Parkinsonism and parkinsons disease

Question 1

CST/pyramidal tract leads to what kind of features

Answer 1

UMN - pyramidal weakness, spasticity

Question 2

basal ganglia leads to what kind of symptoms [extra pyramidal]

Answer 2

hyperkinetic - dystonia, tics, myoclonus, chorea, tremor

hypokinetic - parkinsonism, parkinsons disease

Question 3

cerebellum leads to what kind of symptoms

Answer 3

nystagmus
ataxia
intention tremor

Question 4

what is the parkinsonian syndrome

Answer 4

rigidity, akinesia/bradykinesia and resting tremor

Question 5

what is dystonia

Answer 5

prolonged muscle spasms and abnormal posture

Question 6

what is chorea - ballismus

Answer 6

fragments of movements flow irregularly form one body segment to another causing a dance like appearance
ballismus: if amplitude of these movements is large

Question 7

what motor symptoms does PD present with

Answer 7

tremor, muscle rigidity, akinesia, rest tremor and gait and postural impairment

Question 8

what are motor features in PD divided into

what does a certain course have on the prognosis

Answer 8

tremor dominant - with relative absence of other motor symptoms

non-tremor dom - such as akinetic - rigid syndrome and postural instability gait disorder

mixed

tremor dom - slower rate of progression and less functional disability

Question 9

clinical non motor features of PD

when are they common and what are they associated with

Answer 9

olfactory dysfunction, cognitive impairment, psychiatric symptoms, sleep disorders, autonomic dysfunction, pain and fatigue

common in early PD and before the onset of motor features and assoc with reduced health related quality of life

Question 10

when is PD usually diagnosed 
how long can non motor symptoms be present before motor onset 
how is progression of PD worsened
what is the honeymoon phase 
advanced stages characterised by what 
late stage PD

Answer 10

with the onset of motor symptoms

more than a decade

worsening of motor features

initially ^ responds to symptomatic therapies (honeymoon phase)

emergence of complications of long term symptomatic treatment

resistent motor and non motor features, postural instability, freezing of gait, falls, dysphagia, speech dysfunction

Question 11

after 17 years of disease what happens

after 20 years

Answer 11

80% have gait freezing and falls, 50% report choking

dementia occurs in 83% of patients

Question 12

what is rapid eye movement sleep behaviour

Answer 12

abnormal or disruptive behaviour which occur during rapid eye movement sleep and are often related to dream enactment

Question 13

how is rapid eye movement disorder diagnosed

Answer 13

overnight polysomnography to document REM sleep without atone and to rule out mimics such as obstructive sleep apnoea, seizures

Question 14

what is the treatment for rapid eye movement disorder

Answer 14

clonazepam or melatonin at bedtime

Question 15

PD with RBD (rapid eye movement sleep behaviour disorder) has a disease subtype of what

Answer 15

characterised by more severe autonomic dysfunction, gait impairment and dementia

Question 16

what do individual with isolated RBD have

Answer 16

increase risk f developing a neurodegenerative condition

Question 17

in parkinsons disease what do sections through the brainstem show
pigment loss correlates
what is a neurohistological hallmark of PD

Answer 17

loss of normal dark black pigment in the substantia nigra and locus coeruleus

with dopaminergic cell loss

Lewy bodies

Question 18

M:F ratio of risk for PD
other risk factor
what does early onset dictate

Answer 18

M: F 3:2
age greatest risk factor
<40 - genetic cause likely

Question 19

what do symptomatic treatments do

Answer 19

enhance intracerebral dopamine concentrations or stimulate dopamine receptors

Question 20

give symptomatic drugs

Answer 20

levodopa
dopamine agonists
monoamine oxydase type B inhibitors
amantadine

Question 21

when is treatment initiated in PD

Answer 21

when symptoms cause disability or discomfort aiming to improve function and QOL

Question 22

what responds to treatment early in the disease

Answer 22

bradykinesia and rigidity

Question 23

what are MAO B inhibitors for

whats needed for more severe symptoms

Answer 23

only moderately effective

levodopa and dopamine agonists

Question 24

how does tremor respond to treatment

Answer 24

inconsistently responsive esp in lower doses to dopamine replacement therapy
anticholinergics, trihexyphenidyl or clopazine can be effective for tremor

Question 25

SE of dopamine agonists and levodopa

Answer 25

nausea, daytime somnolence and oedema

Question 26

SE of dopamine agonists

Answer 26

impulse control disorders such as pathaoligcal gambling, hyper sexuality binge eating compulsive spending

Question 27

who should dopamine agonists be avoided in

Answer 27

history of addiction
OCD
impulsive personality
elderly with cognitive impairment as it can be associated with hallucinations

Question 28

SE of levodopa

Answer 28

long term use is associated with motor complications such dyskinesia and motor fluctuations

Question 29

give the 4 long term complications of dopaminergic therapy for PD

Answer 29

motor fluctuations
non motor fluctuations
dyskinesia - involuntary choreiform or dystonic movements
drug induced psychosis - hallucinations, illusions, delusions

Question 30

pharma stuffs to reduce dopamine fluctuations

Answer 30

add a dopamine agonist
add a MAO B inhibitor
add a COMT inhibitor

Question 31

other ways of managing the long term complications of dopaminergic therapies

Answer 31

stable levodopa - carbidopa gel
sub cut infusion of apomorphine
non - dopaminergic treatments such as amantadine and clozapine

Question 32

how is psychosis in PD managed

Answer 32

with clozapine

alternat quetiapine

Question 33

visual hallucinations and delusions in PD patients with dementia

Answer 33

rivastigmine

Question 34

depression assoc with PD

Answer 34

treated with anti depressants

Question 35

the clinical syndrome of parkinsonism - motor symptoms

Answer 35

bradykinesia
rest tremor
rigidity
postural and gait impairment

Question 36

what is bradykinesia

how can it be assessed

Answer 36

slowness of movement with progressive loss of amplitude or speed during attempted rapid alternating movement of body segments - hypomimia, hyophonia, micographia

asking the px to perform some repetitive movements as quickly and as widely as possible or global assessment to spontaneous movements

Question 37

resting tremor is what
when does it vanish and reappear
frequency
hand tremor and PD

Answer 37

involuntary
active moment and reappears after a few sec when arms held outstretched
3-6Hx
hand tremor not typical for PD

Question 38

rigidity is what
how to distinguish rigidity from spasticity owing to UMN lesion
rigidity and resting tremor leads to what
positive froments test is what

Answer 38

increased muscle tone

no increase with higher mobilising speed

cog wheel rigidity

rigidity increases in examined body segment by voluntary movement of other body parts

Question 39

describe postural and gait impairment

Answer 39

stopped posture 
slow 
shuffling steps 
decreased arm swing 
slow turning with multiple small steps 
freezing

Question 40

investigations for PD

Answer 40

rule out hypothyroidism, anaemia
structural brain imaging
PET, DAT
positive levodopa or SC apomorphine challenge

Question 41

red flags in PD ( a lot of them)

Answer 41

symmetrical symptoms 
severe axial or lower limb involvement 
frequent falls 
fast disease progression 
eye movement disorder
tics, myoclonus, chorea
pyramidal or cerebellar dysfunction 
bulbar or psuedobulbar features
parietal associate sensory disturbances
apraxia 
severe cognitive deterioration or psychosis 
marked autonomic dysfunction

Question 42

what is vascular parkinsonism 
rest tremor?
other signs?
levodopa response 
ix

Answer 42

parkinsonism in lower limbs

rest tremor uncommon

spasticity, hemiparesis, pseudo bulbar palsy

poor levodopa response

structural brain imaging

Question 43

drug induced parkinsonism
tremor
presence of what
treatment

Answer 43

symmetrical
coarse postural tremor
orolingual dyskinesia, akathisia

gets better a few months after drug withdrawel

Question 44

essential tremor describe 
seen at rest?
genetic and onset
responds to what
hand tremor

Answer 44

symmetric, postural higher frequency up to 12 Hz
infrequently observed at rest 
autosomal dom - 15 years
alcohol responsiveness 
hand tremor is present is mild

Question 45

multi system atrophy is a common cause of what 
when 
triad of what 
signs 
levodopa response 
MRI

Answer 45

degenerative parkinsonism
60/70s

dysautonomia, cerebellar features and parkinsonism

severe dysarthria, dysphonia, marked antecollis, inspiratory sighing, orofacial dystonia

suboptimal and short-lived response in 1/3

cerebellar and pontine atrophy - hot cross bun sign

Question 46

progressive supra nuclear palsy is what
signs
leveodopa

Answer 46

symm akinetic rigid syndrome with predominant axial involvement 
gait and balance impairment 
vertical gaze supranuclear palsy
retrocollis
staring 

no respose

Question 47

FXTAS when 
genetic
symptoms 
progression 
milder in who
MRI
dx
children can have what

Answer 47

> 50

abnormal number of CGG repeats in the FMR1 gene

cerebellar gait ataxia, postural/intention tremor, parkinsonism, dysautonomia, cognitive decline, peripheral neuropathy

slow disease progression

in females often POF and menopause

MRI with T2 hyper intensities in the middle cerebellar peduncles

confirmation by molecular testing

children may have classical fragile X syndrome