Parkinsons disease and Parkinsonism

Question 1

What is the triad of symptoms in Parkinson’s disease?

Answer 1

Bradykinesia

Resting tremor

Rigidity

Question 2

How does Parkinson’s disease affect posture?

Answer 2

Festinant gait

Flexed trunk

Freezing

Akathesia

Falls

Question 3

What is akathesia?

Answer 3

Feeling of restlessness

Question 4

When should a diagnosis of Lewy Body dementia be considered?

Answer 4

If visual hallucinations and dementia are present before or within a year on parkinsonism onset

Question 5

What mental changes might occur with Parkinson’s?

Answer 5

Depression

Anxiety

Apathy

Question 6

How is speech affected in Parkinson’s?

Answer 6

Speech becomes monotonic, quiet and dysarthric

Question 7

What sensory changes might occur in Parkinson’s?

Answer 7

Anosmia - often an early sign

Question 8

What GI symptoms might Parkinson’s present with?

Answer 8

Constipation

Question 9

What motor signs are seen on examination in Parkinsons?

Answer 9

Asymmetric resting tremor with bradykinesia

Rigidy

‘Cog wheel’ rigidity in the wrist

Diminished guesturing

Micrographia

Question 10

Where might the tremor occur in Parkinsons and what can worsen it?

Answer 10

Tongue, jaw, lower lip, hand, or in the leg/foot

Worsens when distracted with mental tasks

Question 11

What sensory signs are seen on examination in Parkinson’s?

Answer 11

Sensory examination is usually unremarkable

Question 12

What signs are seen on examination of coordination in Parkinsons?

Answer 12

Finger tap: repeated finger taps will diminish in amplitude and speed

Question 13

If ataxia was noted when in an examination otherwise consistent with Parkinson’s disease, what diagnosis might be suspected?

Answer 13

Multiple system atrophy

Question 14

Why isn’t hyperreflexia a sign of Parkinson’s when hypertonia (rigidity) is?

Answer 14

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

Question 15

What gait abnormalities might be seen in Parkinsons?

Answer 15

Shuffling gait

Difficulty turning

Difficulty standing from chair

Freezing of gait

Difficulty taking the first step

Reduced arm swing

Question 16

What might be the result of performing a pull test on Parkinson’s patients?

Answer 16

Postural instability will be revealed

Question 17

What are the first line treatments for Parkinsons disease?

Answer 17

Dopamine agonists e.g. ropinerol

Exogenous dopamine e.g. Levodopa

MAO-B inhibitors

Question 18

What drug should be prescribed with Levodopa and why?

Answer 18

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

Question 19

What is the mechanism of action of Levodopa?

Answer 19

This is a pro-drug which is broken down into Dopamine once in the central nervous system by DOPA decarboxylase

Question 20

Which first line pharmaceutical treatment of Parkinsons is shown to have the best symtpom control?

Answer 20

Levodopa

Question 21

What are the side effects of levodopa?

Answer 21

Nausea & vomiting

Agitation

Postural hypotension

Dizziness

Vivid dreams

Extreme emotional states

Question 22

Why might dopamine agonists be preferrable to Levodopa?

Answer 22

Less likely to cause motor dysfunction/side effects

Question 23

What are the side effects of ropinerol?

Answer 23

Sleep attacks

Risk taking behaviour

Drowsiness

Question 24

Why are anticholinergics/antimuscarinics used in the treatment of Parkinsons?

Answer 24

Help motor symptoms, used when tremor predominates

Question 25

Give an example of an antimuscarinic drug used in the treatment of Parkinson’s.

Answer 25

Orphenadrine

Question 26

What are the contraindications to using anticholinergics/antimuscarinics to treat Parkinson’s?

Answer 26

Urinary retention

Angle closure glaucoma

GI obstruction

Prostatism

Question 27

How are MAO-B inhibitors usually prescribed in the treatment of Parkinsons?

Answer 27

Can be prescribed as monotherapy in very early stages of disease

Otherwise usually prescribed alongside Levodopa

Question 28

What are some of the other causes of Parkinsonism?

Answer 28

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

Question 29

What signs on cranial nerve examination might be seen in Parkinson’s disease?

Answer 29

Check for hyposmia

Masked face is typical in PD

PD patients may have a soft voice and /or mumbled or fast speech

Question 30

What would a finding of impaired vertical eye movements on an examination otherwise consistent with Parkinson’s make you suspicious of?

Answer 30

Progressive supranuclear palsy

Question 31

What is multiple system atrophy?

Answer 31

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

Question 32

What is progressive supranuclear palsy?

Answer 32

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