Progressive disease with no cure - shift from unilateral to bilateral involvement - increasing rigidity and postural flexion - increasingly limited mobility and increasing need for assistance - eventually w/c and/or bed-bound - cause of death usually pneumonia

PD: presentation, diagnosis, exam Flashcards by Meredith Crosier

Parkinson’s Disease

neurodegenerative disorder of subcortical gray matter in the basal ganglia
dopamine loss causes loss of inhibitory control of indirect loop and excitatory control over direct loop results in decreased movement

highest incidence among caucasians, males, and in early to mid 60s

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PD cardinal signs (TRAP)

Tremor (resting): diminishes w/ effort, increase w/ stress/fatigue
Rigidity: not velocity dependent, common in trunk, extremities and neck
Akinesia/bradykinesia: correlates best with severity of loss of dopamine
Postural instability: not common early in diagnosis

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Movement symptoms of PD

resting tremor
rigidity
bradykinesia
postural instability (later on)
micrographia (handwriting getting smaller over time)
festinating gait
freezing
soft speech
masked face
Sialorrhea (drooling) and dysphagia (motor function)

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non-movement symptoms of PD

anosmia
anxiety
apathy
bone health
breathing difficulty
cognitive changes
constipation and nausea
dysautonomia
fatigue
hallucinations
pain & sensory disturbances
sleep disorders

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T/F there is NO diagnostic test for PD

True

based on clinical exam
gold standard: neurological exam at autopsy
no biological marker that confirms diagnosis

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Supportive criteria for diagnosing PD

Clear & dramatic response to dopamine therapy
Levodopa-induced dyskinesia (not unique to PD)
Resting tremor of a limb
Diagnostic testing: loss of olfaction & abnormal cardiac MIBG scintigraphy

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9 absolute exclusions for diagnosing PD

unequivocal cerebellar abnormalities
downward vertical supranuclear gaze palsy
Frontotemporal dementia (w/in first 5 yrs)
parkinsonism restricted to lower limbs longer than 3 yrs
treatment with dopamine receptor blocker (drug induced PD)
absence of response to levodopa
unequivocal cortical sensory loss
normal functional neuroimaging of dopaminergic system
documentation of alternative condition know to produce parkinsonism & plausibly connected symptoms

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PD prognosis

Progressive disease with no cure

shift from unilateral to bilateral involvement
increasing rigidity and postural flexion
increasingly limited mobility and increasing need for assistance
eventually w/c and/or bed-bound
cause of death usually pneumonia

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PD: Stage zero

no signs of disease

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PD: stage 1

unilateral symptoms- tremor, stiffness, slowed movement

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PD: stage 1.5

unilateral symptoms plus ataxial involvement- postural problems

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PD: stage 2

mild bilateral involvement & minor sxs: swallow, talk, and decreased facial expression

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PD: stage 2.5

bilateral involvement, recovers on pull test

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PD: stage 3

bilateral involvement worsened. Postural instability noticed. Person is still independent

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PD: stage 4

Severe disability, able to walk or stand unassisted, but will need help with ADL

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PD: stage 5

person confined to w/c or bed; needs total assistance

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common early presentation of PD

tremor
micrographia
slowness with ADLs
voice changes (soft speech)
difficulty maneuvering in bed
lack of arm swing with gait
dragging the foot with walking

common presentation of PD after 5 years

motor fluctuations: wearing off, on-off phenomena, narrowing therapeutic window
loss of postural control; retropulsion
gait freezing and festination
cognitive changes
medication side effects: dyskinesia, dystonia

Primary objective of medical management of PD

maximize control over the “target” signs and symptoms

patient’s therapeutic response to any individual drug may change over time and requires regular visits and frequent communication between the medical team, the patient, and caregiver to maintain the best management of the disease with the fewest side effects possible

Advantage and mechanism of Carbidopa/Levodopa

Dopamine agonists

COMT inhibitors

MAO inhibitors

Anticholinergic agents

most effective; prolongs capacity to perform ADLs
works by copying actions of dopamine in the brain
inhibits enzyme responsible for metabolism of levodopa
slow metabolism of dopamine
used for treatment of tremor in younger patients

History questions during exam

PMH/co-morbidities
symptom onset
medications: dosing schedule, time of last dose, on/off periods
falls
home set-up and current daily activities
equipment
social support
primary complaint and current symptoms
current exercise regimen

MSK exam

ROM
- rigidity
-posture assessment
-limited cervical and trunk rotation
-hip flexor tightness (thomas test)
Strength
-generally should be WNL
-5x sit to stand: >16 secs correlated with fall risk

Coordination observations

movements bradykinetic, small, fatigue with repetition
no dysmetria
dyskinesia

Sensory exam

Pain:
-MSK
-central neuropathic
Oculomotor and visual:
-visuoperceptual deficits
-abnormalities atypical in early stages of idiopathic PD
-impaired/bradykinetic saccades in late stages
Olfactory disturbances
-odor detection, discrimination, identification
Proprioception:
-decreased sensory integration: joint position sense, postural orientation
-decreased kinesthetic awareness: larger limb displacement required in order to detect movement

cognitive exam

Dementia affects 40-80% of patients -planning -decision-making -goal-directed behavior Strong correlation between attention and the "pace" domain of gait. -gait velocity, step length, and step time -associations with gait variability and executive dysfunction Outcome measure: MoCA (<26/30 = mild, <21/30= PD dementia)

Outcome measures for body structure and function

MoCA MDS-UPDRS Pull test (aka retropulsion test)

Retropulsive pull test

EDGE rating- 1, not recommended due to weak psychometrics instruct patient to take a comfortable stance, examiner stands behind, instruct pt to do whatever it takes to not fall, and examiner provides a sudden, brief backward pull to the shoulders to cause pt to have to regain balance Scoring 0-4 0= recovers independently, ankle reaction or takes 1-2 steps 1= 3 or more steps backward but recovers independently 2= retropulsion, needs to be assisted to prevent fall 3= very unstable, tends to lose balance simultaneously 4= unable to stand without assistance

push-release test

higher sensitivity for both on/off states and specificity for on states vs. pull test Scoring: 0= recovers independently with 1 step of normal length and width 1= 2-3 small steps backward, but recovers independently 2= 4+ steps backward, but recovers independently 3= steps but needs to be assisted to prevent a fall 4= falls without attempting a step or unable to stand without assistance

functional assessment: 6 MWT

measures walking distance, submaximal aerobic capacity/endurance

functional assessment: 10 meter WT

gait velocity MDC comfortable place = 0.18 m/s MDC fast pace = 0.25 m/s age-related normative data

functional assessment: mini BESTest

balance and mobility - APAs - RPAs - Sensory orientation - dynamic gait

functional assessment: MDS-UPDRS part 2

motor experiences of daily living covers speech, saliva mgmt, eating, chewing/swallowing, dressing, hygiene, handwriting, hobbies, bed mobility, walking/balance, freezing

functional assessment: FGA

modified DGI: - removed walk around obstacle - added: gait w narrow BOS, backward walking, walking EC - 18/30 = fall risk - MDC = 4 pts

functional assessment: 5x sit to stand

cut off score of 16 sec = fall risk

functional assessment: 9 hole peg test

finger dexterity MDC = 2.6 seconds for dominant hand; 1.3 sec for non-dominant hand normative data by H&Y stage

functional assessment: participation; PDQ-39 or PDQ-8

``` dimensions: mobility ALDs emotional well-being stigma social support cognition communication bodily discomfort ```

functional assessment: freezing of gait questionairre

score 0-24, higher = more severe complete during 'on' phase item 3: good single question for screening

Parkinson's fatigue scale

16-item patient-rated scale measuring patient's perception of fatigue and its impact on daily activities

fear of falling: ABC-scale

cut-off score 69% predictive of recurrent falls | MDC 11.12

Dual task assessment

loss of automaticity of movements secondary to deficits in basal ganglia = increased difficulty with dual tasking

4 square step test

> 9.68 seconds = increased risk for falls

Atypical exam findings for idiopathic PD

``` early symptoms of: -urinary incontinence -dementia -postural instability -orthostatic hypotension visual changes: -difficulty looking down or complaints of walking down stairs types of parkinsonisms: -progressive supranuclear palsy -multiple system atrophy -corticobasal ganglionic degeneration -lewy body dementia ```