Parkinsons

Question 1

common age and gender in parkinsons

Answer 1

male

diagnosed age 66 usually

Question 2

the four motor features

Answer 2

bradykinesia 
tremor at rest
rigidity 
postural instability 
*must have bradykinesia

Question 3

describe the tremor at rest

Answer 3

rhythmic
asymmetric - doesnt affect both sides equally
pill rolling
feet, lip, jaw
may disappear with voluntary movement and sleep
worsens with mental stress

Question 4

describe the rigidity

Answer 4

lead pipe, cogwheel
neck, trunk, limbs
resistance to passive movement of the limbs

Question 5

describe bradykinesia

Answer 5

slowness of all movements

difficulty initiating movement

Question 6

describe postural instability

Answer 6

later presentation
shuffling gait
narrow base
freezing and falls

Question 7

main difference in symptoms between motor cortex disorders

Answer 7

no muscle weakness

just a communication issue

Question 8

other clinical features

Answer 8

depression
dementia
sleep disturbance
difficultly smelling
micrographia 
dysphagia
lack of expression -hypomimia

Question 9

what happens in the substantia nigra

Answer 9

low dopamine causes parkinsons
high dopamine causes dyskinesia
cells start to die in parkinsons

Question 10

what is the substantion nigra responsible for

Answer 10

controls movements and connects to the motor cortex

Question 11

how does the nigrostriatal pathway achieve smooth muscle movement

Answer 11

ach (inhibitory) and dopamine(excitatory) are in balance

Question 12

what happens when there is much more ach than dopamine

Answer 12

movement becomes jerky and stiff

Question 13

drugs that can cause parkinson like motor symptoms

Answer 13

typical antipsychotics - block all 4 pathways
atypical antipsycotics - selectively block dopamine in mesolimbic pathway
Gi agents - metoclopramide
SSRI
valproic acid
old antihypertensives

Question 14

4 types of extrapyramidal symptoms

Answer 14

dystonia
akathisia
pseudoparkinsonism
tardive dyskinesia

Question 15

risk factors for drug induced parkinsonism

Answer 15

old
femal
high dose of offending drug
history of movement disorder

Question 16

signs its drug induce parkinsonism

Answer 16

symmetric presentation***
onset within a few weeks of starting drug
may take 2-6months to resolve after

Question 17

what is drug induced neuroleptic malignant syndrome

Answer 17

life threatening
due to sudden decrease in dopaminergic transmission
dopamine blocker&raquo_space;»decrease in dopamine transmission or sudden withdrawal from dopamine enhancer

Question 18

FARM symptoms of neuroleptic malignant syndrome

Answer 18

fever
autonomic instability - sweat, HR, BP
rigidity
mental status changes

Question 19

when do symptoms appear in parkinsons

Answer 19

once there is loss of 60-80% of pigmented neurons in the substantia nigra

Question 20

5 ways to treat parkinsons

Answer 20

dopamine precursor
dopamine agonist
NMDA receptor antagonist
COMT or MOAB inhibitor 
block acetylcholine

Question 21

goals of therapy

Answer 21

preserve ability to perform activities of daily living
min AE and treatment complications
improve non motor features

Question 22

what warrants therapu

Answer 22

when diability interferes with social emotional or work life

Question 23

why dont we treat early mild symptoms

Answer 23

ldopa is the best drug but loses effect over time so want to save it

Question 24

anticholinergic MOA

Answer 24

block acetylcholine, relative increase in dopamine

Question 25

amantadine MOA

Answer 25

NMDA antagonist | increases dopamine release

Question 26

MAO-B inhibtor MOA

Answer 26

reduce dopamine breakdown in the cns

Question 27

COMT inhibitor MOA

Answer 27

reduce levodopa breakdown in GI | prolongs half life and increase bioavailability

Question 28

dopamine agonist MOA

Answer 28

directly stimulates dopamine receptors

Question 29

levodopa MOA

Answer 29

converted to dopamine by dopa decarboxylase

Question 30

why cant dopamine just be directly gicen

Answer 30

cant cross the BBB

Question 31

when to use anticholinergics (benztropine)

Answer 31

generally people <60 due to the AE and modest efficacy

Question 32

anticholinergic AE

Answer 32

``` constipation dry mouth eye infections urinary retention blurred vision cognitive impairment headache increased HR overheating ```

Question 33

do you have to taper benztropine

Answer 33

yes over 1 week

Question 34

indication for amantadine

Answer 34

modest effect used early for tremor used alter to reduce ldopa dyskinesia better tolerated in yount patients due to stimulatory effects (normally used for MS fatigue)

Question 35

AE of amantadine

Answer 35

``` confusion, insomnia, nervous anticholinergic GI hypotension livedo reticularis *take in AM ```

Question 36

what is livedo reticularis

Answer 36

reversible diffuse purple red skin in the extremeties not an issue just cosmetic

Question 37

role of MAOBi

Answer 37

early for monotherapy | add on to levodopa to extend on time

Question 38

is tyramine intake a concern wtih selegiline and rasagiline

Answer 38

no

Question 39

AE of selegiline

Answer 39

``` insomnia hallucination confusion orthostatic hypotension take in AM *bc converted to methamphetamine ```

Question 40

AE of rasagiline

Answer 40

GI - take with food

Question 41

which drugs prevent dopamine degradation in the peripheray

Answer 41

comt inhibitors | DDC inhibitors

Question 42

why do comt inhibitors have no effect wihtout levodopa

Answer 42

only role is to prevent dopamine from being broken dow

Question 43

comt inhibitor role

Answer 43

mild improvement prevode 1-2 hr on time longer for levodopa later used as an add on

Question 44

entacapone is a

Answer 44

COMT inhibitor | not covered *

Question 45

AE of COMT inhibitors

Answer 45

``` NV brown orange urine/sweat sweating diarrhea dyskinesia hypotension ```

Question 46

ergot derived dopamine agonist and why its not used

Answer 46

bromocriptine | cardiac valve disease

Question 47

examples of non ergot agonists

Answer 47

pramipexole ropinirole rotigotine

Question 48

rold of dopamine agonists

Answer 48

alone in mild | adjunct to levodopa in patients with motor fluctuations

Question 49

adv and dis of dopamine agonist

Answer 49

less motor complications than levodopa but more AE

Question 50

rotigotine form

Answer 50

patch | not covered*

Question 51

dopamine agonist AE

Answer 51

``` nausea cognitive impairment lower extremity edema impulsivity sleep attacks - caution driving increase levodopa induced dyskinesias ```

Question 52

dose initiation and taper with dopamine agonist

Answer 52

initiate low dose and increase over 4-6 weeks to prevent AE | abrupt withdrawal causes NMS

Question 53

benefits of levodopa

Answer 53

improves disability prolongs ability to work reduced mortality rate

Question 54

primary concern with dopamine

Answer 54

dyskinesias

Question 55

dopamine decarboixylase inhibitors MOA

Answer 55

allows ldopa to cross BBB prevents conversion in periphery also minimizes peripheral AE

Question 56

examples of dopamine decarboxylase inhibitors

Answer 56

carbidopa | benserazide