Parkinsons + Parkinsonism Flashcards

1
Q

What are the 3 main groups of movement disorder?

A
  • Pyramidal
  • Hyperkinetic
  • Hypokinetic
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2
Q

What 2 movement problems are pyramidal?

A
  • Pyramidal weakness

* Spasticity

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3
Q

Name the 5 main hyperkinetic movement disorders.

A
  • Distonia
  • Tics
  • Myoclonus
  • Chorea
  • Tremor
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4
Q

Name the 3 main hypokinetic movement disorders.

A
  • Rigidity
  • Bradykinesia
  • Parkinsons
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5
Q

Extrapyramidal movement disorders can be either ___________ or __________

A
  • Hyperkinetic

* Hypokinetic

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6
Q

What area of the brain do extrapyramidal movement disorders involve?

A

Basal ganglia

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7
Q

What are of the brain does pyramidal movement disorders involve?

A

Corticospinal or pyramidal tract

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8
Q

What 3 things does a ‘parkinsonian’ syndrome refer to?

A
  • Rigidity
  • Akinesia/bradykinesia
  • Resting tremor
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9
Q

What is dystonia?

A

Prolonged muscle spasms and abnormal postures.

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10
Q

What is chorea-ballismus?

A

Fragments of movements flow irregularly from one body segment to another, causing a dance-like appearance.

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11
Q

When can the term ballismus be used?

A

Amplitude of movements is large

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12
Q

What is the basal ganglia?

A

A collection of grey matter with important connections to many other parts of brain

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13
Q

What is the basal ganglia important for?

A

Movement co-ordination

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14
Q

What motor features does PD present with?

A

Tremor, muscular rigidity, akinesia, rest tremor, gait and postural impairment.

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15
Q

Motor features in PD are heterogenous

A

T

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16
Q

There are 2 main groups of motor symptoms in PD. Name these.

A

Tremor dominant PD – with relative absence of other motor sx

Non-tremor dominant PD – such as akinetic-rigid syndrome and postural instability gait disorder.
Also, mixed/intermediate phenotype

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17
Q

There course and prognosis of the 2 types of PD motor symptoms are different

A

T

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18
Q

What is the progression and course like of the ‘tremor dominant PD’?

A

Slower rate of progression and less functional disability.

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19
Q

What do the non-motor features of PD include?

A
  • Olfactory dysfunction.
  • Cognitive impairment.
  • Psychiatric sx.
  • Sleep disorders.
  • Autonomic dysfunction.
  • Pain.
  • Fatigue.
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20
Q

Non-motor sx are common in early PD (as well as before the onset of motor features), and are associated with reduced health-related quality of life.

A

T

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21
Q

When do the non-motor symptoms of PD usually present?

A

Before the onset of the motor symptoms

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22
Q

List the main motor features of PD.

A
  • Tremor
  • Bradykinesia
  • Rigidity
  • Postural instability
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23
Q

List some non motor features of PD that patients might present with.

A

Sleep disorders, hallucinations, GI dysfunction, depression, cognitive impairment/dementia, anosmia.

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24
Q

When can a resting tremor be seen?

A

When the pt is sitting with their hands on their lap

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25
Q

Cog-wheel rigidity is characteristic of PD

A

T

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26
Q

Describe pin rolling.

A

This is another characteristic tremor seen in PD - basically imagine someone rolling a pin between their thumb and index finger (pronation and supination)

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27
Q

When is PD usually diagnosed?

A

When motor symptoms onset

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28
Q

Non-motor symptoms can be present for more than a ______ before onset of motor symptoms

A

Decade

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29
Q

The pathogenic process that causes PD is presumed to be underway during what? What does this involve?

A
  • The premotor phase.

Involves the regions of the peripheral and central nervous system, in addition to the dopaminergic neurones in the SNpc (Substantia Nigra Pars Compacta)

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30
Q

What is the progression of PD characterised by?

A

Worsening motor features, which initially respond well to symptomatic therapies (‘honeymoon phase’).

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31
Q

What are the advance stages of PD characterised by?

A

The emergence of complications related to long term symptomatic treatment, including motor and non-motor fluctuations, dyskinesia and psychosis.

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32
Q

In late-stage PD treatment, resistant motor and non-motor features are prominent. What do these include?

A

Axial motor symptoms …

  • Postural instability
  • Freezing of gait
  • Falls
  • Dysphagia
  • Speech dysfunction
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33
Q

Dementia occurs in __ % of PD patents

A

83%

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34
Q

What kind of sleep disorder to people with PD get?

A

REM sleep behaviour disorder

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35
Q

What is a REM sleep behaviour disorder?

A

Parasomnia - abnormal and disruptive behaviour during sleep

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36
Q

What kind of odd sleep behaviours is seen in someone with PD?

A
  • Talking
  • Laughing
  • Shouting
  • Gesturing
  • Grabbing
  • Punching
  • Kicking
  • Sitting up in bed
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37
Q

Dreams are ________ during REM sleep disorders in PD patients

A

Enhanced

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38
Q

The disordered sleep behaviours that people with PD have is during REM sleep

A

T

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39
Q

How is REM sleep behaviour disorder in PD patients treated?

A

Clonazepam / Melatonin at bedtime

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40
Q

How is REM sleep behaviour disorder in PD patients diagnosed?

A

Overnight polysomnography

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41
Q

What is the ICD criteria for the diagnosis of REM sleep behaviour disorder in PD patients?

A

Overnight polysomnography to document ….

  • REM without atonia (such as sustained or intermittent muscle activity measured by electromyogram)
  • Rule out mimics (ie. obstructive sleep apnoea, non-rapid eye movement parasomnia, seizures).
42
Q

PD pts with RBD tend to have a disease subtype characterized by more severe autonomic dysfunction, gait impairment and dementia

A

T

43
Q

Outline the criteria for the diagnosis of PD.

A

Bradykinesia + 1 or more of the following:

  • Muscular rigidity
  • 4-6 Hz rest tremor
  • Postural instability
44
Q

What is the pathology of PD?

A

Loss of dopaminergic neurones within the SNpc and Lewy body pathology

45
Q

List areas of neuronal loss in PD (except for the substantial nigra).

A
  • Locus ceruleus
  • Nucleus basalis Meynert
  • Pedunculopontine and raphe nuclei
  • Dorsal motor nucleus of vagus
  • Amygdala
  • Hypothalamus
46
Q

Outline the lewy body pathology of PD.

A

*Mis-folded alpha-synuclei – which is insoluble and aggregated – forms intracellular inclusions (LEWY BODIES) and processes (LEWY NEURITES) of neurones.

47
Q

Lewy body pathology is not just seen in the brain in PD, where else is it seen?

A
  • Spinal cord

* PNS

48
Q

What would a section through the brainstem of someone with PD show?

A

Loss of the normallys dark black pigment in the substantia nigra and locus coeruleus

49
Q

What does pigment loss of the substantial nigra in PD really show?

A

Dopaminergic cell loss

50
Q

Name a neurohistological hallmark of PD

A

Lewy bodies

51
Q

What is the greatest risk factor for PD?

A

AGE !!!

52
Q

What is the male : female ratio in PD?

A

3:2

53
Q

What does an early onset of PD (<40 years) usually indicate?

A

A genetic cause

54
Q

In what countries is prevalence of PD higher/lower?

A

Prevalence is higher in Europe, North America and South America, compared to African, Asian and Arabic countries

55
Q

PD is the 2nd most common neurodegenerative disorder after Alzheimer’s.

A

T

56
Q

What is the most common neurodegenerative disorder?

A

Alzheimers

57
Q

What was the first gene to be associated with inherited PD?

A

SNCA, which encodes the protein α-synuclein

58
Q

What is the most common gene to cause of dominant PD?

A

LRRK2.

59
Q

What is the most common genetic cause of recessive PD?

A

Parkin.

60
Q

What is the greatest genetic risk factor for PD?

A

Mutations in GBA.

61
Q

What does GBA encode?

A

β-­‐ glucocerebrosidase

The lysosomal enzyme deficient in Gaucher’s disease

62
Q

List some environmental risk factors for developing PD.

A
  • Beta blockers
  • Pesticides
  • Prior head injury
  • Rural living
  • Agricultural occupation
63
Q

List some factors that decrease your risk of having PD.

A
  • Smoking
  • Coffee
  • NSAID
  • Alcohol
  • Ca channel blocker
64
Q

There are no neuroprotective or disease modifying drugs for PD

A

T :(

65
Q

What do symptomatic treatments of PD do?

A

Enhance intracerebral dopamine concentrations
OR
Stimulate dopamine receptors

66
Q

What is the treatment of PD?

A

Levodopa

67
Q

What drugs can be used in the tx of PD?

A
  • Levodopa
  • Dopamine agonists
  • Monoamine oxydase type B inhibitors
  • Amantadine (less common)
68
Q

When should treatment for PD be started?

A

When symptoms cause disability or discomfort, aiming to improve fn and quality of life.

69
Q

Early in the disease, what do bradykinesia and rigidity respond reliably to?

A

Dopaminergic treatment

70
Q

What tx is needed for more severe symptoms in PD?

A

Levodopa and dopamine agonists

71
Q

MAO B inhibitors are only mildly affective in PD.

A

T

72
Q

What is tremor inconsistently responsive to?

A

Dopamine replacement therapy, especially in lower doses.

73
Q

What drugs are used in the treatment of a tremor in PD?

A

Anticholinergic agents:

  • Trihexyphenidyl
  • Clozapine
74
Q

What side effects are dopamine agonists and levodopa associated with?

A
  • Nausea
  • Daytime somnolence
  • Oedema (more so in dopamine agonists)
75
Q

What kind of disorders can people on Dopamine agonists get?

A

Impulse control disorders

76
Q

Give examples of impulse control disorders.

A
  • Pathological gambling
  • Hypersexuality
  • Binge eating
  • Compulsive spending
77
Q

Who should you not give dopamine agonists to?

A
  • Patients with a history of addiction
  • OCD
  • Impulsive personality
  • Elderly, especially those with cognitive impairment
78
Q

Why should dopamine agonists not be given to elderly people, especially those with cognitive impairment?

A

Due to their association with hallucinations

79
Q

Why is Levodopa the best tx for PD?

A

Provides the greatest symptomatic benefit

80
Q

What is the major disadvantage of Levodopa?

A

Long-term use is associated with motor complications …

  • Dyskinesia
  • Motor fluctuations
81
Q

What are the motor fluctuations associated with long term use of Levodopa in PD?

A

Alterations between periods of good motor symptoms control (on time) and periods of reduced motor symptom control (off time).

82
Q

What are non-motor fluctuations associated with long term use of Levodopa in PD?

A

Alterations between periods of good non-motor symptom control and periods of reduced non-motor symptom control

83
Q

What is dyskinesia?

A

Involuntary choreiform or dystonic movements.

84
Q

When does dyskinesia in PD mostly occur?

A

When levodopa concentrations are at their maximum (peak dose).

85
Q

Less commonly in PD, when might dyskinesia develop?

A

At the beginning, or end of a levodopa dose (diphasic dyskinesia).

86
Q

Describe the drug induced psychosis seen in those with PD on Levodopa.

A

Hallucinations which include minor phenomena, such as the sense of presence or passage hallucinations.
Also well-formed visual – and less commonly non-visual (tactile, auditory, olfactory) – hallucinations. Other psychotic features include illusions and delusions, often with paranoia.

87
Q

People with PD that have been on Levodopa for a long term can develop a drug induced psychosis

A

T

88
Q

What causes the dyskinesia and motor fluctuations in someone on Levodopa?

A

The pulsatile stimulation of striatal dopamine receptors in later disease stages

89
Q

What is the management to reduce dopamine fluctuations?

A
  • A dopamine agonist.
  • Monoamine oxidase type B inhibitor (MOA B inhibitor).
  • Catechol- O – methyltransferase inhibitor (COMT inhibitor).
90
Q

List the dopamine agonist drug formulations.

A
  • Long-acting oral levodopa formulations are being developed.
  • Direct delivery of a stable levodopa-carbidopa gel (‘Duodopa’) into the duodenum via percutaneous endogastric gastrostomy tube, attached to a portable infusion pump.
  • Subcutaneous infusion of the potent dopamine agonist apomorphine.
  • Non-dopaminergic treatments such as amantadine and clozapine can be helpful.
91
Q

What is psychosis in PD most effectively managed with?

A

Clozapine

92
Q

If someone with PD can’t take Clozapine, what is the alternative?

A

Quetiapine – all other neuroleptics should be avoided though

93
Q

What risks are there with Clozapine?

A
  • Idiosyncratic adverse drug reactions.

* Agranulocytosis.

94
Q

Give an example of a cholinesterase inhibitor.

A

Rivastigmine

95
Q

In patients with PD and dementia, who have visual hallucinations and delusions, what can be prescribed?

A

Rivastigmine

96
Q

What is last stage dementia in PD treated with?

A

Rivastigmine

97
Q

What surgical treatments can be used for the treatment of motor sx/complications? What do these target?

A
  • Deep brain stimulation.

* Target either the subthalamic nucleus or globus pallidus internus.

98
Q

What is Primavanserin?

A

Selective serotonin 5-HT@A inverse agonist

99
Q

What can Primavanserin be used to reduce symptoms of in PD?

A

Positive psychotic symptoms, without worsening of motor function

100
Q

Depression associated with PD is treated with antidepressants

A

T