Parkinsons

Question 1

PD PPx?

Answer 1

1. Progressive loss of dopaminergic cells in the substantia nigra of the basal ganglia
2. Accumulation of lewy bodys in remaining neurons
3. Basal ganglia normally exert an inhibitory effect on motor systems to prevent uncontrolled movement - dopamine is required to overcome this inhibitory effect
4. Therefore in PD - lack of dopamine means inhibition persists –> hypokinesia

Question 2

Define PD?

Answer 2

A chronic progressive neurodegenerative condition resulting from loss of dopamine containing cells in the substantia nigra

Question 3

Define parkinsonism?

Answer 3

An umbrella term for the clinical syndrome involving bradykinesia + at least one of tremor, rigidity and or postural instability

Question 4

Define Parkinsons Plus? Causes?

Answer 4

Parkinsonism where the pathology is not PD.

Causes: Drug induced parkinsonism
cerebrovascular disease
Lewy body dementia
multiple system atrophy
pregressive supranuclear palsy

Question 5

Parkinsons Plus vs PD?

Answer 5

Parkinsons plus: 
Patients often have symmetrical onset
, lack of any resting tremor,
 don't respond well to PD medication, 
condition is more rapidly progressive

Question 6

Vascular parkinsons features? When to suspect? DDx? response to Tx?

Answer 6

Suspect in people with PMH or risk factors for vascular disease

Prominent symptoms of urinary incontinence cogntive impairment, gait disturbance
Arm swing may be less inhibited

Consider normal pressure hydrocephalus

Limited/no response to PD medication

Question 7

Features of Multiple system atrophy? Response to Tx?

Answer 7

Also develop autonomic dysfunction including incontinence, dysphagia and dizziness
Ataxia - falls

Short-lived / no response to dopamine Tx

Question 8

Features of Progressive supranuclear palsy?

Answer 8

Affects eye movement, balance, mobility, speech and swallowing
Behavioural and cognitive impairment

Question 9

Drug induced parkinsonism - when to suspect> Tx?

Answer 9

Suspect in people taking neuroleptic drugs (eg. typical anti-psychotics) also prochlorperazine or metaclopramide

Tx: stop the suspected medication
Use atypical antipsychotics

Procyclidine can relieve some drug induced parkinsonsism

Question 10

Most common types of parkinsonism?

Answer 10

vascualr and drug-induced

Question 11

DDx of tremor?

Answer 11

PD

Essential tremor - bilateral and symmetrical, worsens with stress, caffeine, sleep deprivation, typically involves head, neck or voice + limbs, often improves with alcohol and beta blockers

Intention tremor - cerebellar

Wilsons disease

Huntington’s disease

Question 12

Non-motor symptoms of PD?

Answer 12

Depression anxiety fatigue

reduced sense of smell
cognitive impairment
sleep disturbance
constipation

Question 13

When to perform a CT/MRI brain scan in PD?

Answer 13

In patients who fail to respond to therapeutic doses of L-dopa administered for 12wks

Question 14

When to do a SPECT scan?

Answer 14

Considered if essential tremor cannot be distinguished from parkinsonism

Question 15

PD diagnosis? Ix?

Answer 15

Clinical diagnosis

Ix: CT/MRI brain scan
SPECT scan
PET scan
genetic testing (eg. for huntingtons)
Olfactorary testing

Question 16

PD Mx?

Answer 16

Refer urgently to specialist
Support of PD nurse to be offered
Other MDT members: GP, PT, OT, CPN, SALT

exercise shown to be beneficial
Inform DVLA
identify and support carers
recruit voluntary sector both local and national

Question 17

Medication for Motor symptoms of PD? Advantages/disadv?

Answer 17

1st line: Levodopa or dopamine agonist or MAO-B inhibitors

Levodopa - better for motor symptoms with fewer SEs - however higher long-term motor complications
dopamine agonist (eg. Pramipexole, ropinirole) 
MAO-B inihitor (less good for motor symptoms, however few motor complications)

Question 18

Other Tx options except Pharma?

Answer 18

Bilateral subthalamic nucleus stimulation - if refractory to medical treatment