Parkinsons Flashcards
The following are non-motor symptoms of Parkinson’s disease EXCEPT. A.Mood disturbances B.Resting tremor C.Dementia D.Autonomic dysfunction
Mood disturbances are non-motor disturbances in Parkinson’s disease and they include depression, anxiety,
daytime sleepiness, psychosis, and hallucinations.
b) Parkinson’s Disease (PD) is a neurodegenerative disease characterized by the early development of motor symptoms namely: akinesia (paucity of movement), bradykinesia (slowness of movement) rigidity and tremor at rest. These problems result from degeneration of dopaminergic neurons in the midbrain. The degeneration of dopamine-producing cells leads to an imbalance between inhibitory properties of Dopamine and excitatory properties of Acetylcholine in the striatum. Evidence for the widespread neurodegeneration characterizing this disease is the presence of Lewy Bodies (intracellular aggregate of abnormal proteins) present in residual dopaminergic neurons as well as in other areas of the central and peripheral nervous system of patients with PD CORRECT
Dementia is a non-motor symptom. PD is characterized by widespread neuro-degeneration in the noradrenergic, serotonergic, and cholinergic neurons of the brainstem and amygdala, cingulate gyrus and the neocortex. Therefore symptoms are not limited to motor features. After 8 years of disease, the prevalence of dementia can be as high as 78%. Other cognitive problems associated with PD include frontal-lobe dysfunction and memory difficulties
Other non-motor problems include autonomic dysfunction (orthostasis), problems with thermoregulation, constipation, and genitourinary problems like nocturia and urgency
- Which of the following is True regarding Parkinson’s disease? A.This disease does not increase the risk of death B.Degeneration of dopaminergic neurons in the basal ganglia is a characteristic of this disease. C.This disease does not have any familial predisposition. D.Medications like levodopa can cure the disease.
A. Parkinson’s disease does not increase the risk of death Forty percent of patients with PD are living in long term care facilities and they are almost twice as likely to die compared to their age matched cohorts. Hence, it does increase the risk of death
b) The common feature of PD is degeneration of dopamine producing cells of the striatum (caudate nucleus and putamen) which is part of the basal ganglia (globus palidus,substantia nigra, nucleus acumbens and subthalamic nucleus). The degeneration of dopamine producing cells leads to an imbalance between excitatory and inhibitory neuronal outputs and hence the symptoms of PD Correct!!
c) Ten to 15% of people with PD will have an affected first or second degree relative. No clear environmental determinants of PD have been defined.
d) D. Medications like levodopa can cure the disease PD has no cure. Pharmacotherapy focuses on the management of motor symptoms using dopamine agonists like bromocriptine or levodopa which leads to increased production of dopamine. Medication related complications like dyskinesias and “on-off” fluctuations or unpredictable loss of benefit from treatment typically occurs at the 5 year mark.
- Which of the following is FALSE with regards to Deep Brain Stimulator placement for Parkinson’s Disease? A.Patients responsive to dopaminergic therapy and disabling dyskinesias are good candidates for surgery. B.The targeted sites for lead placement are the Subthalamic nucleus and globus pallidus interna C.Anti-Parkinson’s medications should be given the morning of surgery D.The procedure is done through a burr hole usually with the patient awake.
Most centers select patients for deep brain stimulation on the basis of the nature of the patient’s symptoms and the likelihood of a response to therapy. Levodopa-responsive symptoms, tremor, “on-off “ fluctuations and dyskinesias are most likely to improve with deep-brain stimulation. Impairments in gait, balance, and speech are less likely to improve. Hence this is true.
Patients undergoing deep brain stimulation have their medications stopped 12 hours before the procedure for assessment of physiological recordings and behavioral responses after placement of the stimulation electrode in the brain.
The procedure is done through a burr hole and in many cases, general anesthesia is not used during electrode implantation for assessment of physiological recordings and behavioral responses. Anesthesia may be required in selected cases (e.g., in children and in adults with severe anxiety). CT or MRI that is performed on the day of the procedure is registered to the head frame in order to reestablish the target location and to set a trajectory that will avoid blood vessels.
- All of the following are risks of awake Deep Brain Stimulator placement EXCEPT? A.Hemorrhagic stroke B.Infection C.Seizures D.Increased verbal fluency
Based on a literature review of DBS surgery over 10 years, the overall rate of intracranial hemorrhage is 5.0% with symptomatic hemorrhage occurring in 2.1% of patients, and hemorrhage causing permanent deficit or death in 1.1%. Risk factors include a history of hypertension and age. Surgical risk factors include the use of MER (micro-electrode recording) and the number of MER penetrations, as well as a trajectory that involves a sulcus or ventricle. The use of MR imaging for guidance and verification of DBS electrode placement helps to avoid these surgery-related risk factors.
Rates of infection requiring further surgery have ranged from 1.2 to 15.2%. Infections most often require device removal and a period of antibiotic treatment before consideration of device replacement. The majority of organisms cultured were consistent with skin flora, with Staphylococcus aureus being the most common pathogen
Post-procedural seizures have been reported, with an estimated incidence of 2.4%
Impairments in gait, balance, and speech are less likely to improve with deep brain stimulator placement. In fact, side effects of DBS include memory deficits and difficulties with speech. In a meta-analysis of 42 articles, small declines were found in psychomotor speed, memory, attention, executive functions, and overall cognition; and moderate declines were found in both semantic (participants are asked to say words in certain categories like “animals” and “fruits”) and phonemic fluency (test where participants are asked to recite words that begin with “p” for example). GPI-DBS resulted in fewer neurocognitive declines than STN-DBS
- Regarding peri-operative management of patients with Parkinson’s Disease, which of the following is true? A.Thankfully, they are not at risk for aspiration B.Attention should be directed to continuing their Levodopa-carbidopa peri-operatively when possible C.Autonomic insufficiency is not a problem in this patient population D.There is evidence that depolarizing agents causes dangerous increases in potassium in patients with PD
Patients with PD are predisposed to aspiration because they often have dysphagia and dysmotility. Impaired coordination in breathing and swallowing and incomplete upper esophageal sphincter (UES) relaxation and a reduced UES opening, both associated with high intrabolus pressure are prevalent in PD. The prevalence may be as high as 52%
The half life of levodopa is 90 minutes therefore even a brief interruption of therapy can lead to an acute exacerbation of symptoms of PD or neuroleptic malignant syndrome characterized by akinesia, hyperthermia, muscle rigidity, and autonomic dysfunction. Hence, one should attempt to continue them as early as possible.
Autonomic insufficiency affects the ability of PD patients to respond to hypovolemia, and vasodilatation associated with general anesthesia.
In a series of 7 patients with PD undergoing general anesthesia in which Succinylcholine was administered, ABG’s were obtained 3-5 min. after Succinylcholine administration and in 5 patients no changes in K+ were noted; 1 patient had an increase in K+ by 0.2 meq/L ; and in another a 0.2 meq/L decrease in K+.
The following are recognized features of Parkinson’s disease
a) Tremor
b) Orthostatic hypotension
c) Dry Mouth
d) Restrictove ventilatory defects
e) Glomerulonephritis
The following dregs are oral treatments which can be used as single agents to treat PD
a) Levodopa
b) Bromocriptine
c) Selegiline
d) Apomorphine
e) Enacapone
Movement disorders may be precipitated by
a) Alfentanil
b) Propofol
c) Ondansetron
d) Prochlorperazine
e) Levodopa
Question1The following anti-emetics are contraindicated in patients with Parkinson’s disease:
a.Prochlorperazine.
b.Domperidone.
c.Droperidol.
d.Metoclopramide.
e.Cyclizine.
a) True. Prochlorperazine is a dopamine receptor antagonist that belongs to the phenothiazine class of antipsychotic agents. Anti-emetics with dopamine antagonist activity are contraindicated in Parkinson’s disease, as they cause an exacerbation of parkinsonian symptoms, e.g. rigidity, freezing and bradykinesia.
b) False. Domperidone is also a dopamine receptor antagonist, but it cannot cross the blood-brain barrier. Domperidone therefore has only peripheral activity, and so is safe for use in Parkinson’s disease.
c) True. Droperidol is a butyrophenone with dopamine receptor antagonist activity, which is therefore contraindicated in Parkinson’s disease.
d) True. Metoclopramide is a benzamide, whose anti-emetic activity is through dopamine receptor antagonism, and is therefore contraindicated in Parkinson’s disease.
e) False. Cyclizine is a histamine H1-receptor antagonist, and is therefore safe to use in Parkinson’s disease
Question2The following are common clinical features of Parkinson’s disease:
a.Dysphasia.
b.Sialorrhoea.
c.Intention tremor.
d.Constipation.
e.Sleep disturbance.
a) False. Dysphagia (but not dysphasia) is common in advanced Parkinson’s disease.
b) True. Sialorrhoea is common in advanced Parkinson’s disease.
c) False. The classic triad of symptoms in Parkinson’s disease is bradykinesia, muscle rigidity and resting tremor (not intention tremor).
d) True. Constipation is a common symptom in Parkinson’s disease, and may pre-date diagnosis.
e) True. Sleep disturbance is also very common in Parkinson’s disease, and may pre-date diagnosis.
Question3Options for managing dopaminergic medication in the perioperative period include:
a.Continuing usual oral medication.
b.Modified-release levodopa with dopamine decarboxylase inhibitor via nasogastric tube.
c.Dopamine infusion.
d.Transdermal rotigotine.
e.Subcutaneous apomorphine
Rationale
True. Parkinson’s disease patients undergoing minor and moderate surgery may be able to continue their usual oral treatment regimes by taking their mediation up until anaesthetic induction, and then immediately postoperatively.
False. Modified-release medication cannot be administeredviaa nasogastric tube - the dispersible equivalent has a different bioavailability, and a 30% dose reduction must be made.
False. Dopamine cannot pass through the blood brain barrier as there is no cell membrane dopamine transport protein, and dopamine is too polar to diffuse freely across cell membranes.
True. Parenteral rotigotine is a viable option for the perioperative management of most Parkinson’s disease patients, with online calculators available to convert usual oral medication to a single rotigotine patch.
True. Subcutaneous apomorphine infusion is also used in the perioperative period, although it has a number of serious side-effects and practical issues, including the dosing regime and the need to pre-load with suitable anti-emetics.
Question4Strategies to reduce post-operative delirium include:
a.Involvement of the patient’s PD Nurse Specialist or PD physician.
b.Routine administration of low-dose haloperidol in those with a history of hallucinations or delusional ideation.
c.Optimally managing pain and hydration, avoiding constipation, sensory impairment and unnecessary immobility.
d.Agreeing a pre-operative delirium management plan including individualised and general non-pharmacological measures.
e.Withholding dopamine agonist medications for around one week post-operatively.
a) True. Early pre-and post-operative involvement of a patient’s usual PD clinicians will allow appropriate optimisation of their clinical status and provide continuity.
b) False. Haloperidol and other typical antipsychotic medications are contraindicated in PD.
c) True. Post-operative delirium is best managed by non-pharmacological measures, including reorientation, nursing in a suitable environment, effective management of pain and hydration, and early mobilisation.
d) True. Delirium interventions must reflect the multi-factorial nature of the condition.
e) False. On occasion it may be necessary to reduce dopamine agonist medications where neuropsychiatric complications occur but there is no evidence to support routine discontinuation of medication, and indeed this could be dangerous with precipitation of DAWS.
