SE of Levodopa therapy?

Answer 9

1. Hallucinations + confusion
2. Postural hypotension
3. N + V
4. Motor SE after prolonged use: (due to lost capacity to store DA)
   a. Dyskinesia: involuntary movements
   b. Wearing off
   c. On/Off effect : Dyskinesia + Agitation / Severe Parkinsonism e.g. freezing

Question 10

How do you dx PD?

Answer 10

1. Clinically

2. SPECT scan is the only NICE approved if cannot differentiate Parkinsonism from PD.

Question 11

Benign Essential Tremor

Answer 11

often confined to tremor only but some have gait and balance disturbances too

Question 12

Drug Induced Parkinsonism

Answer 12

dopamine antagonists can induce parkinsonism

Anti-emetics, Anti-psychotics.

Question 13

Drug Induced Parkinsonism

Answer 13

dopamine antagonists can induce parkinsonism
Anti-emetics, Anti-psychotics.
Most resolve when drug stopped
However patient may still require anti-psychotic - Quetiapine is a safer choice for such patients

Question 14

Drug Induced Parkinsonism

Answer 14

dopamine antagonists can induce parkinsonism
Anti-emetics, Anti-psychotics.
Most resolve when drug stopped
However patient may still require anti-psychotic - Quetiapine is a safer choice for such patients