Week 8: Parkinsons

Question 1

Diagnosis is based on clinical presentation. Classical signs of pD are:

Answer 1

• tremor
• bradykineasia
• muscle rigidity
• postural instability
• resting/ unilateral
• slowness of movement
• Cog wheel
• gait & balance

Question 2

Explain the pathology of parkinsons

Answer 2

 Neuronal cell death in the substantia nigra pars
compacta
 By diagnosis 60-70% of Dopamine producing
cells have died
 This loss continues in spite of treatment
 With further loss, there is further reduction in
Dopamine levels and associated progression of symptoms

Question 3

Describe the link between alpha Synuclein, Lewybodies & Parkinsons

Answer 3

 Deposition of a protein called alpha synuclein
 Agragates abnormally & forms clumps /Lewy
body
 Damages nerve cell - possibly why the cells die
 Increased interest in Alpha Synuclein based therapies to prevent its formation
 Very promising research- eg.antibodies
directed towards this unwanted protein

Question 4

What is the Braak Theory?

Answer 4

• the earliest sign of parkinsons are found in the enteric NS, the medulla in particular, olfactory bulk (smell)
• under theory parkinsons only progresses to substantial nigra and cortex over yrs
• been pushed aside why? evidence that the non-motor symptoms like loss of sense of smell, hyposmia, sleep disorders + constipation may come after motor features of the disease by several years.
• So researchers are increasingly focused on non-motor symptoms to detect PD as early as possible to look for ways to stop it.

Question 5

Goals of Parkinsons treatment is to?

Answer 5

Regain balance of dopamine and acetylcholine.
Deficit of Dopamine results in
bradykinesia & muscle rigidity.

Imbalance of Acetylcholine
results in tremor

Question 6

Timing of medication

slide 22-24

Answer 6

 Levodopa has a very short half life – hence has to be taken regularly
 Timing is highly significant for steady plasma DA levels-to provide optimum relief of symptoms.
 Correct timing of medication may dictate how mobile and safe the person with PD is or how well they can communicate/other
 Levodopa should never be stopped abruptly

 Response to drugs is variable
 Individual regimes need to be devised
 The regime must achieve optimum balance between benefits & side effects
 Levodopa best taken before meals (levodopa an amino acid & hence
competes with other dietary amino acids
 Delayed gastric emptying- affects absorption of medications

Question 7

What are some side effects of Therapy

Answer 7

End of Dose Failure - with progression of condition
On/ Off Phenomenon- unable to function
Dyskineasia- Involuntary movements
Dystonia- abnormal posturing

Question 8

What is dystonia

Answer 8

 Manifestation of underlying disease
 Involuntary muscle contractions which
produce abnormal sustained posturing
 Can affect any part of the body eg. feet, toes, neck
 Mostly occurs in the “off ” state but can occur as a peak dose effect
 Can be distressing & painful – report to neurologist as medication adjustment may reduce distress. Stretching / Botox

Question 9

Long term complications of Parkinsons medication

Dyskinesia

Answer 9

• Writhing, wriggling involuntary movement
• can affect any part of the body- e.g. head, trunk, limbs and vary in severity- mild, moderate, sever.
• usually occur at peak dose, end dose or both (biphasic)

Question 10

What are the motor change that occur in PD and why?

Answer 10

The basal ganglia require dopamine to plan & control well learnt automatic movements & complex skills
-people with PD have BG dysfunction resulting in impaired initiation, quality & control of automatic movements.

Motor changes:
-short shuffling gait/ reduced or absent arm swing
 Akinesia (Absence or poverty of movement)
 Freezing (motor block)
 Problems turning – increases falls risk (difficulty turning / rolling over in bed)
 Festination (running, difficulty stopping)
•Reduced pincer grip (hands feel clumsy) •Problems dual tasking (eg.walking & talking)
•Balance problems (Loss of postural •reflexes) Falls
•Reduced “scanning” of environment – • reduced neck movement

Question 11

Tell me what happens in a freezing episode

Answer 11

• sudden inability to move, as if feet stuck to the floor.
• can last a few moments to 15-20 mins or more
• usually occurs in confined spaces
• can occur in the ‘on’ or ‘off’ state document the time this occurs. This will assist the prescribing doctor when adjusting medications.

Question 12

What are strategies to enhance movement for patients

Answer 12

• rehearse in mind before starting
• reduce distractions
• use visual cues to trigger a movement
• use auditory cues e.g. Say out loud ‘left right or one two’
• use physical cues e.g. Rock from side to side or tap on your leg saying ‘one two’

Question 13

What are destination

Answer 13

• Sudden episoe of an involuntary increase of the stepping rate (hastening) together with a minimisation of step length
• use cues to help regulate i.e. ‘heel-toe’
• arange living enviro to mae it easier to move around + reduce persons chances of falling
• try and avoid cluttering small spaces as it can increase ‘freezing’ spaces.

Question 14

What is the Etiology of dye-autonomia in PD

Answer 14

• In PD, Lewy body pathology has been identified in both central and peripheral autonomic systems
• this results in abnormal activation of the parasympathetic & sympathetic systems producing constipation, delayed gastric emptying, urinary retention, erectile dysfunction, orthostasis & heat and cold intolerance.

Question 15

Orthostatic Hypotensions in PD (form of low blood pressure causing dizziness)
Management

Answer 15

• no swift changes of position- stand up slowly
• eliminate or reduce antihypertensive meds if possible
• Have PD medications reviewed
• increase dietary salt and fluid
• compression stockings
• Avoid/ reduce caffein and alcohol
• avoid excessive increase in body temp (bath, sauna)
• eat frequent small meals
• elevate head of bed by 30deg-40

Question 16

What are the causes of Constipation in PD

Answer 16

• Colonic dysmotility + anorectal dysfunction
• Lewybody pathology within the myenteric plexus of the colon > slowed transit time and occasionally megacolon, intestinal pseudo obstruction and volvulus
• combination of disordered contraction & relaxation of the muscles of defecation > excessive straining, pain, sense of incomplete evacuation
• Faecal incontinence (losse stool) in PD sometimes due to overflow around faecal impaction -x-ray.

Additional factors:

• medications
• lack of dietary fibre
• inadequate fluid intake
• lack of exercise
• aging
• other co-morbidities.

Question 17

Other issues in PD patients?

Answer 17

Swallowing- drooling, fatigue during meals, difficulty taking medications 9chi=oking),

Nutrition- prevent dehydration, weight loss due to swallow problems and reduced fine motor skill, nutritional supplements.

Communication:
Reduced facial expression, Soft voice, reduced eye blink (staring), bradyphrenia (slowness in thinking)

Question 18

Pain in parkinsons

Answer 18

• experienced by 70-80% of people with PD
• most unrecognised & under treated NMS
• mentioned by James P in his original essay
• peripheral mechanical pain
• central neurological pain


 Areas of brain thought to influence pain perception are affected in Parkinson’s
 PWP may have less ability to modulate the heightened sense of pain within the pain matrix
Painmanagement: dopaminergic therapy
 Treat depression as can augment the subjective feeling of pain
 Gabapentin for neuropathic types of pain
 Atypical Neuroleptics for oral/genital pain

Question 19

Explain Peripheral mechanical pain

Answer 19

 Dystonic – painful dystonic spasms
associated with “off”+ biphasic states
Affects hands, toes, feet - inversion, curling, extension, flexion. Dystonic pain can also involve the neck or jaw
 Muscoskeletal /rheumatic- rigidity, hypokinesia - aching, cramping, arthraltic
 Neuritic/radicular - pain in region of a nerve root
 Akathitic discomfort- sense of restlessness, need
to move, intolerance of remaining still
 Skin biopsies have revealed alpha synuclein path in peripheral nerves of PWP (but not MSA,PSP or CBD)

Question 20

Explain Central Pain

Answer 20


 Burning, stabbing, tingling, formication (like insects crawling on skin)
 Similar to neuropathic pain
 Not always on side most affected + can involve the face, head, epigastrium, abdomen, pelvis, rectum & genitalia
 Oral pain syndrome “burning mouth”
 Tend to occur in “off” periods but not abolished by levodopa or motor nerve blocks

Question 21

What are the Neuropsychiatric changes in Parkinsons

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Answer 21

 Anxiety
 Depression
 Sleep-disturbance  Hallucinations
 Paranoia
 Dementia
Medicationsideeffect ImpulseControldisorder Gambling / Shopping / Hypersexual