Parkinsons Flashcards
PD cardinal features
Tremor
-pill rolling
-worse at rest and with distraction
-usually in hand
-legs, lips, tongue, jaw but rarely head
-usually begins unilateral then spreads contralaterally over years
Bradykinesia
-often described as weak, tired, incoordination
-often starts distally and unilaterally
-develops into freezing and festination
Rigidity
-begins unilaterally on side of tremor
-cogwheeling or lead pipe resistance
-intensified by distraction
-striatal hand, decreases arm swing, stooped posture
Postural instability
-late sign
-frequent falls
-fall or multiple steps with pull test
PD motor features
Craniofacial
-hypomimia (masked face)
-dysarthria
-hypophonia
-dysphagia
-sialorrhea
Visual
-blurred vision
-eyelid opening apraxia (difficulty opening eyelids)
-decreases blink reflex
Musculoskeletal
-micrographia
-dystonia
-myoclonus
-stopped posture, camptocormia
Gait
-shuffling
-freezing
-festination (quick short steps)
PD non motor features
Cognitive impairment
-dementia is late sign
-if dementia before or begins concurrently with Parkinsonism, likely Lewy body dementia
Psychosis
-from Lewy body disease and medications
-hallucinations (mainly visual)
-delusions (usually paranoid)
Mood disorder
-depression
-apathy
-anxiety
Sleep disorders
-fatigue
-sleep attacks, excessive daytime sleepiness
-insomnia
-restless leg syndrome
-REM sleep behaviour disorder
Autonomic dysfunction
-orthostasis
-constipation
-urinary frequency, urgency, incontinence
-sexual dysfunction
Pain
-generalised or focal
-sharp, burning, tingling
Skin
-seborrheic dermatitis (eczema face, scalp, trunk)
Parkinson’s plus differentials
Lewy body dementia
-PD dementia only if onset >1 year after parkinsonism onset
Multiple system atrophy
-Parkinsonism or cerebellar motor dysfunction
-Autonomic dysfunction
-Nocturnal stridor, sleep apnoea, RSBD
-Symmetricla onset
-Poor response to levodopa
-Cognitive function more preserved
Corticobasal degeneration
-progressive and asymmetric movement disorder
-prominent cognitive impairment
Progressive supranuclear palsy
-Knees and trunk extended, broad based gait
-Fall backwards
-Resting tremor is rare
-Up and down gaze palsy, overcome by dolls eye
-Poor response to levodopa
Secondary Parkinson’s
Drug induced
-Typical and atypical antipsychotics
-Metaclopramode
-Prochlorperazine
Toxins
-carbon monoxide
-cyanide
Head trauma
Brain lesions in striatonigral circuits
-hydrocephalus
-tumour
-chronic subdural haematoma
Metabolic
-hyperparathyroid
-chronic liver failure
Neurogenetic
-Wilson’s
-Huntington’s
Infectious/post infectious
PD pharmacological options
Levodopa
-Gold standard
-Best for motor control
-Preferred option in advanced stages
-Can be used at any age
-In combination with MAO or DAs
MAO B inhibitors
-Mild symptoms
-Preference for once daily dosing
-Only has modest benefit
Amantodine
-Younger patients (under 50)
-High risk of dyskinesia (female, young, low weight)
-Tremor predominant
Dopamine agonists
-Moderate symptoms
-Younger patients
-High risk for dyskinesia (young, female, low weight)
Anticholinergics
-Younger
-Tremor predominant
MAO B inhibitors
Options
-Selegeline
-Rasagiline
-Safinamide (usually as adjunct to levodopa)
MOA
-Monoamine oxidase (A in the gut and B in the brain) catabolises dopamine, serotonin, adrenaline and noradrenaline
-MAO inhibitors irreversibly inhibit MAO
Adverse effects
-Nausea
-Headache
-Depression
-Serotonin syndrome
Amantadine
MOA
-Unknown
Adverse effects
-Livedo reticularis
-Confusion
-Hallucinations
-Nightmares
Dopamine agonists
Options
-Pramipexole
-Ropinirole
-Rotigotine (patch)
MAO
-Specific agonist for D2 receptor
Avoid in
-Over 70’s
-History of ICD
-Cognitive impairment
-Excessive daytime sleepiness
-Hallucinations
Adverse effects
-Less dyskinesia than levodopa
-Nausea, vomiting
-Sleepiness
-Orthostasis
-Confusion
-Hallucinations
-Peripheral oedema
-Compulsive disorders
-Withdrawal syndrome with sudden cessation
Anticholinergics
Options
-Trihexyphenidyl
-Benztropine
MAO
-Blocks post ganglionic parasympathetic receptors
-Dopamone and acetylcholine usually in balance in basal ganglia
-Dopamine depletion in PD means cholinergic drugs exacerbate, and anticholinergics drugs improve, Parkinson’s symptoms
Adverse effects
-Avoid in >65s
-Cognitive impairment
-Blurred vision
-Dry mouth
-Dry red itchy skin
-Constipation
-Urinary retention
Levodopa
Options
-levodopa/carbidopa (sinemet)
-levodopa/benserazide (madopar)
-IR preferred initially. No advantage to MR
MAO
-Lack of striatal dopamine in PD
-Levodopa is prodrug. Converted to dopamine after crossing BBB
-Carbidopa/benserazide inhibits peripheral decarboxylation of levodopa, reducing nausea and orthostasis
Adverse effects
-Motor fluctuations and dyskinesia in 50%
-Nausea is most common
-Headache
-Sleepiness
-Confusion
-Hallucinations, delusions
-Orthostasis
Dopaminergic dopamine agonist and levodopa side effects
Acute akinesia and NMS with abrupt cessation
Peripheral neuropathy
Dopamine dysregulation syndrome -uncommon
-addictive dopaminergic medication overuse
-Tolerance to mood elevating effect of dopaminergics -> withdrawal -> increased dose despite dyskinesia
Punding
-sometimes occurs with DDS
-repetitive, prolonged often purposeless, stereotyped behaviours
-eg sorting and disassembling
Impulse control disorder
-Almost 50%
-Compulsive behaviour
-Minor (eg cleaning) to destructive (gambling, hypersexuality)
PD swallowing restrictions
Wearing off after 3-4 hours
-Missing <24 hours usually ok
-Most symptoms masked by acute illness
Risk of neuroleptic malignant syndrome
Risk of acute akinesia
Non oral options
-Levodopa via NG
-Orally disintegrating levodopa/carbidopa
-Rotigotine patch
-Apomorphine injection
PD second line options
Deep brain stimulation
-Probes on subthalamic nucleus or internal globus pallidus
-Significant motor fluctuations, tremor or dyskinesia
-Not too elderly with reasonable cognitive function
Duodopa
-Levodopa/carbidopa gel suspension
-Continuous infusion through percutaneous gastrojejunostomy tube
-Externally carried pump
-Useful for significant motor fluctuations
Apomorphine
-Dopamine agonist
-More potent than other oral DAs
-Continuous or intermittent subcut infusion
-Useful for freezing episodes
Neuroleptic malignant syndrome
Associated medications
-Antipsychotics
-Metoclopramide, prochlorperazine, promethazine, domperidone
-Levodopa or DA withdrawal
Tetrad
-mental state change
-rigidity
-hyperthermia
-autonomic instability (HR, BP, RR)
Elevated CK
Treatment
-Restart usual antiparkinsons medication
-Supportive care
-Consider benzos, dantrolene, bromocriptine, amantadine
-ICU
