Week 3 - movement disorders (parkinsonism) Flashcards
Is the tremor associated with Parkinson’s disease a coarse or fine tremor ?
fine tremor
In what circumstances does the tremor associated with Parkinson’s disease worsen?
- at rest
- with distraction
- with anxiety
Is the tremor associated with Benign essential tremor a coarse or fine tremor ?
coarse tremor
When is the tremor associated with benign essential tremor worst ?
during movement/action
Which one has a more familial element..
a) parkinson’s disease?
b) benign essential tremor ?
benign essential tremor
List some conditions that cause a tremor worse on movement …
- benign essential tremor
- hyperthyroidism
- drug induced tremor
- dystonic tremor
- exaggerated physiological tremor
As well as the hands, where else does a tremor often occur in a patient with essential tremor ?
- hands
- legs
- jaw
Does essential tremor cause bradykinesia and gait disorder, like parkinsonism does ?
not usually !
What pharmacological intervention can be effective in reducing essential tremor ?
non specific beta blockers e.g propranolol
What are the cardinal features of parkinsonism ?
- bradykinesia
- rigidity
- resting tremor
- postural and gait instability (this is an extra one!)
Which is the most common condition that can cause the features of parkinsonism ?
idiopathic parkinson’s disease
What is the common pattern of clinical signs of parkinsonism i idiopathic parkinson’s disease ?
asymmetrical
(usually unilateral on presentation)
What are the common signs/symptoms of idiopathic parkinson’s disease ?
- bradykinesia
- rigidity
- resting tremor
- postural/gait instability (shuffling gait)
- stooped posture
- hypomimia (mask face)
- reduced blinking rate
- hypophonia (quiet, monotonous voice)
- hypographia (small handwriting)
- REM sleep disturbance (vivid dreams, acting them out)
- insomnia
What is the principal management of idiopathic parkinson’s disease ?
- levodopa or dopamine agonist
- physical therapy/activity
What are the conditions that fall under the term of parkinsonism ?
- idiopathic parkinson’s disease
- vascular parkinsonism
- dementia with lewy bodies
- drug induced parkinsonism
- PSP (progressive supranuclear palsy)
- MSA (mutlisystems atrophy)
- CBD (corticobasal degeneration)
- normal pressure hydrocephalus
Which of the parkinsonism conditions usually present bilaterally ?
- vascular parkinsonism
- drug induced parkinsonism
- MSA (multisystem atrophy)
Why does vascular parkinsonism usually present bilaterally ?
- vascular parkinsonism is caused by microvascular damage to vessels of/surrounding substantia nigra
- damage to blood vessels is usually symmetrical as the precipitants (e.g glucose) travel through every vessel equally
Which drug class cause drug induced parkinsonism ?
antipsychotics
In which conditions are antipsychotics most commonly used ?
- schizophrenia
- bipolar
- tourette’s disorder
- nausea and vomiting
- dizziness/vertigo in the elderly
Which type of parkinsonism is the only condition to include sensory abnormalities ? why ? what type of sensory deficits ?
CBD (cortico basal degeneration)
because it involves the cortex which has sensory and motor components- other types of parkinsonism mainly target the substantial nigra
- pins and needles
- tingling
- numbness
- alien limb phenomenon
What is an early sign of MSA (mutlisystem atrophy) ?
dysphagia occurs quite early on and is rapidly progressive
Which type of parkinsonism is associated with cerebellar signs ? what cerebellar signs ?
PSP (progressive supranuclear palsy)
- severe postural instability (poor balance)
- dis-coordination
- slow or slurred speech
What specific sign is seen on MRI that is indicative of PSP ?
hummingbird sign
= reduction in mid brain volume
What are the main signs of vascular parkinsonism ?
- predominant lower body rigidity
- lack of facial expression
- less common to see tremor
What is the treatment for vascular parkinsonism ?
50% respond to levodopa
What are the main signs of dementia with lewy bodies ?
- cognitive decline predating physical signs (approx 6 months before)
- prominent visual hallucinations (often involving animals)
- fluctuations in alertness
- physical signs of idiopathic parkinson’s
- REM-sleep disorder (vivid dreams, act out dreams etc)
What is the management of dementia with lewy bodies ?
shared care with psychiatry, neurology and geriatrics
What is the treatment for drug induced parkinsonism ?
it is usually irreversible, but you would stop or reduce the drug and liaise with psychiatry
What are the signs of drug induced parkinsonism ?
- drug history of antipsychotics
- symmetrical rigidity
- lack of facial expression
What are the signs of MSA (multisystem atrophy) ?
- rapid progression
- early onset dysphagia
- postural hypotension
- bladder instability
- symmetrical parkinsonism signs
what is the treatment for MSA (multisystem atrophy) ?
levodopa and supportive treatments
What are the signs of PSP (progressive supranuclear palsy) ?
- vertical gaze palsy (can’t look up easily in H test)
- early falls (due to severe postural instability and discoordination)
- truncal rigidity
- hummingbird sign on MRI
What is the treatment for PSP (progressive supranuclear palsy) ?
- speech and language review
- supportive therapies
What are the signs of CBD (corticobasal degeneration) ?
- asymmetrical parkinsonism
- dyspraxia
- sensory deficits (numbness, pins and needles, tingling)
- alien limb phenomenon (feeling estranged from a limb)
What is the treatment for CBD (corticobasal degeneration) ?
- symptomatic control
- does not respond well to levodopa
What are the signs of normal pressure hydrocephalus ?
- memory loss
- gait disturbance
- bladder incontinence
What is the management of normal pressure hydrocephalus ?
- diagnostic lumbar puncture and CSF removal, then a…
- ventricolo-peritoneal shunt
What are some signs of parkinsonian gait disorder ?
- small step/shuffling gait
- loss of arm swinging
- broad based stance
- impaired turning
- asymmetry
- freezing
- fenestrated/festinant gait (small steps, picking up speed as they go)
What is the frequency (Hz) of the resting tremor seen in parkinson’s disease ?
4 - 6 Hz
What is the UK PDS Brain Bank criteria for diagnosing parkinson’s disease ?
3 steps …
- bradykinesia with at least one other cardinal symptom (rigidity, tremor, postural instability)
- exclude a history of drug induced, repeated strokes, head injury, unilateral after 3 years, cerebral tumour etc…
- three or more of:
- unilateral onset
- persistent asymmetry affecting side of onset most
- rest tremor
- progressive disorder
- excellent response to levodopa
- severe levodopa induced chorea
- levodopa response for over 5yrs
- clinical disease course of over 10yrs
What is the recommended first step of management in a patient with parkinsonian symptoms ?
refer to movement disorder clinic before medication - drugs can influence presentation and make diagnosis in clinic harder
What is the epidemiology of parkinson’s disease ?
- more common in men
- incidence is 10-20 out of 100,000
What are the first line drug options for treatment of parkinson’s disease ?
in order of preferred drug class
- co-beneldopa / co-careldopa (levodopa and a dopa decarboxylase inhibitor)
- ropinirole (dopamine agonist)
- rotigotine (dopamine agonists)
- pramipexole (dopamine agonist)
- rasagaline (MAO-B inhibitor)
- selegiline (MAO-B inhibitor)
When should levodopa medications be commenced ?
as late in the disease progression as is tolerable by patient because long term use can exacerbate symptoms
(this is mostly only in patients under 60, if 60+ usually start but on smaller doses)
What are some PMHx risk factors for vascular parkinsonism ?
- diabetes
- HTN
- stroke
- ischaemic heart disease
What is a common initial side effect of levodopa treatment ?
nausea
vomiting
diarrhoea
postural hypotension
What is a common investigation used when a patient presents with signs of any type of parkinsonism ?
MRI brain
Who is involved in the MDT for parkinson’s disease ?
- specialist nurses
- physio
- speech and language therapist
- occupational therapist
- pharmacist
- psychologists
- dieticians
- social workers
- carers
What are some side effects to be wary of in the dopamine agonist meds (ropinirole, rotigotine, pramipexole..) ?
- confusion
- hallucinations
- impulse control disorders (gambling, hyper sexuality, overspending etc)
do not use in Pts with known cognitive/psychiatric impairments and counselling is required before starting these meds
What is the 4 stages of progression of parkinson’s ?
- pre diagnosis - usually not overt symptoms
- diagnosis and treatment - good response to meds at first
- complex - development of drug associated dyskinesias/motor problems or cognitive decline
- palliative - poor drug response and cognitive decline/dementia predominates. swallowing may be impaired and require feeding therapies (PEG). discussions about end of life care.
describe what causes parkinson’s to a patient …
- there are neurones in the brain that deliver dopamine around
- dopamine is important for lots of things like mood, memory and motor skills
- unfortunately genetics and environment can cause those neurones to deteriorate
- this causes a lack of dopamine delivery around the brain which can cause the motor signs, and decrease in memory and mood.
