Parkinsons Flashcards
What are the clinical features of Parkinsonism?
- Bradykinesia - slowness in initiation of voluntary movement with progressive reduction in speed and amplitude of repetitive actions
- Muscular rigidity
- 4-6Hz rest tremor
- Postural instability (pull test)
What are the non motor symptoms of Parkinson’s?
- Dementia
- depression
- Anxiety
- constipation
- urinary urgency/nocturia
- Erectile dysfunciton
- Excessive salivation
- Low BP/postural hypotension
- Speech difficulty
- hallucination and delusion
- Seborrheic dermatitis/sweating
- REM sleep behaviour disorder
- Restless legs syndrome
- Reduced olfactory funciton
- Fatigue/daytime somnolence
- Pain and sensory symptoms
What are non Parkinson’s causes of Parkinsonism
- Drug induced
- PSP - progressive super nuclear palsy - difficulty with vertical gaze
- MSA - multiple systems atrophy
- Cortical basal disease - one sided symptoms, dystonia in affected arm
- Lewy body dementia - visual hallucination and fluctuation in cognition
- Vascular Parkinsonism
What is the exclusion criteria of parkinsons?
• cerebellar signs (MSA)
•Vertical gaze palsy (PSP)
•Parkinsonian features restricted to the legs for >3 years (vascular)
•Absence of L-dopa response
•Cortical sensory loss, ideomotor apraxia or progressive aphasia. CBD.
•Normal FPICT SPECT scan
What are the red flag symptoms in Parkinsons
- Rapid gait impairment requiring wheelchair use within 5 years
- No progression of motor symptoms/signs over 5 years
- marked bulbar dysfunction
- Inspiratory respiratory dysfunction
- Severe autonomic failure within 5 years
- Recurrent falls because of impaired balance within 3 years
- Dystonic anterocollis within 10 years
- Absence of non-motor features within 5 years
- Unexplained pyramidal signs or symmetrical presentation
What is the pharmacological aim of the treatment of parkinsons?
To restore dopamine levels
What is the clinical aim of the treatment of parkinsons?
- To improve motor symptoms and quality of life
* There is no evidence of neurological-protection
What are the Parkinson disease drug classes?
- L-dopa
- Dopamine agonists
- MAO-B inhibitor
- COMT - inhibitor
Explain the preparations of L-dopa
- L-dopa with a dopa decarboxylase inhibitor:
- L-dopa and carbidopa = sinemet
- L-dopa and benserazide = madopar
What is the dosing of L-dopa preparations?
200-1000mg/day across 3-5 doses
What are the adverse effects of L-dopa?
- Peripheral: nausea, vomiting, postural hypotension
* Central: confusion, hallucinations
Name the dopamine agonists
- Ropinirole
- Pramipexole
- Rotigotine
- Apomorphine
What are the differences in effect of the dopamine agonists and L-dopa?
Dopamine agonists:
•Have a longer half life than L-dopa
• Are less efficacious that L-dopa
• Have fewer motor complications than L-dopa
What are the side effects of the dopamine agonists?
- Dopaminergic side effects
- Daytime somnolence
- Impulse control disorders (e.g. pathological gambling, hyper sexuality)
Name the MAO-B inhibitors
- Selegiline
* Rasagiline
Name the COMT inhibitors
- Entacapone
* Opicapone
What are the COMT inhibitors prescribed with and why?
- Co prescribed with L-dopa
* Results in a longer half life of L-dopa
What are the side effects of COMT inhibitors?
- Dopaminergic
* Diarrhoea
What is amantadine prescribe for in parkinsons?
Anti-dyskinetic effect
What are the side effects of amantadine?
- Confusion
* Livedo reticularis
Why are anticholinergics prescribed in Parkinsonism and give an example
- Procyclidine
* Anti tremor effect
Why is botulinum toxin used in parkinsons?
- Roles in sialorrhoea, blepharospasm
- Eyelid-opening
- Apraxia
- Other focal dystonia
What are the motor problems in advanced parkinsons?
- Motor complications
- On/off fluctuations
- L-dopa induced dyskinesia (wearing off effect of L-dopa)
What are the axial problems in advanced parkinsons?
- Gait difficulties (including gait freezing)
- Change in posture
- Poor balance/falls
- Speech/swallowing difficulties
What are the cognitive problems in advanced Parkinsons?
- dementia
* hallucinations/psychosis
What are the treatment options specifically for advanced Parkinsons?
- Apomorphine pen injection or subcutaneous pump
- Intrajejunal duodopa infusion
- Deep brain stimulation surgery
What is deep brain stimulation?
- allows the electrical stimulation of target nucleus (most commonly Sub Thalamic Nucleus)
- Provides a targeted, adjustable, non-destructive, and reversible way of modulation pathological brain circuits
- There are 3 implantable components
What are the implantable components of deep brain stimulation?
- Brain leads (containing electrodes at the distal end)
- Neurostimulator (AKA implantable pulse generator/IPG)
- Extension wires
What are the motor Parkinson disease emergencies?
- Motor- severe off periods
- Severe dyskinesia
- Parkinson-hyperpyrexia syndrome
What are the non-motor Parkinson disease emergencies?
- Acute psychosis
- Impulsivity
- Dopamine dysregulation
- Dysautonomia (postural hypotension, dysphagia, intestinal pseudo-obstruction)
What are the other Parkinson disease emergencies?
- falls
* device related: DBS/apomorphine pump/duodopa pump failure
Aside from medications, what are the other things to consider in the management of parkinsons?
- Bone health
- Exercise
- Support groups
- Advanced care planning
