[13] Idiopathic Parkinson's Disease Flashcards
(107 cards)
1
Q
What is Idiopathic Parkinson’s Disease more simply and commonly known as?
A
Parkinson’s Disease
2
Q
What is Parkinson’s disease?
A
A long-term degenerative disorder of the CNS
3
Q
What part of the nervous system does Parkinson’s disease mostly affect?
A
The motor system
4
Q
What are the main pathological features of Parkinson’s disease?
A
- Cell death in the brain’s basal ganglia
- Presence of Lewy bodies in neurones
- Death of astrocytes
- Increases in microglia in substantia nigra
5
Q
What cells die in the basal ganglia in Parkinson’s disease?
A
The dopamine secreting neurones of the substantia nigra pars compacta
6
Q
What percentage of dopamine secreting neurones are affected by the time of death in people with Parkinson’s disease?
A
Up to 70%
7
Q
What are Lewy bodies?
A
Accumulation of the protein alpha-synuclein
8
Q
How many major pathways connect the basal ganglia to other brain areas?
A
5
9
Q
What are the 5 major pathways connecting the brain to the basal ganglia?
A
- Motor
- Oculo-motor
- Associative
- Limbic
- Orbitofrontal
10
Q
Which of the 5 major communicating pathways to the basal ganglia are affected in Parkinson’s disease?
A
All of them
11
Q
What is the result of the effect Parkinson’s disease has on the communicating pathways to the basal ganglia?
A
It explains many of the symptoms of the disease as the circuits are involved in a wide variety of functions
12
Q
What functions are affected by Parkinson’s disease’s effect on the communicating pathways to and from the basal ganglia?
A
- Movement
- Attention
- Learning
13
Q
What is the normal role of the basal ganglia in motor control?
A
It exerts a constant inhibitory influence on a wide range of motor systems
14
Q
What is the effect of the basal ganglia exerting a constant inhibitory influence on parts of the motor system?
A
Stops them from being active at inappropriate times
15
Q
What happens to the basal ganglia’s inhibitory effects when a decision is made to perform a particular action?
A
The inhibition is reduced for the required motor system
16
Q
What facilitates the reduction of inhibition?
A
Dopamine
17
Q
What is the result of high levels of dopamine?
A
Promotion of motor activity
18
Q
What is the result of low levels of dopamine?
A
Hypokinesia
19
Q
What is the result of the hypokinesia caused by dopamine depletion, for example in Parkinson’s disease?
A
Greater exertion of effort required for any given movement
20
Q
What are the risk factors for Parkinson’s disease?
A
- Increasing age
- History of familial PD (younger onset)
- Mutation in the gene encoding glucocerebrosidase
- MPTP exposure
- Pesticide exposure
- Male
- Head injuries
21
Q
What are the main features of Parkinson’s disease?
A
- Tremor
- Rigidity
- Bradykinesia
22
Q
What is the frequency of the tremor in Parkinson’s disease?
A
4-6 Hz
23
Q
When is the tremor in Parkinson’s disease present?
A
At rest
24
Q
What can be done to make the tremor more noticeable in assessing Parkinson’s disease?
A
Get the patient to concentrate e.g. recite months backwards
25
When is the Parkinson's disease tremor absent?
During activity
26
Where does the tremor in Parkinson's disease start?
Usually one limb on one side or both limbs on one side
27
How can the tremor in Parkinson's disease progress?
Can become generalised
28
How is rigidity assessed in Parkinson's disease?
Seen as an increase in resistance to passive movement
29
What can rigidity produce in many patients with Parkinson's disease?
Flexed posture
30
What may cause the rigidity to increase in a patient with Parkinson's disease?
Asking them to perform an action in the opposite limb
31
What is the term for increased rigidity in Parkinson's disease when performing a task with the opposite limb?
Contralateral synkinesis
32
How does bradykinesia present in Parkinson's disease?
Slowness of voluntary movement and reduced autonomic movements
33
When is bradykinesia particularly noticeable in Parkinson's disease?
Reduced arm swing when walking
34
How can further symptoms of Parkinson's disease be divided?
- Physical
| - Cognitive/psychiatric
35
What are the extra physical symptoms of Parkinson's disease?
- Gait disturbance
- Balance issues
- Anosmia
- Nerve pain
- Urinary incontinence
- Nocturia
- Constipation
- ED
- Postural hypotension
- Hyperhidrosis
- Dysphagia
- Drooling
- Insomnia
36
What gait disturbances may be seen in Parkinson's disease?
- Difficulty in starting to walk
- Shuffling gait
- Unsteadiness on turning
- Difficulty in stopping
37
What are the cognitive and psychiatric symptoms of Parkinson's disease?
- Depression
- Anxiety
- Slight memory problems
- Problems with planning and organisation
38
What long-term problems may patients with Parkinson's disease suffer from despite treatment with L-dopa?
- Motor fluctuations
- Axial problems
- Parkinson's disease dementia
39
What percentage of people experience the long-term problems associated with Parkinson's disease after L-dopa treatment?
50-90%
40
When may the long-term problems associated with Parkinson's disease present?
After a 'honeymoon period' of 5-10 years post L-dopa initiation
41
What is the problem with long-term motor fluctuations seen in later Parkinson's disease?
They are difficult to treat
42
What axial problems may be seen in later Parkinson's disease?
Disturbance of gait, speech and balance that don't respond to Parkinson's disease medication
43
What is thought to cause the intractable (with Parkinson's disease medications) axial problem's seen in late Parkinson's disease?
Axonal degeneration outside the substantia nigra where dopamine is not the neurotransmitter
44
What are the treatment options for the axial problems of late Parkinson's disease?
- Physiotherapy
- Occupational therapy
- Speech and language therapy
45
What is Parkinson's disease dementia?
Dementia occurring more than one year after diagnosis with Parkinson's disease
46
What are the three typical features of Parkinson's disease dementia?
- Presence of Parkinsonism in limbs
- Frequent visual hallucinations
- Frequent fluctuations of lucidity
47
Why is Parkinson's disease dementia difficult to treat?
Confusion and hallucinations may be worsened by the treatment for Parkinson's disease
48
What medications can treat Parkinson's disease dementia without worsening the Parkinsonism?
Atypical antipsychotics
49
Who is less likely to get the long-term problems associated with later Parkinson's disease?
People who are diagnosed after 70
50
How is Parkinson's disease usually diagnosed?
Clinically
51
When may investigations in suspected Parkinson's disease be helpful?
To exclude other causes of the presentation
52
What investigations may be useful in Parkinson's disease?
- CT or MRI brain
- SPECT
- Genetic testing
- Olfactory testing
53
When might a CT or MRI brain be useful in assessing Parkinson's disease?
- In patients who fail to respond to therapeutic doses of L-dopa
- To exclude rare secondary causes
54
When might a SPECT scan be useful in patients with suspected Parkinson's disease?
To diagnose when the tremor cannot be clinically differentiated from an essential tremor
55
Why might genetic testing be needed in patient's with suspected Parkinson's disease?
To rule out Huntington's disease
56
Why is olfactory testing useful in suspected Parkinson's disease?
To differentiate it from other Parkinsonian disorders
57
What are the differentials for Parkinson's disease?
- Lewy-Body dementia
- Progressive supranuclear palsy
- Essential tremor
- Antipsychotic use
- Multiple systems atrophy
- Alzheimer's disease with parkinsonism
- Metabolic abnormalities
- Vascular Parkinsonism
- Toxin exposure
- Infections
58
How can an essential tremor be distinguished from a Parkinsonian tremor?
It is worse on movement
59
If a diagnosis of Parkinson's disease is suspected what should be done?
Refer quickly to a specialist
60
Why should anti-Parkinsonian medications not be withdrawn or allowed to fail suddenly?
It can cause acute akinesia or neuroleptic malignant syndrome
61
What may cause anti-parkinosnian medication to fail suddenly?
Poor absorption e.g. gastroenteritis
62
What is neuroleptic malignant syndrome?
Typically a life-threatening reaction to anti-psychotic medication
63
What are the symptoms of neuroleptic malignant syndrome?
- Fever
- Altered mental status
- Muscle rigidity
- Autonomic dysfunction
64
What is acute akinesia?
A life-threatening complication of Parkinson's disease clinically similar to neuroleptic malignant syndrome
65
What is the first-choice drug for Parkinson's disease dependent on?
- Age
- Symptoms
- Lifestyle
- Preference
66
What are the main first-line options for treating Parkinson's disease?
- Levodopa
- Dopamine agonists
- MAO-B inhibitors
67
What are the advantages of Levodopa?
- Most improvement in motor symptoms
| - Fewer adverse side effects
68
What is the disadvantage with L-dopa?
Most motor complications
69
What are the disadvantages of dopamine agonists?
- Less improvement in motor symptoms
| - More adverse side-effects
70
What is the advantage of dopamine agonists?
Less motor complications
71
What are the advantages of MAO-B inhibitors?
- Fewer motor complications
| - Fewer adverse effects
72
What is the disadvantage of MAO-B inhibitors?
Less improvement in motor symptoms
73
What should be offered to people with early stage Parkinson's disease and motor symptoms affecting QoL?
Levodopa
74
What should be offered to patients with early stage Parkinson's disease without motor symptoms affecting QoL?
Choice of:
- L-dopa
- Dopamine agonists
- MAO-B inhibitors
75
What should be given to patients and relatives orally and in writing when commencing treatment for Parkinson's disease?
Information about risks and side-effects
76
What are the important risks of starting Parkinson's disease treatment?
- Impulse control disorders
- Excessive sleepiness and sudden onset of sleep
- Psychotic symptoms
77
What drugs to treat Parkinson's disease cause impulse control disorders?
All, especially dopamine agonists
78
What drugs to treat Parkinson's disease can cause excessive sleepiness and sudden onset of sleep?
Dopamine agonists
79
What drugs to treat Parkinson's disease can cause psychotic symptoms?
All, especially dopamine agonists
80
What should be offered as an adjunct to L-dopa if a patient with Parkinson's disease develops dyskinesia or motor fluctuations?
Choice of:
- MAO-B inhibitor
- Dopamine agonists
- COMT inhibitors
81
What should be considered if dyskinesia in Parkinson's disease is not managed by first-line adjunctive therapies?
An ergot-derived dopamine agonist. Failing that amantadine
82
What other management aspects (besides medical) must be considered in a patient with Parkinson's disease?
- Physiotherapy
- Occupational therapy
- Speech and language therapy
- Nutrition
83
What physiotherapy is required in Parkinson's disease?
Parkinson's disease specific physiotherapy for those with balance or motor function problems
84
What occupational therapy is require in Parkinson's disease?
Parkinson's disease specific OT for people having difficulties with ADL's
85
What group of patient's with Parkinson's disease is speech and language therapy good for?
People experiencing problems with communications, swallowing or saliva
86
What additional speech and language assistance can be considered for those struggling to communicate with Parkinson's disease?
Alternative and augmentative communication equipment
87
What protein related nutritional measures should a person with motor fluctuations on L-dopa in Parkinson's disease follow?
Eat most protein in the last meal of the day
88
What supplements should people with Parkinson's disease take?
Vitamin D
89
What non-motor symptoms of Parkinson's disease also require management?
- Depression
- Drooling of saliva
- Impulse control disorders
- Orthostatic hypotension
- Parkinson's disease dementia
- Psychotic symptoms
90
How can depression be managed in Parkinson's disease?
Standard treatments for depression
91
What is the first-line treatment for drooling in Parkinson's disease?
SALT
92
If SALT is ineffective at treating drooling in Parkinson's disease what can be tried next?
Glycopronium bromide
93
Which group of patients with Parkinson's disease do impulse control disorders tend to develop in
Those on any dopaminergic therapy
94
Who with Parkinson's disease is at an increased risk of developing impulse control disorders?
Those with a history of previous impulsive behaviours or history of alcoholism
95
What is the first step of managing impulse control disorders in Parkinson's disease?`
Gradually reducing any dopamine agonists and monitoring for improvement and withdrawal symptoms
96
What should be done to treat impulse control disorders in Parkinson's disease if modifying dopaminergic therapy is not effective?
Offer CBT
97
What steps should be considered when addressing orthostatic hypotension in Parkinson's disease?
- Review medication
| - Consider midodrine
98
What medications can contribute to orthostatic hypotension in Parkinson's disease?
- Anti-hypertensives
- Dopaminergics
- Anticholinergics
- Antidepressants
99
What can be given to treat Parkinson's disease dementia?
Cholinesterase inhibitors
100
What psychotic symptoms can occur in Parkinson's disease (as a result of treatment)?
- Hallucinations
| - Delusions
101
When should psychotic symptoms in Parkinson's disease not be treated?
If it is well tolerated by the patient and their family
102
How can psychotic symptoms be managed in Parkinson's disease?
- Reduce dose of Parkinson's disease medications that may cause them
- Consider quetiapine
103
What must be taken into account when reducing Parkinson's disease medications to reduce psychotic symptoms?
Possible withdrawal effects
104
Who can quetiapine be given to for psychotic symptoms in Parkinson's disease?
People with no cognitive impairment
105
What can be given if no other treatments are effective at treating psychotic symptoms of Parkinson's disease?
Clozapine
106
What additional referral can be made at any time for patients with Parkinson's disease?
Palliative care referral
107
What are the potential complications of Parkinson's disease?
- Infections
- Aspiration pneumonia
- Bed sores
- Poor nutrition
- Falls
- Contractures
- Bowel and bladder dysfunction
