Parkinsonisms

Question 1

What are the clinical features of Idiopathic Parkinson’s disease?

Answer 1

Asymmetry of clinical signs, often unilateral at initial presentation

Extrapyramidal triad:

1. Resting tremor - worse at rest, usually affects the hands (pill-rolling) but can involve lips, chin and legs, 4-6Hz
2. Bradykinesia
3. Increased tone - cogwheel rigidity

Less frequent blinking
Hypomimia
Hypophonia
Micrographia

Postural/gait instability:
Stooped posture (camptocormia)
Reduced arm swing
Freezing - especially at doorways, patterned carpets and obstructions
Difficulty initiating gait
Difficulty turning
Festinant gait - rapid short steps with accelerating speed, often with stooped, forward leaning posture

Non-motor symptoms:
Autonomic dysfunction (Postural hypotension, constipation, urinary frequency/urgency, dribbling of saliva)
REM sleep disturbance
Anosmia/hyposmia

Neuropsychiatric symptoms:
Psychosis, dementia, depression

Question 2

What are the clinical features of Vascular Parkinsonism?

Answer 2

Secondary to small vessel disease but also small strokes

Similar features to idiopathic PD, but mainly lower limb is affected
Postural instability and falls
Tremors are less common
Rigidity present in lower limbs
Lack of facial expression
Residual signs and symptoms of previous stroke

Question 3

What are the clinical features of Drug-Induced Parkinsonism?

Answer 3

history of dopamine blocking medications e.g. antipsychotics such as haloperidol and long-term antiemetics such as metoclopramide

Symmetrical rigidity
Lack of facial expression

Question 4

What are the clinical features of Normal Pressure Hydrocephalus?

Answer 4

Triad of dementia, gait disorder (similar to PD) and bladder instability

Signs of normal pressure hydrocephalus on neuroimaging

Question 5

Which conditions are known as “Parkinson-plus syndromes”?

Answer 5

Lewy body dementia
Multi-system atrophy
Progressive supra nuclear palsy
Cortico-basal degeneration

Question 6

What are the clinical features of Lewy body dementia?

Answer 6

Triad of dementia, Parkinsonism and visual hallucinations

Fluctuations in alertness

Question 7

What are the clinical features of Multi-systems atrophy?

Answer 7

Prominent early autonomic complications (hypotension, urinary incontinence, impotence)
cerebellar and pyramidal signs

Parkinsonism is symmetrical
Rigidity > tremor

Question 8

What are the clinical features of Progressive Supranuclear Palsy?

Answer 8

Early postural instability and falls
Vertical gaze palsy
Rigidity in trunk > in limbs
Little tremor
Symmetrical onset
Speech and swallowing problems
Reduction in midbrain volume in MRI - hummingbird sign

Question 9

What are the clinical features of cortico-basal degeneration?

Answer 9

Asymmetrical Parkinsonism
Apraxia (alien limb phenomenon)
Cortical sensory deficit

Question 10

What differential diagnosis are there for tremor in Parkinson’s disease?

Answer 10

Benign essential tremor:
Familial
5-10Hz
Symmetrical
Kinetic tremor
Postural tremor (without latency, unlike PD)
Worsens with activity and improves with rest and alcohol

Dystonic tremor:
Tend to affect head and neck, as well as thumb extension
Irregular
Asymmetrical
Kinetic tremor
Postural tremor (position-dependent)
Worsened by specific motor tasks

Question 11

What is 1st line treatment for PD patient with motor symptoms that decrease their quality of life?

Answer 11

Levodopa combined with carbidopa (co-careldopa) or benserazide (co-beneldopa)

Carbidopa and benserazide are dopa-decarboxylase inhibitors that reduce the incidence of peripheral side effects and improve therapeutic response

Question 12

What is 1st line treatment for PD patient with motor symptoms that do not decrease their quality of life?

Answer 12

Levodopa, or

Dopamine agonist (non-ergot derived) - pramipexole (oral), ropinirole (oral), rotigotine (patch), or

MAO-B inhibitor - rasagiline or selegiline

Question 13

Which PD medication improves motor symptoms and ADLs more but is more likely to have motor complications?

Answer 13

Levodopa

Levodopa improves motor symptoms and ADLs more, and is more likely to have motor complications, than dopamine agonists and MAO-B inhibitor

Question 14

Which PD medication produces impulse control disorders?

Answer 14

Levodopa, dopamine agonist and MAO-B inhibitor

Question 15

Which PD medication is more likely to produce motor complications (fluctuations and dyskinesia)?

Answer 15

Levodopa more likely than dopamine agonist and MOA-B inhibitor

Question 16

Which PD medication is more likely to produce psychotic symptoms, excessive sleepiness and sudden onset of sleep?

Answer 16

Dopamine agonists and MAO-B inhibitor are more likely than levodopa

Question 17

If a patient continues to have symptoms on the optimal levodopa treatment or develops dyskinesia, what medication does NICE recommend should be used as an adjunct?

Answer 17

dopamine agonist
MAO-B inhibitor
COMT inhibitor - entacapone or tolcapone

Only use ergot-derived dopamine agonist as adjunct to levodopa if non-ergot not working

Consider Amantadine if dyskinesia not adequately managed

Question 18

What medication should be given to PD dementia patient?

Answer 18

Mild-moderate = acetylcholinesterase inhibitor (e.g. rivastigmine)

If acetylcholinesterase inhibitor not tolerated then try memantine

Question 19

What treatment options are there for those with Advanced Parkinson’s disease?

Answer 19

Apomorphine - give domperidone to control nausea and vomiting associated with apomorphine

Levodopa-carbidopa intestinal gel

Deep brain stimulation

Question 20

What emergency condition can occur in Parkinson’s patients that withdraw from medication abruptly?

Answer 20

Neuroleptic malignant syndrome

Typical features include: 
Pyrexia
Cough
Stiffness
Autonomic lability
Agitated delirium with confusion