S2_L1: Parkinson's Disease Flashcards
Identification:
Proponent of Parkinson’s Disease
James Parkinson
Fill in the blanks:
PD results from (1)____ of dopamine-producing cells in the (2)_____.
- degeneration
- substantia nigra
Identification: Components of the TRAP mnemonic.
Tremors
Rigidity
Akinesia / Bradykinesia
Postural Instability
Matching Type: Clinical Manifestation with its characteristics / feature
- Develop stoop / forward-flexed posture
- Decreased speed & amplitude of complex voluntary movement
- Pill rolling at rest
- Cogwheeling
- Pinching & circling can elicit it
Choices:
A. Tremors
B. Limb Rigidity
C. Bradykinesia
D. Postural Instability
- D
- C
- A
- B
- C
TRUE OR FALSE: Camptocornia is when patients have their trunk & head bowed downward (extreme forward flexion of the spine) & correspondingly severe stooping occur.
True
Source: Merritt; Adams & Victor
Identification: Which stage of PD is “bilateral involvement but no postural abnormality”?
Stage II
Matching Type: Differential dx c hx
- Present for many years; + family history
- Parkinsonism w/ autonomic system dysfunction
- Involuntary movement, cognitive or behavioral problem
- Exposure to haloperidol or metoclopramide
- Gradual onset; tremor; gait disturbance; slowed movements
Choices:
A. Drug-Induced Parkinsonism
B. Multisystem Atrophy
C. Idiopathic Parkinson’s Disease
D. Huntington’s Disease
E. Essential Tremor
- E
- B
- D
- A
- C
Identification:
In this condition, orthostatic hypotension & skin changes are findings in the physical exam.
Multisystem Atrophy
Identification:
In this condition, tremor with arms raised & head & voice involved are findings in the physical exam.
Essential Tremor
Matching Type: Clinical Manifestation with its characteristics / feature
- slowness in initiation & execution of voluntary movements
- increase muscle tone & resistance to movement
- At rest, when person sits, arm shakes & stops when person attempts to grab something
- Righting reflex
Choices:
A. Tremors
B. Limb Rigidity
C. Bradykinesia
D. Postural Instability
- C
- B
- A
- D
Identification:
5 ways to elicit bradykinesia
- Micrographia
- Tapping fingers or feet
- Twiddling of hands
- Pinching & circling
- Tapping with the heel
Matching Type: Classification of Parkinsonism
- Wilson’s Disease
- Lewy Body Dementia
- Juvenile Parkinsonism
- Related to drugs
- Shy-Drager Syndrome / Autonomic Impairment
A. Primary / Idiopathic
B. Secondary / Acquired
C. Heredodegenerative
D. Multiple-System Degenerative Parkinsonism-Plus
- C
- D
- A
- B
- D
Matching Type: Classification of Parkinsonism
- Progressive Supranuclear Palsy / Steele-Richardson Olszewski
- Huntington’s Disease
- Multisystem Atrophy
- Related to infections, toxins
- Corticobasal Degeneration
A. Primary / Idiopathic
B. Secondary / Acquired
C. Heredodegenerative
D. Multiple-System Degenerative Parkinsonism-Plus
- D
- C
- D
- B
- D
Identification:
A critical modulator of striatal output that is markedly decreased in Parkinson’s disease.
Dopamine
Identification:
It is a chronic age-related progressive disorder of the Central Nervous System, the most common movement disorder, & 2nd most common neurodegenerative disease after Alzheimer’s Disease.
Parkinson’s Disease
Source: Merritt
TRUE OR FALSE: PD is more commonly seen in males than females.
True
Male to female: 3:2
Enumeration: what the
Oxidative Stress Theory states
Alterations in the substantia nigra of patients w/ PD is suggestive of oxidative damage.
Matching Type: Classification of Parkinsonism
- Lubag (X-linked dystonia-parkinsonism)
- Hemiatrophy-hemiparkinsonism-syndrome
- Sporadic olivopontocerebellar degeneration / Cerebellar Impairment
- Neurodegeneration with brain iron accumulation
- Striatonigral degeneration / Parkinsonism
A. Primary / Idiopathic
B. Secondary / Acquired
C. Heredodegenerative
D. Multiple-System Degenerative Parkinsonism-Plus
- C
- B
- D
- C
- D
Matching Type: PD Late Disabilities
- Cognitive impairment
- Dyskinesia
- Incontinence
- Motor fluctuation
- Speech disturbance
Choices:
A. Levodopa-related disability
B. Non-levodopa-related disability
- B
- A
- B
- A
- B
Matching Type: PD Late Disabilities
- Gait disturbance
- Reduced response
- Neuropsychiatric toxicity
- Dysphagia
- Falls
Choices:
A. Levodopa-related disability
B. Non-levodopa-related disability
- B
- A
- A
- B
- B
Matching Type: Secondary effects of PD
- hallucination, depression, & psychosis
- constipation & hypersalivation
- orthostatic hypotension & arrhythmia
- increased urinary frequency
Choices:
A. Gastrointestinal effects
B. Genitourinary effects
C. Central nervous system effects
D. Cardiovascular effects
- C
- A
- D
- B
Enumeration:
4 Surgical treatment options for PD
- Pallidotomy
- Thalamotomy
- Thalamic stimulation
- Transplantation of fetal cells
Identification:
Most often used to rule out an etiology of secondary Parkinson’s disease
Tests, imaging
Identification:
It is one of the new technologies used to visualize dopamine uptake in the substantia nigra & basal ganglia.
Positron Emission Tomography (PET) Scan
Identification:
It can be helpful for diagnosis of Parkinsonian syndromes & non-parkinsonisms, particularly essential tremor.
Single Photon Emission Computed Tomography (SPECT)
TRUE OR FALSE: In diagnosis of PD, there must be at least two “cardinal” features present, with at least one of them being resting tremor or bradykinesia.
True
Source: Merritt
Fill in the blanks:
In clinical criteria of PD, there is the presence of at least 2 of the 3 cardinal features of parkinsonism: (1), (2), and (3).
1-3: Tremor, rigidity, bradykinesia
Fill in the blanks:
In clinical criteria of PD, there is evidence of (1)___, & absence of clinical features of (2)___, & absence of etiology known to cause (3)___ features.
- disease progression
- alternative diagnosis
- similar
Fill in the blanks:
In clinical criteria of PD, there is the presence of at least two of the following:
* Marked response to (1),
* Asymmetry of (2),
* Asymmetry of (3)
- levodopa
- signs
- onset
Modified True or False: Oxidative Stress Theory
Choices: A if true, B if false
- Increased iron levels
- Increased glutathione levels
- Decreased aluminum levels
- Lack of compensatory rise in iso-ferritins
- Selective defect in complex I of mitochondrial respiratory chain
- A
- B
- B
- A
- A
In the oxidative stress theory, there is evidence of oxidative damage to: (1-4).
- Lipids
- DNA
- Proteins
- Tyrosine-containing molecules
Enumeration:
The 2 symptomatic with neuroprotection treatment
- Dopamine agonists
- Selegiline
TRUE OR FALSE: Globus pallidus internus pallidotomy entails the surgical resection of parts of the globus pallidus. This procedure improves contralateral dyskinesia.
True
Modified True or False: Management Therapies
Choices: A if true, B if false
- Urinary urgency: apomorphine
- Urinary retention: oxybutynin
- Daytime sleepiness: selegiline
- Nightmares: amitriptyline, clonazepam
- Hypersalivation: antihistamine, anticholinergic
- B
- B
- A
- A
- A
Modified True or False: Management Therapies
Choices: A if true, B if false
- Tenesmus: clonazepam, apomorphine
- Orthostatic hypotension: domperidone, desmopressin
- Panic attacks and depression: liquid levodopa, amitriptyline
- Pain: amitriptyline, fluvoxamine, SSRIs
- Constipation: fiber, polyethylene glycols, laxatives
- Sweating crises: 3-blockers, anticholinergic agents
- A
- A
- A
- A
- A
- A
TRUE OR FALSE
Management therapy for dysphagia is to reduce levodopa dosage & gastrostomy tube feeding is advised. Management therapy for dysphonia is speech therapy & liquid levodopa.
Both statements are false.
Dysphagia - liquid levodopa, gastrostomy tube
Dysphonia - reduce levodopa dosage, speech therapy
TRUE OR FALSE: Parkinsonism, also known as parkinsonian syndrome, is viewed as a striatal dopamine deficiency disorder.
True
Source: Merritt
TRUE OR FALSE: In parkinsonism, majority is from Parkinson’s disease, followed by parkinson plus syndromes & drug induced, extrapyramidal symptoms.
True
Fill in the blanks: The proposed etiologies of PD are (1)___, (2)___, and the influence of (3)___. The latter is known as the backbone of PD risk.
- environmental toxins or drugs
- genetic susceptibility
- aging
Source: Merritt
Fill in the blanks: In young onset PD, the onset is (1)___ years old, while in juvenile onset PD, it is (2)___ years old.
- < 40
- < 20
Identification: It is the major cause of young onset autosomal recessive PD & isolated juvenile PD.
Parkin mutation
Fill in the blanks: Mutations in (1)___ and (2)___ are seen in autosomal dominant PD. This leads to the accumulation of excessive (3)___ that can be harmful to the neurons.
- ɑ synuclein
- ubiquitin carboxyl hydrolase
- protein
Identification: The 4 components of non-pharmacologic management
Education, support, exercise, & nutrition
Matching Type:
- Can stimulate the subthalamic nucleus
- Implantation of embryonic dopaminergic cells into the denervated striatum to replace degenerated neuronal cells
- High-frequency stimulation that induces functional inhibition of target regions of the brain by implanting an electrode into a target site
- A subcutaneously placed pacemaker is present
Choices:
A. Deep brain stimulation
B. Globus pallidus internus pallidotomy
C. Fetal nigral transplantation
- A
- C
- A
- A
Matching Type:
- Bromocriptine
- Carbidopa-L-dopa
- Selegiline
- Entacapone
- Benztropine
Choices:
A. Dopamine agonist
B. MAO-inhibitor
C. COMT Inhibitor
D. Anticholinergic
E. Levodopa
- A
- E
- B
- C
- D
Matching Type:
- Rasagiline
- Tolcapone
- Pramipexole
- Amantadine
- Pergolide
Choices:
A. Dopamine agonist
B. MAO-inhibitor
C. COMT Inhibitor
D. Anticholinergic
E. Levodopa
- B
- C
- A
- A
- A
Matching Type:
- Increases the bioavailability of levodopa
- No benefit in reducing levodopa induced motor fluctuations
- Indirect dopamine agonist
- Block muscarinic cholinergic receptors
- Mainstay of therapy
Choices:
A. Amantadine
B. Selegiline
C. COMT Inhibitor
D. Anticholinergic
E. Levodopa
- C
- B
- A
- D
- E
Matching Type:
- Its downside is hepatocellular injury & possible neurotoxicity in PD
- Monoamine oxidase-B (MAO-B) inhibitor
- Long-term use leads to dyskinesias & motor response fluctuations (“on-off” phenomenon)
- Restores motor function -> less hyperkinesis
- Its adverse effects include: restlessness, confusion, depression, nausea, hypotension
Choices:
A. Amantadine
B. Selegiline
C. COMT Inhibitor
D. Anticholinergic
E. Levodopa
- C
- B
- E
- D
- A
TRUE OR FALSE: At present, L-dihydroxyphenylalanine (L-dopa) is the most effective agent for the treatment of PD.
True
Source: Adams & Victor
Matching Type:
- One of its effects is orthostasis
- Can be efficacious for tremor & dystonia
- Improves bradykinesia & tremor
- Useful adjunct in early stage of PD & in patients w/ mild response fluctuations
- Most effective treatment for tremor
Choices:
A. Amantadine
B. Selegiline
C. COMT Inhibitor
D. Anticholinergic
E. Levodopa
- E
- D
- A
- C
- A
Matching Type:
- Catechol-O-methyl-transferase
- Its peripheral side effects are dry mouth, blurred vision, urinary retention, constipation
- Discovered serendipitously because it is an antiviral med
- Safinamide
- May induce oxidative stress due to increased dopamine turnover & free radical formation
Choices:
A. Amantadine
B. Selegiline
C. COMT Inhibitor
D. Anticholinergic
E. Levodopa
- C
- D
- A
- B
- E
Matching Type:
- Opicapone
- Can be used as monotherapy or as adjunct therapy to levodopa
- Precursor of dopamine
- Neuroprotective effects: Reduces oxidative stress and free radical production
- Its central side effects: confusion, memory loss
Choices:
A. Amantadine
B. Selegiline
C. COMT Inhibitor
D. Anticholinergic
E. Levodopa
- C
- A
- E
- B
- D
Matching Type:
- Decreases dopamine reuptake
- Symptomatic effects are mild
- Decreases dopamine metabolism
- It is taken up by dopamine nerve terminals in the striatum
- Cholinergic neurons directly opposes the function of dopamine
Choices:
A. Amantadine
B. Selegiline
C. COMT Inhibitor
D. Anticholinergic
E. Levodopa
- A
- B
- B
- E
- D
Identification: Four classes of drugs in the treatment of PD
- Direct-acting dopamine agonists
- Indirect-acting dopamine agonists
- Precursor of dopamine
- Anticholinergics
Identification: In neuroprotective treatment, these 2 drug groups act as scavengers of free radicals
- MAO B inhibitors
- Dopamine agonists
Fill in the blanks: The loss of dopamine-producing neurons in the substantia nigra results in the imbalance between dopamine, a/an (1)____ neurotransmitter, & the (2)___ neurotransmitter acetylcholine.
- inhibitory
- excitatory
Identification: Parkinsonism is a combination of BTR. BTR stands for?
Bradykinesia
(Resting) Tremors
Rigidity
Identification: 3 drug therapies for treating associated symptoms of PD
- Beta-blockers
- Antihistamine
- Tricyclic antidepressants
Identification: Which stage of PD is “Bilateral involvement with postural instability; patient requires substantial assistance”?
Stage IV
Identification: Which stage of PD is “Mild to moderate bilateral disease, mild postural imbalance, but still able to function independently”?
Stage III
Identification: Which stage of PD is “Unilateral involvement, including the major features of tremor, rigidity, or bradykinesia; minimal functional impairment”?
Stage I
Fill in the blanks: Dopamine agonists serve as scavengers of free radicals and (1)___ dopamine turnover & there is (2)___ in oxidative stress.
- decrease
- increase
Fill in the blanks: Essential Tremor & Physiologic Tremors are (1)___ Hz and are (2)___ and/or (3)____. Resting Tremors are (4)___ Hz and disappear with (5)___ and (6)___.
- 8-12
- Kinetic
- Postural
- 4-6
- Sleep
- voluntary movement
Fill in the blanks: PD is a neurodegenerative disease associated with (1)___ of the substantia nigra and loss of dopaminergic input to the (2)___. Most symptoms do not appear until striata dopamine levels decline by at least (3)___.
- depigmentation
- basal ganglia
- 70-80%
Fill in the blanks: Levodopa is converted to dopamine by (1)___. Afterwhich, dopamine gets stuck in the (2)___. Conversely, COMT becomes (3)___ & competes with levodopa in crossing the (4)____ & going to the CNS.
- dopa decarboxylase
- Gastrointestinal tract
- 3-OMD
- blood-brain barrier
Identification: The presence of angle closure glaucoma is a contraindication to the use of this drug class.
Anticholinergic / Antimuscarinic drugs
TRUE OR FALSE: The most widely used synthetic preparations of anticholinergic drugs are trihexyphenidyl & benztropine, which block ACh from binding to receptors.
True
Source: Adams & Victor, Merritt
TRUE OR FALSE: Other motor features in PD are Restless Limb Syndrome, Akathisia, Loss of postural reflex, change in speech quality, freezing, and PD dementia.
True.
Source: Merritt
Matching Type:
- Feet seemingly becomes glued to the floor. Abruptly afterward, the feet become “unstuck” and gait resumes.
- Delay/slowness in cognitive processing
- Tendency to fall backward can occur when a pt arises from seating or when walking backward
- Crawling sensations in the legs and may be associated with periodic limb movements during sleep
- Near-constant state of discomfort leading to voluntary movements
Choices:
A. Retropulsion
B. Bradyphrenia
C. Restless Limb Syndrome
D. Akathisia
E. Freezing
- E
- B
- A
- C
- D
Source: Merritt
Identification: When a patient accelerates in quick forward steps in attempt to avoid falling backward.
Festination of gait
Source: Merritt
Identification: These were the first effective medications used for PD. It may be used as a secondary pharmacologic option because of the side effects of levodopa and of dopaminergic agents.
Anticholinergic / Antimuscarinic Drugs
Matching Type:
- Writing becomes smaller over time
- Voice becomes less audible and, finally, the patient only whispers. Soft, monotonous, cluttered speech.
- Extreme version of stammering with repetition of a word’s initial syllable
- May manifest Froment’s Sign
- Syllables are inadequately separated, resulting in words that run together.
- Monotonous tone with a lack of inflection
Choices
A. Tachyphemia
B. Essential tremor
C. Hypokinetic Dysarthria
D. Micrographia
E. Aprosody
F. Palilalia
- D
- C
- F
- B
- A
- E
TRUE OR FALSE: Levodopa produces an immediate symptomatic response. The development of non-levodopa-responsive features such as freezing & autonomic dysfunction, is possible.
True
Identification: These are the hallmark of PD & are largely composed of ubiquitin and aggregated α-synuclein (αSyn). They are eosinophilic proteinaceous cytoplasmic inclusions, surrounded by a faint halo that are present in many of the remaining cells of the pigmented nuclei of the SN.
Lewy bodies
Identification: It is the repetitive to- & fro flexion extension or rotatory unilateral movement. It is accentuated by stress, anxiety, walking, excitement, & concentration.
Tremors
TRUE OR FALSE: Normally, DA & ACh neurons are both balanced. However, in PD, ACh is increased, dopamine is decreased. This fluctuation causes tremors & rigidity.
True
Source: Ninja Nerd
Matching Type:
- Tracing circles in the air
- Reduction in small facial muscle movements imparts the characteristic expressionless “masked” appearance
- Inability to inhibit blinking in response to a tap over the bridge of the nose or glabella. Unsuppressed reflex of obligate blinking.
- Intermittent resistance to slow movement. It is more common in the UE.
- Created from phenylalanine, which is subsequently converted to tyrosine
Choices:
A. Myerson Sign
B. Hypomimia
C. Cogwheeling
D. Levodopa
E. Froment Sign
- E
- B
- A
- C
- D
Identification: There is involuntary hypertonia of skeletal muscles. When the examiner passively moves the limb, a mild resistance appears from the start & continues evenly throughout movement.
Limb Rigidity
Fill in the blanks: The usual blink rate of 12 to 20/min is reduced in the parkinsonian patient to (1)___, and with it there is a slight widening of the palpebral fissures, creating a (2)___.
- 5 to 10/min
- stare
