Parkinsonism and Movement Disorders

Question 1

What are the 4 classical features of Parkinsons

Answer 1

Bradykinesia
Rigidity
Tremor
Postural instability

Question 2

Additional features Parkinsons (10)

Answer 2

Micrographia 
Abnormal gait 
Hypomimia
Anosmia 
Dysphagia 
Depression 
Dementia 
Drooling/dribbling saliva 
Urinary incontinence 
Disturbed REM sleep

Question 3

What is hypomimia

Answer 3

Expressionless/mask like face

Question 4

What are the 6 types of Parkinsons?

Answer 4

Idiopathic Parkinsons 
Vascular Parkinsonism 
Dx induced Parkinsonism 
Lewy Body dementia 
Progressive Supranuclear Palsy 
Multi-system Atrophy

Question 5

Features suggesting Idiopathic Parkinsons Disease (5)

Answer 5

Unilateral onset
Upper limb predominance 
Tx responsive to Levodopa 
Presenting w/ bradykinesia 
Clinical course 10y or >

Question 6

Features suggesting vascular Parkinsonism (6)

Answer 6

Lower limb predominance 
Bilateral onset 
PS w/ falls + gait problems, change in voice, cognitive deficits early 
Stepwise rapid progression 
Poor response to levodopa 
Atherosclerotic RF

Question 7

Dx induced Parkinsonism features (2)

Answer 7

Hx of being on antiP or antiemetics

Resolves when drug is stopped

Question 8

Features suggesting Lewy Body dementia (3)

Answer 8

Prominent cog impairment PS at same time as PD
Prominent hallucinations
Fluctuations in consciousness level

Question 9

Features suggesting progressive supranuclear palsy (3)

Answer 9

Eye signs - vertical gaze palsy
Cognitive impairment w/ frontal disinhibition
Not responsive to dopaminergic Tx

Question 10

Features suggesting multi-system atrophy (3)

Answer 10

Prominent autonomic features - orthostatic HoTN, incontinence, importence, difficulty reg body T
Cerebellar signs -ataxic dysarthria 
Reduced loudness/breath support 
Fatigue 
Weak/hoarse quality of voice 
Not responsive to Tx

Question 11

Features that reduce the likelihood of Parkinsons (9)

Answer 11

Young age
Bilat Sx @ onset
Positional/intentional tremor 
Stepwise progression 
Arms spared 
Cognitive decline @ onset
Repeated strokes/head injuries/encephalitis 
Cerebellar signs 
Babinksi's sign

Question 12

Gait abnormalities PD

Answer 12

Slow to initiate
Shuffling
Festination
Freezing

Question 13

Which pathway of the brain is particularly affected in PD

Answer 13

ML pathway (substantia nigra) 
Dopamine

Question 14

Appearance of PD on a PET scan

Answer 14

Normal = comma appearance 
PD = looks like a full stop

Question 15

Prevalence Parkinsons >80

Answer 15

2%

Question 16

RF Parkinsons (3)

Answer 16

Age
FHx
Non-smoker

Question 17

Prevalence of essential tremor

Answer 17

5%

Question 18

Features of essential tremor (4)

Answer 18

Postural, not resting
Arms/head, not legs
Better after alcohol
Will not progress to other Sx

Question 19

Which Dx does essential tremor show a slight response to

Answer 19

Propranolol

Question 20

Diagnostic tests PD (3)

Answer 20

Predominantly clinical
CT brain
DATscan

Question 21

Use of DATscan in PD diagnosis

Answer 21

DDx between parkinsons and other causes of parkinsonism

Question 22

What is the 1st line Mx of PD in elderly pt

Answer 22

Levodopa

Question 23

How does Levodopa work

Answer 23

Replaces dopamine and prevents peripheral breakdown

Question 24

What Sx does levodopa predominantly improve

Answer 24

Stickness

Question 25

SE Levodopa (6)

Answer 25

``` Nausea Impulsive/compulsive behaviour Hallucinations/delusions Chorea Dyskinesia ```

Question 26

E.g.s of Dopamine agonists (2)

Answer 26

Rotigotine | Ropinorole

Question 27

SE DA agonists

Answer 27

Pyshocsis

Question 28

2 e.g.s of adjuncts to Levodopa

Answer 28

COMT inhibitors | Amantidine

Question 29

What is Amantidine particularly useful for

Answer 29

Patients w/ prominent dyskinesias

Question 30

What interventional Tx is used in younger pt w/ PD

Answer 30

Deep brain stimulation

Question 31

Non-pharma Mx PD (4)

Answer 31

Perform a CGA Social care/support OT Physiotherapy

Question 32

Components of CGA for PD

Answer 32

``` Medical - are Sx PD progression or is something else happening Psych - depression, MOCA, Fct - physio asessment/aids/rehab Enviro - equipment for assistance Social - care packages/benefits ```

Question 33

Importance q to ask about when adjusting PD Tx (4)

Answer 33

Parkinsonism Sx Fluctuations in motor capabilities Hallucinations Dyskinesias

Question 34

Tx options for Multisystem atrophy (6)

Answer 34

``` Improve breath support Practice pitch/intonation exercises Voice exercises to improve vocal fold contact + vocal flexibility Alternative communication aids Conversation support Fatigue Mx ```

Question 35

Specific PS Sx PSP

Answer 35

Speech changes Language processing difficulties (understanding + expression) Word finding difficulties Visual problems (up/down gaze) Frontalis overactivity (reduces blinking, prolongs eye contact)

Question 36

Swallowing issues in multi-system atrophy (5)

Answer 36

All mm movements = slowed + reduced in range Oral stage problems Reduced coordination between oral and pharyngeal stage Slowed oral transit times Reduced jaw movement Reduced vocal fold closure Sensory changes --> silent aspiration

Question 37

Swallowing issues in PSP

Answer 37

Behavioural changes --> eating too quickly/chain drinking Close supervision + prompting = essential Usually noticed within 1st y disease onset Reduced chewing skills Reduced tongue control Residue accumulates in throat