Parkinsons

Question 1

What does the extrapyramidal system do?

Answer 1

Control the motor system
Inhibtiion
Coordination
Like traffic lights for movements

Question 2

What NT is to do with the extrapyramidal system in the substantia nigra?

Answer 2

Dopamine

Question 3

Parkinsons gait

Answer 3

Shuffling
Difficulty turning initiation
Later = freezing episodes, gait initiation difficulty

Question 4

Why do you get Parkinsoniam symptoms with Lewy body dementia?

Answer 4

Lewy bodies are part of parkison pathology. In parkinsons physical symptoms start first

Question 5

What diseases show a Parkinsonian tremor?

Answer 5

Parlkinsons
Wilsons disease
Parkinsonism eg MSA

Question 6

When is the tremor in Parkinson?

Answer 6

Resting tremor

Question 7

What can stop essential tremor

Answer 7

Alcohol

Question 8

Why should you not prescribe some anitemetics eg metaclopramide long term?

Answer 8

Causes parkinsonian symtpoms

Question 9

What is parkinsonism?

Answer 9

Bradykinesia + one of
Tremor
Rigidity
Postural instability

Question 10

What is parkinsons disease?

Answer 10

Idiopathic progressive neurodegenerative condition caused by degeneration of dopaminergic neirones in substantiat nigra at basal ganglia

Question 11

Causes of parkinsonism

Answer 11

Parkinsons disease
Drugs
Progressive supranuclear palsy or Steele Richardson Olszewski syndrome
Multiple systems atrophy
Wilsons disease
Post encephalitis
Demenita puglistitica or Chronic traumatic encephalopathy - chronic head trauma eg boxing
Toxins = CO, MPTP, copper

Question 12

Pathology of parkinsons disease

Answer 12

Loss pigmented dopaminergic neurones in pars compacta of substantia nigra
Presence of Lewy bodies and neurites

Question 13

Complications of parkinsonism

Answer 13

Infections eg aspiration pneumoinia
Bed sores
Poor nutrition
Falls
Contractures
Bowel and bladder disorders
Acute akinesia

Question 14

What happens to rigidity and tone in parkinsons?

Answer 14

Increase - lead pipe and cog wheeling rigiditiy

Question 15

Parkinsons gait

Answer 15

Decreased arm swing
Festinating - shuffling steps, difficult to stop, flexed trunk
Freezing
Cant turn corners

Question 16

What condition is ass with a blank facial expression?

Answer 16

Parkinsons

Question 17

Autonomic symptoms of parkinsonism

Answer 17

Reduced sense of smell
Constipation
Frequency/urgency
Dribbling
Sweating

Question 18

What disorder often precedes signs of parkinsons by a few years?

Answer 18

REM sleep disorder

Question 19

What happens in REM sleep disorder?

Answer 19

Lose movement inhibition control in sleep - act act dreams, move violently in bed

Question 20

Symptoms of progressive supranuclear palsy vs PD

Answer 20

Impairment of vertical gaze
Early postural instability
Symmetrical onset
Speecha dn swallowing problmes
Little tremor

Question 21

What symptoms in Lewy body first?

Answer 21

Fluctuating cognition with visual hallucinations and early dementia
THEN motor signs

Question 22

Symptoms of MSA on top of PD

Answer 22

Early autonomic disturbanvce - postural hypotension, impotence/incontinence
Cerebellar signs

Question 23

Signs of corticobasal degeneration

Answer 23

Akinetic rigidity in one limn
Cortical sensory loss
Apraxia

Question 24

hat is seen in vascular parkinsonism?

Answer 24

Pyramidal signs eg diabetic/HPTNsicve patients who fall or have gait problems

Question 25

Investigations for parkinsonism

Answer 25

Clinical diagnosis - exclusion CT/MRI brain - tumours PET, sPECT, DAT scans gENETIC TESTING Olfactory testing Caeruloplasmin levels Syphilis serology

Question 26

When do you test caeruloplasmin levels and syphilis serology in parkinsonism?

Answer 26

young onset or atypical disease Caeruloplasmin = wilsons disease syphilis

Question 27

What disease is normally looked for on genetic testing

Answer 27

Huntingtons Parkinsons is 5% monogenic

Question 28

What do PET, SPECT and DAT scans measure

Answer 28

Dopaminergic function of basal ganaglia where diagnosis unclear

Question 29

Mental health conditions ass with parkinsons

Answer 29

Depression, anxiety, and apathy. Dementia and cognitive impairment. Impulse control disorders and psychotic symptoms (delusions and hallucinations).

Question 30

symptoms other than mental health, autonimc and motor parkinsons

Answer 30

Nausea and vomiting. Pain. Sleep disturbance and daytime sleepiness. Aspiration pneumonia. Pressure sores.

Question 31

What happens to efficacy of parkinsons drugs over time?

Answer 31

Decrease

Question 32

Motor complications related to medicaitons parkinsons

Answer 32

End of dose fading - benefit wears off before take next dose ON off phenomenon Dose failures

Question 33

ON off phenomenon parkinsons

Answer 33

Years of use Increasingly rapid fluctuations between on and off periods due to fluctuating responses to levodopa

Question 34

Dyskinesic movement in parkinsons

Answer 34

Choreiform Dystonic

Question 35

What is a life threatening syndrome if parkinsons drugs are suddenly stopped?

Answer 35

Neuroleptic malignant syndrome

Question 36

Symptoms of neuroleptic malignant syndrome?

Answer 36

fever, altered mental state, muscle rigidity, and autonomic dysfunction.

Question 37

How does autonomic dysfunctinon present

Answer 37

Bladder problmes Sexual problems Excessive sweating and saliva Weigth loss Dysphagia Orthostatic hypotension Comstipation

Question 38

What drugs can induce parkinsonism?

Answer 38

Antipsychotics metoclopramide Phenothiazines eg chlorpromazene

Question 39

Why give levodopa with carbidopa or benserazisde?

Answer 39

Carbidopa/benserazide are decarboxylase inhibitors - prevent peripheral metabolism of L dopa

Question 40

Side effects of levodopa

Answer 40

Dyakinesia, dry mouth On off effect Drowsiness Anorexia Palpitations Postural hypotnesion Psychosis

Question 41

When is levodopa used in parkinsons?

Answer 41

Early stages PD when motor symptoms impact QOL

Question 42

When are dopamine recetpor agonists and MAO B inhibitors used in PD?

Answer 42

Early and symptomatic Advanced - with Ldopa control fluctuations

Question 43

Which type of dopamine agonist is preferred?

Answer 43

Non ergot - fewer side effects

Question 44

Non ergot derived dopamine examples

Answer 44

Pramipexole, ropinirole

Question 45

What do before offer ergot derived dopamine agonists in Ldopa?

Answer 45

CXR, ECG, ECHO, ESR, creatinine and close monitoring

Question 46

Ergot derived dopamine agonists

Answer 46

Bromocriptine, cabergoline, lisuride

Question 47

What is the risk of ergot derived dopamine agonists

Answer 47

Pulmonary, retroperitoneal and cardiac fibrosis

Question 48

Side effects of dopamine agonists

Answer 48

Impulse control disorders Excessive daytime somnolence Hallcuinations Postural hypotension Nasal congestion

Question 49

What type of drgus are selegiline, rasagiline

Answer 49

MAO-B inhibitors

Question 50

What do MAO B inhibitors do?

Answer 50

Inhibit dopamine breakdown secreted by dopaminergic neurones

Question 51

Effect of COMT inhibitors on LDOPA

Answer 51

Increases half life

Question 52

What can be used to treat drug induced parkinsonism?

Answer 52

Antimuscarinics eg procyclidine, benzatropine, trihexyphenydil

Question 53

2nd line treatment PD

Answer 53

COMT inhibtiprs Entacapone, tolcapone

Question 54

When is apomorphine used in PD?

Answer 54

Severe motor complications - decrease 'off' periods and dyskinesia Rescue SC or infusion

Question 55

What can treat postural tremor in PD?

Answer 55

propanolol

Question 56

Why is haloperidol CI in parkinsons

Answer 56

Sedative blocks dopamine receptors - worsens symptoms

Question 57

What does missing medications cause in parkinsons?

Answer 57

Rigidity

Question 58

How administer meds if cant tolerate oral

Answer 58

NG tube OR Rigotine patch based on usual levodopa dose

Question 59

Diagnosis of parkinsons

Answer 59

BRADYKINESIA+ at least one of Muscular rigidity 4-6 Hz resting tremor Postural instability asymmetrical tremor, excellent response to levodopa, progression

Question 60

Pathology of parkinsons

Answer 60

Aggregation of alpha synucelin/lewy bodies

Question 61

What sign see in vascular parkinsons

Answer 61

Frontal release/applause sign Ask to clap they continue clapping - frontal lobe affected

Question 62

Causes of vascular parkinsonism

Answer 62

- Chronic microvascuar disease - Basal ganglia stroke Normal DAT scan

Question 63

Postural alterations in parinsons

Answer 63

- Antecolitis - stooped - Pisa - lateral lean - Camptocormia - bent double

Question 64

Management of PDD

Answer 64

Co-careldopa - levodopa + COMT-i (MAO )

Question 65

Wht side effect comon with levodopa

Answer 65

Nausea and vomitting

Question 66

What is athetosis

Answer 66

coiling, snake like

Question 67

Dystonia

Answer 67

fixed upper posture, jerky

Question 68

Chroea

Answer 68

Large, restless, dancy movement

Question 69

Ballsimus + what causes

Answer 69

flinging movment (normally hemi due to lesion in basal ganglia, stroke, hypoglycaemia (one arm)

Question 70

Myoclonus + what causes

Answer 70

rapid sudden movement, epilepsy, anoxic brain injury (lauds adams syndrome → antiepileptic drugs eg kepra), painkillers eg large opiod doses, amitryptilline etc

Question 71

Causes of drug induced parkinsosnism

Answer 71

Antiemetics e metoclopramide, prochlorperazine Typical antipsychotics eg haloperidol Atypical eg aripirazole Any dopamine anatagonists - > akathisia

Question 72

What is tardive dyskinesia

Answer 72

Grimacing, lip smakc and purse, tonue move, chorea

Question 73

What causes tardice dyskinesia

Answer 73

Long term use anti dopaminergic agents - increased sensitivty to dopamine