Parkinsons 3A

Question 1

What is Parkinson’s disease?

Answer 1

Loss of dopaminergic neurones from substantia nigra pars compacta

Question 2

Is It the MC neurodegenerative disorder?

Answer 2

2nd MC after dementia

Question 3

RF for Parkinsons
Protective factors?

Answer 3

fHx, males, increased age,

Protective = smoking, caffeine, physical activity

Question 4

Pathology ?

Answer 4

To initiate movement - nigrostriatal pathway signals striatum to STOP firing to SNpr therefore stop movement inhibition

Degenerated SNpc = Harder to initiate movement

Question 5

Cardinal Sx of Parkinson’s

Answer 5

Bradykinesia (slow movement, smaller writing, can’t do buttons, small steps, reduced arm swing)

Resting tremor
(At rest, unilateral, U/L pill rolling thumb, 3-5Hz)

Rigidity
(cogwheel, lead pipe)

Postural Instability (Parkinsonism, camptocormia - abnormal posture - bent forwards)

Question 6

What is often seen early?

Answer 6

anosmia (partial loss of smell)
constipation common

Question 7

What are some other signs of Parkinson’s?

Answer 7

Hypomimia (expressionless face)

Micrographia (small tailing off writing)

Postural hypotension (autonomic failure)

REM sleep disorder

Seborrhoea (high seborrheic dermatitis - red scaly patches)

Punding (non goal orientated behaviour)

Urinary freq/urge/incontinence

Sweating

Hypersalivation

Erectile dysfunction

Question 8

Why can’t dopamine be given itself?

Answer 8

Doesn’t cross BBB

Question 9

What is a Ddx for parkinsons?

Answer 9

Lewy body dementia (associated with parkinsons)

Question 10

If a patient has Parkinson Sx then dementia?
Dementia then Parkinson Sx?

Answer 10

Parkinson dementia
Lewy body dementia with Parkinsonism

Question 11

what medications exacerbate Parkinson’s Sx?

Answer 11

Antipsychotics (eg. haloperidol)
Metoclopramide
(drug induced often = bilateral resting tremor - inhibit movement)

Question 12

what is cogwheel and lead pipe rigidity?

Answer 12

Cogwheel = jerky tremor superimposed on hyperfine, elicited on reinforcement

Leadpipe = smooth tremor throughout movement

Question 13

Name some Parkinson’s Plus syndromes?

Answer 13

Lewy body dementia
Multiple system atrophy
Progressive supranic palsy
Cortico-basal degeneration
Wilsons disease, drug induced, NPH (Neurogenic orthostatic hypotension)

Question 14

what Sx do you get in lewy body dementia?

Answer 14

Dementia / hallucination then parkinsons

Question 15

what Sx do you get in multiple system atrophy?

Answer 15

Parkinsonism + cerebellar + autonomic features - postural hypotension, incontinence, impotence

Question 16

what Sx do you get in progressive supranic palsy?

Answer 16

Parkinsonism + fixed upwards gaze

Question 17

what Sx do you get in cortico-basal degeneration?

Answer 17

Parkinsonism + alien limb / loss of control of one hand - moved itself

Question 18

If parkinsons is suspected in GP, what is done?

Answer 18

urgent referral

Question 19

Dx of Parkinsons?
what is found?

Answer 19

Clinical
(bradykinesia + 1 other Sx)

MRI = Normal

DaT scan = 2 dots instead of 2 commas (basal ganglia usually 2 commas)

Post excisional biopsy = loss of DA neurones in SN + Lewy bodies (ubiquitin + alpha synuclein)

Question 20

MDT Tx of parkinsons?

Answer 20

OT
SALT
PT
Vit D suppose
manage complications eg. hyper salivation, constipation

Question 21

what is the first line medical Tx of parkinsons?

Answer 21

Co-careldopa (L-DOPA + decarboxylase-i)

Question 22

what does carbidopa do?
how does it help L-DOPA?

Answer 22

Prevents L-DOPA breakdown before reaching brain

L-DOPA = Converted to DA (an amino acid) taken up by serotinergic neurones

Question 23

Why is a decarboxylase inhibitor given?

Answer 23

enzyme breaks down LDOPA so need inhibitor

Question 24

What is the problem with LDOPA?

Answer 24

Initially works very well BUT soon body becomes resistant to it, effects were off so dont give LDOPA too early (eg. v mild Sx)
‘on - off’ fluctuations, well controlled periods with sudden decline following

Add MAO-i or COMT-i

Question 25

L-DOPA is good to give to who?
SE of L-DOPA?

Answer 25

motor Sx impacting QOL
Over 65

Postural hypotension, confusion, psychosis, chorea

Question 26

What is second line medical Tx of parkinsons?

Answer 26

COMT-i = entacapone

DA Agonisms

Amantadine

Question 27

what are the SE of entacapone (COMT-i)?

Answer 27

orange urine
dyskinesia (worsens L-DOPA effect)

Question 28

what are the 2 groups of DA agonist and give examples of each?

Answer 28

Ergot derivatives = Bromocriptine, cabergoline

Non ergot derived = Ropinerole, pramipexole

Question 29

what is long term tx of parkinsons?

Answer 29

deep brain stimulation

Question 30

SE of ergot and non ergot derivatives?

Answer 30

Ergot = pulmonary / CV fibrosis

Non ergot = hallucinations

Question 31

what is the shared care plan?

Answer 31

specialist Dx + starts Tx
GP monitors + refers back if problems