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Week 3 - movement disorders (parkinsonism) Flashcards

1
Q

Is the tremor associated with Parkinson’s disease a coarse or fine tremor ?

A

fine tremor

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2
Q

In what circumstances does the tremor associated with Parkinson’s disease worsen?

A
  • at rest
  • with distraction
  • with anxiety
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3
Q

Is the tremor associated with Benign essential tremor a coarse or fine tremor ?

A

coarse tremor

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4
Q

When is the tremor associated with benign essential tremor worst ?

A

during movement/action

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5
Q

Which one has a more familial element..
a) parkinson’s disease?
b) benign essential tremor ?

A

benign essential tremor

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6
Q

List some conditions that cause a tremor worse on movement …

A
  • benign essential tremor
  • hyperthyroidism
  • drug induced tremor
  • dystonic tremor
  • exaggerated physiological tremor
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7
Q

As well as the hands, where else does a tremor often occur in a patient with essential tremor ?

A
  • hands
  • legs
  • jaw
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8
Q

Does essential tremor cause bradykinesia and gait disorder, like parkinsonism does ?

A

not usually !

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9
Q

What pharmacological intervention can be effective in reducing essential tremor ?

A

non specific beta blockers e.g propranolol

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10
Q

What are the cardinal features of parkinsonism ?

A
  • bradykinesia
  • rigidity
  • resting tremor
  • postural and gait instability (this is an extra one!)
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11
Q

Which is the most common condition that can cause the features of parkinsonism ?

A

idiopathic parkinson’s disease

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12
Q

What is the common pattern of clinical signs of parkinsonism i idiopathic parkinson’s disease ?

A

asymmetrical
(usually unilateral on presentation)

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13
Q

What are the common signs/symptoms of idiopathic parkinson’s disease ?

A
  • 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
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14
Q

What is the principal management of idiopathic parkinson’s disease ?

A
  • levodopa or dopamine agonist
  • physical therapy/activity
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15
Q

What are the conditions that fall under the term of parkinsonism ?

A
  • 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
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16
Q

Which of the parkinsonism conditions usually present bilaterally ?

A
  • vascular parkinsonism
  • drug induced parkinsonism
  • MSA (multisystem atrophy)
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17
Q

Why does vascular parkinsonism usually present bilaterally ?

A
  • 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
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18
Q

Which drug class cause drug induced parkinsonism ?

A

antipsychotics

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19
Q

In which conditions are antipsychotics most commonly used ?

A
  • schizophrenia
  • bipolar
  • tourette’s disorder
  • nausea and vomiting
  • dizziness/vertigo in the elderly
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20
Q

Which type of parkinsonism is the only condition to include sensory abnormalities ? why ? what type of sensory deficits ?

A

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

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21
Q

What is an early sign of MSA (mutlisystem atrophy) ?

A

dysphagia occurs quite early on and is rapidly progressive

22
Q

Which type of parkinsonism is associated with cerebellar signs ? what cerebellar signs ?

A

PSP (progressive supranuclear palsy)

  • severe postural instability (poor balance)
  • dis-coordination
  • slow or slurred speech
23
Q

What specific sign is seen on MRI that is indicative of PSP ?

A

hummingbird sign

= reduction in mid brain volume

24
Q

What are the main signs of vascular parkinsonism ?

A
  • predominant lower body rigidity
  • lack of facial expression
  • less common to see tremor
25
What is the treatment for vascular parkinsonism ?
50% respond to levodopa
26
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)
27
What is the management of dementia with lewy bodies ?
shared care with psychiatry, neurology and geriatrics
28
What is the treatment for drug induced parkinsonism ?
it is usually irreversible, but you would **stop or reduce the drug** and liaise with psychiatry
29
What are the signs of drug induced parkinsonism ?
- drug history of antipsychotics - symmetrical rigidity - lack of facial expression
30
What are the signs of MSA (multisystem atrophy) ?
- rapid progression - early onset dysphagia - postural hypotension - bladder instability - symmetrical parkinsonism signs
31
what is the treatment for MSA (multisystem atrophy) ?
levodopa and supportive treatments
32
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*
33
What is the treatment for PSP (progressive supranuclear palsy) ?
- speech and language review - supportive therapies
34
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)*
35
What is the treatment for CBD (corticobasal degeneration) ?
- symptomatic control - does not respond well to levodopa
36
What are the signs of normal pressure hydrocephalus ?
- memory loss - gait disturbance - bladder incontinence
37
What is the management of normal pressure hydrocephalus ?
- diagnostic lumbar puncture and CSF removal, then a… - ventricolo-peritoneal shunt
38
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)*
39
What is the frequency (Hz) of the resting tremor seen in parkinson’s disease ?
4 - 6 Hz
40
What is the UK PDS Brain Bank criteria for diagnosing parkinson’s disease ?
3 steps … 1. bradykinesia with at least one other cardinal symptom *(rigidity, tremor, postural instability)* 2. exclude a history of drug induced, repeated strokes, head injury, unilateral after 3 years, cerebral tumour etc… 3. 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
41
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
42
What is the epidemiology of parkinson’s disease ?
- more common in men - incidence is 10-20 out of 100,000
43
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)*
44
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)*
45
What are some PMHx risk factors for vascular parkinsonism ?
- diabetes - HTN - stroke - ischaemic heart disease
46
What is a common initial side effect of levodopa treatment ?
nausea vomiting diarrhoea postural hypotension
47
What is a common investigation used when a patient presents with signs of any type of parkinsonism ?
MRI brain
48
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
49
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
50
What is the 4 stages of progression of parkinson’s ?
1. **pre diagnosis** - usually not overt symptoms 2. **diagnosis and treatment** - good response to meds at first 3. **complex** - development of drug associated dyskinesias/motor problems or cognitive decline 4. **palliative** - poor drug response and cognitive decline/dementia predominates. swallowing may be impaired and require feeding therapies (PEG). discussions about end of life care.
51
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.

Y4 Geriatrics (6 decks)

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