2: Movement Disorders - Parkinsons Disease

Question 1

Define Parkinsonism

Answer 1

Syndrome caused by extra-pyramidal triad of tremor, hypertonia and bradykinesia

Question 2

Define Parkinson’s Disease

Answer 2

Disease caused by degeneration of dopaminergic neurons in substantia nigra

Question 3

Explain prevalence of parkinson’s disease with age

Answer 3

Increases

Question 4

Which gender is PD more common

Answer 4

Male

Question 5

What can cause Parkinsonism

Answer 5

• Wilson’s disease
• Anti-dopaminergic medications (Antipsychotics, Metclopramide)
• MTTP
• Post-encephalitis
• Dementia Puglistica
• CO poisoning

Question 6

What is dementia pugilistica

Answer 6

Dementia caused by repetitive head trauma

Question 7

What causes Parkinson’s disease

Answer 7

Idiopathic

Genetic (PINK1)

Question 8

What are 4 risk factors for Parkinson’s disease

Answer 8

• FH
• Pesticide exposure
• Genetics (LRRK2)
• Diet - vitamin D Deficiency

Question 9

If PD unilateral or bilateral symptoms

Answer 9

Unilateral

Question 10

What is the triad of symptoms on PD

Answer 10

• Tremor
• Bradykinesia
• Rigidity

Question 11

Explain bradykinesia in PD

Answer 11

• Difficultly initiating movement
• Movements are slow and decrease with amplitude with repetitive movement = micrographia
• Shuffling gait, stops when reaches objects
• Expressionless face

Question 12

What tremor is present in PD

Answer 12

Pill-rolling tremor, present at rest

Question 13

When is tremor worse in PD

Answer 13

Worse at rest. Exacerbated when stressed or tired

Question 14

What are the two types of rigidity in PD

Answer 14

Lead-pipe

Cog wheel

Question 15

What is lead-pipe rigidity

Answer 15

No tremor present

Question 16

What is cog-wheel rigidity

Answer 16

Mix of hypertonia and tremor

Question 17

What are 5 other symptoms of PD

Answer 17

• Drooling
• Unhabituated glabella reflex
• Psychiatric disturbance
• REM sleep disorder
• Postural hypotension

Question 18

What psychiatric features are common in PD

Answer 18

Depression (40%)

Psychosis

Question 19

When does REM sleep disorder occur in PD

Answer 19

Before motor symptoms

Question 20

When does impaired olfaction occur in PD

Answer 20

Before motor symptoms

Question 21

Why does postural hypotension occur in PD

Answer 21

Autonomic dysfunction

Question 22

What are Parkinson plus syndromes

Answer 22

Syndromes that occur with Parkinsonism

Question 23

What are the 4 Parkinson plus syndromes

Answer 23

• Multiple System atrophy
• Lewy body dementia
• Progressive supra nuclear palsy
• Cortical-Basal degeneration

Question 24

What is multiple system atrophy also referred to as

Answer 24

Shy Drager

Question 25

Explain presentation of multiple system atrophy

Answer 25

Presents with: - Early autonomic symptoms - Cerebellar signs - Parkinsonism

Question 26

What are 3 symptoms of early autonomic involvement

Answer 26

Erectile Dysfunction Postural hypotension Bladder atony

Question 27

What is the mnemonic to remember cerebellar signs

Answer 27

DANISH

Question 28

What are cerebellar signs

Answer 28

DDK Ataxia Nystagmus Intention tremor Slurred/Stacato speech Hypotonia

Question 29

What imaging is ordered in MSA

Answer 29

MRI

Question 30

What sign on MRI is pathognomic of MSA

Answer 30

Hot-Cross Bun Sign

Question 31

What is progressive supra nuclear palsy also called as

Answer 31

Steele-Richardson-Olszewki Syndrome

Question 32

What are symptoms of Progressive Supranuclear Palsy

Answer 32

- Impaired vertical gaze. Downward gaze is worse than upward - Dolls eye reflex is preserved - Parkinsonism - Trunk rigidity - Slurred speech

Question 33

What may patients with PSP struggle with

Answer 33

Reading | Walking down stairs

Question 34

What is dolls-eye reflex

Answer 34

Eyes remain still when head moves

Question 35

What imaging is ordered in PSP

Answer 35

MRI

Question 36

What sign is pathognomic of PSP

Answer 36

Humming bird sign

Question 37

What is problem,w with managing PSP

Answer 37

Poor response to L-Dopa

Question 38

What is classic presentation of cortic-basal degeneration

Answer 38

Akathisia of a limb = causing alien limb syndrome Dementia Apraxia Cortical sensory loss

Question 39

Explain presentation of drug-induced parkinsonism compared to PD

Answer 39

Bilateral Quicker onset of symptoms Rigidity and tremor are rare

Question 40

What is offered to treat PD

Answer 40

Levo-dopa and dopa decarboxylase inhibitor

Question 41

When is levodopa and peripheral dopa decarboxylase inhibitor offered

Answer 41

If symptoms are impacting a patient's QOL

Question 42

What may be given with Levodopa to improve compliance

Answer 42

COMT inhibitor

Question 43

What is second-line in PD

Answer 43

Monoamine Oxidase Inhibitor

Question 44

Name a monoamine oxidase inhibitor

Answer 44

Selegiline

Question 45

When are MAOI indicated

Answer 45

If symptoms are not impacting patient's QOL

Question 46

What is third-line for PD

Answer 46

Dopamine agonist

Question 47

Name a dopamine agonist

Answer 47

Pramiprexole, Ropinirole

Question 48

When are dopamine agonists preferred

Answer 48

Younger patients

Question 49

What is offered for dyskinesia in PD

Answer 49

Amantidine

Question 50

What is the MOA of amantaidine

Answer 50

NMDA antagonist

Question 51

What surgical treatment can be used in PD

Answer 51

DBS of sub thalamic nucleus

Question 52

When is deep brain stimulation of sub thalamic nucleus indicated in PD

Answer 52

Advanced Parkinson's disease refractory to medical treatment

Question 53

What drug is given for postural hypotension in PD

Answer 53

Midodrine

Question 54

What is the MOA of midrodrine

Answer 54

Acts on peripheral a-receptors to increase vascular resistance

Question 55

What is used to manage drooling in PD

Answer 55

Glycopyronium bromide