Parkinsons disease and Parkinsonism Flashcards
What is the triad of symptoms in Parkinson’s disease?
Bradykinesia
Resting tremor
Rigidity
How does Parkinson’s disease affect posture?
Festinant gait
Flexed trunk
Freezing
Akathesia
Falls
What is akathesia?
Feeling of restlessness
When should a diagnosis of Lewy Body dementia be considered?
If visual hallucinations and dementia are present before or within a year on parkinsonism onset
What mental changes might occur with Parkinson’s?
Depression
Anxiety
Apathy
How is speech affected in Parkinson’s?
Speech becomes monotonic, quiet and dysarthric
What sensory changes might occur in Parkinson’s?
Anosmia - often an early sign
What GI symptoms might Parkinson’s present with?
Constipation
What motor signs are seen on examination in Parkinsons?
Asymmetric resting tremor with bradykinesia
Rigidy
‘Cog wheel’ rigidity in the wrist
Diminished guesturing
Micrographia
Where might the tremor occur in Parkinsons and what can worsen it?
Tongue, jaw, lower lip, hand, or in the leg/foot
Worsens when distracted with mental tasks
What sensory signs are seen on examination in Parkinson’s?
Sensory examination is usually unremarkable
What signs are seen on examination of coordination in Parkinsons?
Finger tap: repeated finger taps will diminish in amplitude and speed
If ataxia was noted when in an examination otherwise consistent with Parkinson’s disease, what diagnosis might be suspected?
Multiple system atrophy
Why isn’t hyperreflexia a sign of Parkinson’s when hypertonia (rigidity) is?
The basal ganglia does not influence motor control directly through the LMN, instead going through the thalamus to the motor cortex
Thus damage to the basal ganglia does not affect the stretch reflex or SLR
The rigidity in Parkinsons is caused by abnormal activation of the LLR
What gait abnormalities might be seen in Parkinsons?
Shuffling gait
Difficulty turning
Difficulty standing from chair
Freezing of gait
Difficulty taking the first step
Reduced arm swing
What might be the result of performing a pull test on Parkinson’s patients?
Postural instability will be revealed
What are the first line treatments for Parkinsons disease?
Dopamine agonists e.g. ropinerol
Exogenous dopamine e.g. Levodopa
MAO-B inhibitors
What drug should be prescribed with Levodopa and why?
A DOPA-decarboxylase inhibitor e.g. carbidopa
Levodopa is broken down in the peripheral nervous system causing lots of unwanted side effects, carbidopa stops this happening
Also allows for a smaller dose of Levodopa to be used
What is the mechanism of action of Levodopa?
This is a pro-drug which is broken down into Dopamine once in the central nervous system by DOPA decarboxylase
Which first line pharmaceutical treatment of Parkinsons is shown to have the best symtpom control?
Levodopa
What are the side effects of levodopa?
Nausea & vomiting
Agitation
Postural hypotension
Dizziness
Vivid dreams
Extreme emotional states
Why might dopamine agonists be preferrable to Levodopa?
Less likely to cause motor dysfunction/side effects
What are the side effects of ropinerol?
Sleep attacks
Risk taking behaviour
Drowsiness
Why are anticholinergics/antimuscarinics used in the treatment of Parkinsons?
Help motor symptoms, used when tremor predominates
Give an example of an antimuscarinic drug used in the treatment of Parkinson’s.
Orphenadrine
What are the contraindications to using anticholinergics/antimuscarinics to treat Parkinson’s?
Urinary retention
Angle closure glaucoma
GI obstruction
Prostatism
How are MAO-B inhibitors usually prescribed in the treatment of Parkinsons?
Can be prescribed as monotherapy in very early stages of disease
Otherwise usually prescribed alongside Levodopa
What are some of the other causes of Parkinsonism?
Vascular Parkinson’s
Parkinson plus syndromes: multiple system atrophy, progressive supranuclear palsy
Drug induced: anti psychotics (haloperidol, typical antipsychotics), antiemetics (metocloprimide), SSRI (fluoxetine)
Trauma
Toxin induced – Carbon monoxide, Cu
What signs on cranial nerve examination might be seen in Parkinson’s disease?
Check for hyposmia
Masked face is typical in PD
PD patients may have a soft voice and /or mumbled or fast speech
What would a finding of impaired vertical eye movements on an examination otherwise consistent with Parkinson’s make you suspicious of?
Progressive supranuclear palsy
What is multiple system atrophy?
Degeneration of nerve cells in specific areas of the brain causeing problems with movement, balance, and autonomic functions of the body, such as bladder control or blood-pressure regulation
What is progressive supranuclear palsy?
A progressive degenerative disease involving death of certain parts of the brain, causing falls, lunging forwards, difficulty with eye movements particularly vertically, loss of balance and dementia
