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parkinsons Flashcards

1
Q

define parkinsons

A

chronic, progressive neurodegenerative conditions that occurs secondary to loss of dopaminergic neurones within substania nigra

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2
Q

what is parkinsonism?

A
  • Parkinsonism: bradykinesia and at least one of: resting tremor, rigidity, postural instability
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3
Q

who is more at risk of parkinson’s?

A

Epidemiology: 1.5x more common in men
- One of the most common neurological disorders  lifetime risk of 2.7%
- Peaks between ages of 55-65yrs and has slowly progressive onset

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4
Q

what does the basal ganglia do?

A

Physiology: basal ganglia are involved in movement  helps start and fine tune movement by motor cortex
- Functions of basal ganglia: inhibition of muscle tone, coordinated/ slow/ sustained movement, suppression of useless patterns of movement, initiation of movement

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5
Q

what causes parkinson’s?

A

Aetiology: idiopathic
- Very small proportion (2-3% of the cases) are causes by monogenic causes – single gene variant causing disease
- Majority of cases are linked to complex interaction between genetics and environment

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6
Q

when may parkinson’s present?

A

PD may not be apparent until a substantial number of neurones have been lost within substania nigra (around 50-80%)

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7
Q

what is the direct pathway within basal ganglia and what does it do?

A

Direct pathway: mostly stimulatory pathway: shorter pathway and mostly off and linked to D1 receptors
- Activation of direct leads to a series of neural connections through basal ganglia and eventually leads to initiation of movement
- dopamine that is released from substania nigra via dopaminergic neurones are able to activate the direct pathway via D1  leading to generation of movement

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8
Q

what is the indirect pathway in the basal ganglia and what does it do?

A

indirect pathway: mostly an inhib pathway – a longer and linked to D2 receptors
- activation is essential to inhib muscular tone to prevent unnecessary movement
- dopamine released from substania nigra via dopaminergic neurones are able to inhib the inhibitory pathway  generation of movement

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9
Q

how is dopamine involved within parkinson’s?

A

dopamine: acts on direct and indirect pathway to permit movement generation
- this process is finely tuned and provides coordinated movement
- PD: issue with initiation of movement

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10
Q

how may the symptoms present in PD?

A

Symptoms: unilateral symptoms at onset with gradual onset that develop into bilateral signs
- Motor symptoms
- Non motor complications: depression, dementia, sleep disturbances, autonomic dysfunction causing ill-health

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11
Q

what are the three main features of PD?

A

Classic features: bradykinesia, resting ‘pill rolling’ tremor and cogwheel rigidity

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12
Q

what shows bradykinesia?

A
  • Bradykinesia: general slowing of voluntary movements, reduced arm swing, reduction in the amplitude with repetitive movements
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13
Q

what indicates a tremor?

A
  • Tremor: can be induced by distraction, pill rolling movement:
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14
Q

describe pill rolling tremor

A

rubbing grains of sand in between finger and thumb

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15
Q

how may rigidity present?

A
  • Rigidity: increase resistance to passive movement, cogwheel due to superimposed tremor
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16
Q

apart from the classic three symptoms seen within PD, what other symptoms/ features may be seen?

A
  • Expressionless face – parkinsonian mask
  • Micrographia – small writing
  • Soft voice
  • Drooling of salvia
  • Shuffling gait – festinating gait
  • Glabellar tap:
  • Depression
  • Bowel and bowel symptoms: urgency, incontinence, constipation
  • Sleep disorder
  • Sexual dysfunction
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17
Q

what is glabellar tap?

A

repeated tapping of forehead and associated with persistent blinking

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18
Q

how is the diagnosis of PD made?

A

Diagnosis: clinical judgement made by bradykinesia and another major feature of parkinsonism
- UK parkinson’s disease society (PDS) brina bank diagnosis criteria

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19
Q

what are the 4 steps involved in the parkinson diagnosis?

A
  1. identification of features
  2. identify exclusion criteria
  3. identification supporting PD
  4. absence of red flags
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20
Q

what signs identify parkinsons?

A
  • Bradykinesia + (muscular rigidty/ postural instability/ resting tremor) - one of the three as well as bradykinesia
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21
Q

what need to be excluded within PD diagnosis?

A
  • Repeated strokes and stepwise progression
  • Head trauma – history
  • Definite encephalitis
  • Sustained remission
  • Unilateral features after 3 years
    oculogyric crisis
    antipyschotic/ dopamine depleting drugs
    other atypical neuro features
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22
Q

what is oculogyric crisis?

A

form of dystonic movement characterised by paroxysmal, conjugate and typically upward deviation of eyeball which can occur for hours to seconds  usually acute

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23
Q

what supports parkinsons - need 3 of these points?

A
  • Progressive disorder, unilateral disorder, resting tremor
  • Persistent asymmetry
  • Excellent response to levodopa
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24
Q

what neuro red flags need to be out ruled for PD diagnosis?

A
  • Rapid development of gait impairment, early bulbar dysfunction, non -progressive motor symptoms, reps dysfunction, early severe autonomic dysfunction
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25
Q

what is parkinson plus syndrome?

A

group of conditions that may get mistaken for parkinsons
- They affect wider area and can cause more complex disease

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26
Q

what are parkinson plus syndrome examples?

A

MSA
dementia with Lewy Body
progressive supranuclear palsy
corticobasal degeneration

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27
Q

what is MSA and how is it different to parkinsons?

A
  • MSA: mutli system atrophy – adult onset, rapidly progressive characterised by autonomic dysfunction – severe postural hypotension, urogenital dysfunction  poor response to levodopa
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28
Q

what is PSP and how is it different to PD?

A
  • Progressive supranuclear palsy (PSP): typically presents at 50-60yrs and characterised by vertical gae, dysarthria and cognitive decline. Tremor is rare
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29
Q

what is dementia with lewy body and how does it differentiate to PD?

A
  • Dementia with Lewy Body (DLB): early onset dementia with <1yr has Parkinson features. May have hallucinations and fluctuating consciousness
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30
Q

what is seen within corticobasal degeneration?

A
  • Corticobasal degen (CBD): progressive dementia, parkinsonism and limb apraxia.
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31
Q

what is apaxia?

A

Apraxia: problems with motor planning eg unable to wave hello

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32
Q

what investigations are needed?

A
  • Clinical diagnosis
  • Neuro imaging – CT/MRI to rule out others eg cerebrovascular disease
  • PET: with fluorodopa to help localise dopamine deficiency within basal ganglia
  • Striatal dopamine transporter using 123I-FP-CIT single photon emission CT – DaTscan  differentiate Parkinsonism from essential tremor
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33
Q

what are motor complications of PD?

A
  • Motor ‘on-off’ fluctuations- switch from dyskinesia to immobility within minutes
  • Dyskinesia – hyperkinetic movement due to dosing of medications
  • Freezing of gait – can not complete movement
  • Wearing off phenomenon – towards end of dose
  • Falls
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34
Q

what are non motor complications of PD?

A
  • Aspiration pneumonia
  • Nutritional deficiency, dysphagia, weight loss
  • Bladder, bowel and sexual dysfunction
  • Pressure sores, postural hypotension
  • Impulse control disorders and psychosis
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35
Q

describe the tremor in Parkinson’s?

A
  1. Tremor: 4-6Hz, worse at morning (at rest), asymmetrical  can be both sides but it will be worse on dominant side, pill rolling
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36
Q

describe features of bradykinesia?

A
  • Micrographia, spidery writing
  • Repetitive movements go from large – small
  • Face: parkinson’s mask, lack of eye blinking (serpentine stare)
  • Gait: slow hesitant, stooped posture, inability to stop or turn, poor arm swing
  • Speech: initially monotonous, as PD worsens it becomes tremulous, slurring dysarthria (due to bradykinesia, tremor, rigidity)
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37
Q

describe cogwheel rigidity

A
  1. Cogwheel rigidity: seen in those with damage in extrapyramidal damage tracts no matter what pressure/ velocity it will not give way
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38
Q

name some conditions that can have parkinsonism?

A

dementia with lewy body, wilsons – build up of copper (can go into basal ganglia)
drug induced
parkinson plus syndromes

39
Q

what drugs can cause parkinsonism?

A
  • Drug induced: dopamine antagonists (anti-psychotics, metoclopramide, MPTP)
40
Q

describe the parkinson plus syndromes

A
  • Parkinson plus: MSA (Parkinson features + autonomic dysfunction + ataxia), PSP (slow movements + Parkinson + cant look up with eyes)
41
Q

what features would you assess for parkinson’s?

A
  1. Observe: face, tremor (ask them to close eyes and count back)
  2. Assess upper tone: demonstrate cogwheel rigidity, kinnier Wilson  distract them and lift one arm and then test tone on another
  3. Repetitive hand movements: writhing, glabellar tap (tap forehead eventually you would stop blinking but in PD keep blinking)
  4. Speech, get them to stand up, assess gait and turning
  5. Retropulsion and anteropulsion: pulling on shoulders and they would fall in that direction
42
Q

what is wilsons disease?

A

disorder of cu metabolism

43
Q

what is low cauroplasm?

A

gh urinary copper and low serum copper

44
Q

what can copper deposition do?

A
  • Copper deposition: basal ganglia disease, liver cirrhosis, kaiser-fleischer rings, kidney disease, low IQ, cardiomyopathy
45
Q

how would copper deposition cardiomyopathy present on an ECG?

A

ST segment depression
T wave inversion

46
Q

how do you treat wilsons disease?

A

penicillamine (copper chelating agent)

47
Q

name some tremor differentials?

A
  • Anxiety
  • Hyperthyroidism
  • Drugs eg B2 agonists
  • Cerebellar disease (intentional)  stroke, alcoholism, B12 deficient. Seen on finger to nose test
  • Essential tremor
48
Q

describe an essential tremor?

A
  • 5-8Hz
  • Tremor occurs when trying to adopt a posture
  • Shaking occasionally at rest on intention
  • Typically worse on upper limbs
49
Q

what can make an essential tremor worse?

A

caffeine, poor sleep, stress/ anxiety

50
Q

what can make an essential tremor improved?

A

alcohol

51
Q

how can manage essential tremor?

A

: sleep and stress controls. Beta adrenergic antagonists  propranolol, primidone, topiramate.

52
Q

what is chorea?

A

dance like (choreography)  rhythmical, non purposeful movements

53
Q

what conditions can cause chorea?

A
  • Basal ganglia lesion, huntingtons, sydenham’s (rheumatic fever caused by strep A), benign hereditary chorea
54
Q

what drugs can cause chorea?

A
  • Drug causes: levodopa, phenytoin, alcohol, oral contraceptive
55
Q

what is athetosis?

A

slow moving, typically in fingers

56
Q

what can cause athetosis?

A
  • Causes: damage to basal ganglia (ischaemia, athetoid cerebral palsy – due to kernicterus, excess bilirubin, associated with dystonia’s)
57
Q

what is hemiballismus?

A

: violent, contouring, continuous movements – usually rotational
- Unilateral

58
Q

what can cause hemiballismus?

A
  • Secondary to infarction/ haemorrhage of contralateral subthalamic nucleus
  • Eg left sided stroke would cause this on right side
59
Q

what is myoclonus?

A

violent, sudden jerks of single or groups of muscles

60
Q

what can cause myoclonus?

A
  • Causes: nocturnal, paramyoclonus multiplex
61
Q

what is seen in neuroleptic complications?

A

akathisia
acute dystonia
chronic traditive dyskinesia

62
Q

what is akathisia?

A

restless, repetitive and irresistible to move

63
Q

what is acute dystonia?

A

acute muscle contractions, spasmodic torticollis (neck), trismus (in mouth), oculogyric crisis (dystonia of the eyes)

64
Q

how is neuroleptic complications get resolved?

A

IV anti-muscarinics

65
Q

what is chronic tarditive dyskinesia?

A

mouthing and lip smacking, grimaces, eye blinking  seen after several months of anti-psychotics

66
Q

what drugs can cause neuroleptic complications?

A

anti-psychotics and some anti-emetics

67
Q

what are tics?

A

idiosyncratic movements of face, neck or hands which are part of normal motor gestures

68
Q

what can be seen as simple tics?

A
  • Simple tics: sniffing, facial grimaces are common in childhood and may resolve
69
Q

what is gilles de la tourettes syndrome?

A

multiple tics (motor and speech)
- Associated with behavioural problems eg ADHD or OCD
- Childhood and adolescence, more common in males
- Lifelong

70
Q

what is dystonia?

A

prolonged muscular contraction eg spasm

71
Q

what are causes of dystonia?

A
  • Causes: primary torsion dystonia, dopamine responsive dystonia,
72
Q

what drugs can induce dystonia?

A
  • Drug induced: metoclopramide, prochlorperazine, anti-psychotics
73
Q

how can you distinguish between asterixis and tremor?

A

Asterixis: can be distinguished from tremor on the basis of prolonged absence of EMG activity during flapping  seen in hypercapnia, encephalitis

74
Q

what signs are seen in Multi system atrophy - MSA?

A

autonomic dysfunction
cerebellar dysfunction

75
Q

what is seen with dementia LB?

A

parkinsons
hallucinations, delusions
REM sleep disorder
fluctuating consciousness

76
Q

what can be seen in PSP?

A

balance issues, mobility, frequent falls
change in behaviour

77
Q

what is PSP?

A

progressive supranuclear palsy

78
Q

what is CBD?

A

corticbasal degeneration

79
Q

what signs are seen in CBD?

A

problems recalling words, aphasia, short term memory loss

80
Q

why is levodopa prescribed with peripheral decarboxylase inhib?

A

helps dopamine go in

81
Q

what is COMT inhib?

A

carbidopa-levodopa

82
Q

give an example of COMT inhib?

A

entacapone

83
Q

what is the MOA of COMT inhib?

A

prevents dopamine breakdown

84
Q

give an example of a dopamine agonist?

A

rotigotine

85
Q

what is the risk in using dopamine agonists?

A

pulmonary fibrosis
impulse issues

86
Q

what can be seen within impulse issues with dopamine agonists?

A

addiction - internet, sex, shopping

87
Q

give examples of monoamine oxidase-B inhib?

A

selegiline
rasagiline

88
Q

what is the moa of monoamine oxidase B inhib?

A

prevents dopmaine breakdown

89
Q

what are the mian side effects of levodopa?

A

dyskinesia - excessive motor activity from too much dopamine

90
Q

what signs are seen in dyskinesia?

A

dystonia, chorea, athetosis

91
Q

what is athetosis?

A

writhing/ twisting of wrists

92
Q

what can be prescribed to help in dyskinesia from excess levadopa?

A

amantadine

93
Q
A

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