Parkinsonism and Movement Disorders Flashcards
What is the role of the basal ganglia
Involved in initiation and modulation of movement
They receive input from the cortex, process it and relay back to the cortex via the thalamus
What can basal ganglia disease lead to
Hypokinesia (little movement) - rigidity, bradykinesia
OR
Hyperkinesia (too much movement) = tics, myoclonus, chorea, tremor etc
What are the pyramidal features
Pyramidal weakness
Spasticity
What is happening to the incidence of Parkinson’s
It is increasing with our ageing population
Second most common neurodegenerative condition
What are the pathological hallmarks of Parkinson’s disease
Loss of the black pigment of the substantia nigra – loss of dopaminergic neurons
Therefore decreased dopamine
Presence of Lewy bodies
Only seen after death as need to section the brain to view
What are the motor symptoms of Parkinson’s
Tremor - resting Bradykinesia - slow movement and slow to initiate Rigidity - cogwheel or lead pipe Postural instability - falls Stooped, fixed posture Lack of facial expression Shuffling gait Micrographia - small handwriting
What are the non-motor symptoms of Parkinson’s
Sleep disorders - REM and poor sleep Hallucinations Gastrointestinal dysfunction - constipation Bladder issues - increased frequency and urgency Depression and anxiety Cognitive impairment / dementia Anosmia - loss of smell Voice changes - lower
How many of the neurons must be lost before Parkinson’s symptoms appear
Around 60%
What are the main patterns of motor symptoms in Parkinson’s
Tremor dominant - relative absence of other symptoms
- associated with slower progression
Non-tremor dominant
How do you test bradykinesia
Finger tapping test
Get patient to repeatedly tap finger together as fast as they can
will be slower and the amplitude will start decreasing (less space each time)
What is lead pipe rigidity
constant resistance throughout passive movement
Like trying to bend a lead pipe
What is cog-wheel rigidity
When you try and move the limb, it will click round in steps like moving around a cog-wheel
Attributed to the underlying tremor
How do you diagnose Parkinson’s
It’s a clinical diagnosis - based on symptoms
Never really a definite diagnosis as this requires brain pathology which obviously cannot be done in
Can do a brain scan to rule out other structural causes etc.
What symptoms alongside the common PD ones suggest the diagnosis is not Parkinson’s
Early-onset bulbar problems, dementia and hallucinations, preferential involvement of lower limbs
Prominent eye movement disorder
Intrusive early autonomic problems
What tests can be done to assess/diagnose Parkinsons
DAT scans can be used
Looks for dopamine activity - will be round instead of comma shaped
How do you test for a supra-nuclear gaze palsy
Ask them to look up (keeping head still) and then down (independently first then by following finger)
If they also cannot fix on a point when moving their head then it means it isn’t just a eye muscle problem
if the patient cannot do these movements it is a SN gaze palsy
Which sex is more commonly affected by Parkinson’s
Men are around 1.5x more likely to get it
Does Parkinson’s affect lifespan
Yes
It has an increased mortality and shorter life span
What are the risk factors for developing Parkinson’s
Advancing age is the major one
Positive family history - genetics
Male sex
May be some environmental triggers - pesticide, head injury, beta blockers etc
What treatments are available for Parkinson’s
Symptomatic treatments enhance intracerebral dopamine concentrations or stimulate dopamine receptors
Levodopa - replaces dopamine
Dopamine agonists
Monoamine oxidase inhibitors (type B) - prolongs available dopamine
Anticholinergic agents, trihexyphenidyl, or clozapine, can be effective for tremor
When should you start treatment for Parkinson’s
When symptoms cause disability or discomfort aiming to improve function and quality of life
What are the side affects of levodopa
Nausea
Daytime sleepiness
Oedema
Motor complications - dyskinesia and motor fluctuation (good/bad periods)
What are the side effects of dopamine agonists
Nausea Daytime sleepiness Oedema Impulse control disorder - gambling, sex, spending or eating Hallucinations and psychosis
Who should dopamine agonists be avoided in
patients with a history of addiction, obsessive-compulsive disorders and impulsive personality
Can lead to issues with impulse control
Which of the Parkinson’s drugs gives the best symptomatic benefit
Levodopa
What is bradykinesia
Slowness of movement with progressive loss of amplitude or speed during attempted rapid alternating movement
What is hypomimia
decreased facial expression and eye blinking
What is micrographia
Progressively smaller handwriting
What type of tremor is seen in Parkinson’s
Resting tremor
Rhythmic oscillatory involuntary movement
Vanishes with active movement
Most distinguishing resting tremor is “Pill-rolling”-type
What is rigidity
Increased muscle tone felt during passive movement
Resistance is felt throughout full range of movement
Describe gait in someone with Parkinson’s
Stooped posture Slow Slow turning Short, shuffling steps Decreased arm swing Festination (very fast succession of steps and difficulties stopping)
REM sleep disorders are common in Parkinson’s - true or false
TRUE
What are the signs that suggest its not Parkinson’s
Absence of asymmetry of symptoms Severe axial or lower limb involvement* Frequent falls* Fast disease progression Eye movement disorder Other unexpected movement disorder Severe cognitive deterioration or psychosis* Marked autonomic dysfunction
What are the signs of vascular parkinsonism
Affects predominantly lower limbs
Resting tremor is rare
Poor response to levodopa
Structural brain imaging will guide diagnosis - vascular lesions
What are the signs of drug induced Parkinsonism
Parkinsonism tends to be symmetrical
Often coarse postural tremor
Symptoms appear after starting a drug
Improvement / resolution within few months of complete drug withdrawal
Can be caused by drugs that block the action of dopamine
Is Parkinson’s more commonly idiopathic or familial
Idiopathic is much more common!
Parkinson’s symptoms are usually symmetrical - true or false
False
Usually asymmetrical
What is an intention tremor
One that gets worse as you approach a target that you are trying to touch
Brought on by the action
Cerebellar tremor
What is a postural tremor
Tremor when hands are held out in front of the person
Seen in anxiety, essential tremor or drug-induced
What is a re-emerging tremor
tremor which disappears on movement will slowly reappear as the hands are held out for a period of time
Common in PD
What are power and reflexes like in Parkinson’s
Normal
Are tremors extrapyramidal or pyramidal
Extrapyramidal
What is the triad of symptoms in Parkinson’s
Tremor - resting
Bradykinesia - the hallmark
Stiffness - rigidity
What is a REM sleep disorder
Where someone will act out in their sleep
Purposeful movement - kicks, punches
Shouting out
Which medications can sometimes lead to Parkinson’s symptoms
Anything that interferes with the dopamine pathway
Some psychiatric drugs are dopamine blockers
Metoclopramide
Smoking increases risk of Parkinson’s - true or false
False
some evidence suggests it is protective
What occupational hazards can increase your risk of Parkinson’s
Pesticide exposure - agriculture
Manganese exposure - not common in UK
How is tone affected in Parkinson’s
It is increased - rigidity
How do you assess cerebellar symptoms
DANISH Dysdodekinesia Ataxia Nystagmus Intention tremor Speech Heel to shin movement
What conditions can be associated with Parkinson’s - also called Parkinson plus
Lewy body dementia
Progressive super-nuclear palsy (loss of vertical gaze and postural instability early on)
Cortical basal syndrome (Parkinson symptoms for basal with ataxia - alien limb movement for cortical)
Multi-system atrophy
Have Parkinson’s like symptoms as well as others on top
