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Parkinson's Disease Flashcards

1
Q

What is the annual incidence of PD?

A

1/8000

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2
Q

What is the prevalence of PD?

A

1/800

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3
Q

What percentage of over 65s are affected by PD?

A

1%

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4
Q

What is the median age of onset of PD?

A

60

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5
Q

What is roughly the time from PD disease onset to death?

A

15 years

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6
Q

What is the classical pathology of PD? Be specific

A

Loss of pigmented neurons in ventrolateral tier of SNPC with alpha synuclein inclusions in surviving nigral neurons (Lewy Bodies)

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7
Q

What percentage of PD cases present before age 45?

A

Roughly 15%

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8
Q

How much more likely are non-smokers to get PD than smokers?

A

Twice as likely

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9
Q

What is the major environmental toxin linked loosely to a PD like picture?

A

MPTP

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10
Q

9 major iatrogenic (drug) causes of Parkinsonism?

A 
Antipsychotics
Prochlorperazine 
Metaclopramide 
Several CCBs
Amiodarone
Valproate
Lithium
Ciclosporin
Chloroquine
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11
Q

5 major degenerative differentials for PD?

A 
PSP
MSA
Vascular Parkinsonism - diffuse subcortical white matter ischaemia
DLB
Acute vascular Parkinsonism
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12
Q

What are the 4 key diagnostic features of PD?

A

Fatiguable bradykinesia with slowing of initiation of movements
Postural instability
Rigidity
Coarse, slow resting tremor (pill rolling)

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13
Q

What are the 4 major differentials for the PD rest tremor?

A

Severe essential
Holmes tremor/rubral tremor
Dystonic tremor
Neuropathic tremor

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14
Q

How might rigidity in early PD manifest as a complaint?

A

Muscle stiffness and aching discomfort

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15
Q

How would you describe the rigidity in PD?

A

Lead pipe

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16
Q

What early complaints might be heard in PD?

A

Difficulty with fine motor - doing up buttons, stirring, wiping, brushing teeth, getting things out of pockets…
Muscle aches and stiffness
Dragging or slowness of a limb
Tremor

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17
Q

What defines early onset in PD?

A

Less than 40 (/45)

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18
Q

What prodromal features of PD may be seen?

A

Major depressive illness or stress may unmask
Fatigue
Bradykinesia, mental inflexibility
Autonomic Sx
Frozen shoulder, low back pain (?due to mobility problems)
REM sleep behaviour disorder
Anosmia

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19
Q

What is Braak’s hypothesis?

A

That PD begins in the peripheral autonomic system, olfactory bulb and dorsal nucleus of vagus before spreading rostrally in a prion like mechanism

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20
Q

What is the name of the hypothesis that PD starts in the autonomic and olfactory system?

A

Braak’s hypothesis

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21
Q

What autonomic Sx may be seen early in PD?

A

Thermodysregulation
Dribbling saliva e.g. At night onto pillow
Colonic motility disturbance and constipation
Erectile dysfunction

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22
Q

What does vertical saccadic slowing suggest in the context of Parkinsonism?

A

PSP

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23
Q

What does delay in initiation of vertical saccades in the context of Parkinsonism suggest?

A

CBD

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24
Q

What do horizontal square wave jerks and gaze evoked nystagmus suggest in the context of Parkinsonism?

A

MSA

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25
Q

How may speech differentiate types of Parkinsonism?

A

Monotonous and quiet in PD
Growly and slow in PSP
Nasal and whining in MSA

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26
Q

What eyelid signs may suggest PSP?

A

Eyelid apraxia

Near-absent spontaneous blinking

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27
Q

What should babinski signs in Parkinsonism without cervical spondylotic myelopathy/prev stroke make you think about?

A

Is it MSA (maybe PSP)
Genetic pallidopyramidal syndrome e.g. Hallervorden-Spatz (PKAN) or another NBAI such as Kufor-Rakeb syndrome or PLA2G6 neuroaxonal dystrophy

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28
Q

Why is lying and standing BP after 2 mins important in assessing PD?

A

Postural hypotension of over 20 systolic may suggest increasing risk of falls if starting on dopaminergic meds

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29
Q

What should significant orthostasis preceding Parkinsonism make you think about?

A

Is it MSA-P

30
Q

What might be a useful way to distinguish between PD and essential tremor on exam?

A

Get patient to hold arms/hands outstretched - latent interval of a few seconds before tremor appears in PD vs tremor present straight away in essential

31
Q

What is the possibly arbitrary definition of DLB?

A

Dementia occurring within the first year of onset of Parkinsonism or before onset

32
Q

What rating scales may be useful in analysing disease response for PD especially early on?

A

UPDRS (parts 2 and 3)

33
Q

What might make you reconsider a presumptive PD diagnosis?

A

Poor response to therapy (750mg/day LDopa) at 4 months, having doubled dose at 3 months

34
Q

What constitutes a formal acute levodopa challenge?

A

250mg of levodopa/benserazide with finger tapping and timed walking tests at baseline and 1 hour then 2 hours
With all PD meds stopped overnight beforehand and domperidone if nauseous

35
Q

What should be done for a bradykinetic-rigid predominant phenotype of presumed PD that hasn’t responded to initial LDopa therapy? Looking for what?

A

MRI
Hot cross bun sign in pons, pontocerebellar atrophy, hyperintense putaminal rim on T2 - MSA
Midbrain and superior cerebellar peduncle atrophy (hummingbird/penguin sign) - PSP
Vascular Parkinsonism - subcortical white matter ischaemia and striatocapsular infarcts
Secondary Parkinsonism e.g. Basal ganglia calcification

36
Q

What might be a good investigation for predominantly tremulous patients with suspected PD?

A

DAT scan, as normal DAT excludes PD

37
Q

2 important surgical causes of Parkinsonism?

A

Supratentorial meningiomas

Communicating hydrocephalus

38
Q

What is the middle cerebellar peduncle sign and what does it suggest?

A

Increased white matter T2 signal in middle cerebellar peduncle
With tremor, ataxia and Parkinsonism suggests fragile X premutation (FRXTAS) esp if FH/male patient

39
Q

What is ephedrone toxicity and what can it cause? Where is it a major problem?

A

Subacute bradykinesia, severe dysarthria, dystonic posturing and walking and severe postural instability with backwards falls
Due to illicit ephedrone IV injection, made from sudafed (pseudoephedrine)
Big in Eastern Europe

40
Q

What is the initial maintenance dose of L dopa?

A

50mg TDS

/62.5mg TDS if with a DDCI (carbidopa/benserazide)

41
Q

What is the max L dopa dose per day with aim to reduce long term side effects?

A

600mg/day

42
Q

What is the main role of L dopa sparing agents?

A

To avoid on-off phenomena and end of dose deterioration, and also peak dose choreoathetosis

43
Q

What is the best drug to reduce dyskinesias in PD?

A

Amantadine

44
Q

What drugs might be useful for off-period dystonia in earlier onset PD patients?

A

Anticholinergics

45
Q

Commonly used MAO-B inhibitors in PD?

A

Selegiline

Rasagiline

46
Q

What are commonly used COMT inhibitors?

A

Entacapone

Tolcapone

47
Q

What are commonly used dopamine agonists?

A

Rotigotine - patch
Ropinerole
Pramipexole
Apomorphine

48
Q

What might be a reasonable starting drug for patients with mild motor disability only in PD?

A

Rasagiline - a MAO-B inhibitor

49
Q

What are the 3 best methods of managing refractory motor fluctuations for PD?

A

Apomorphine subcut administration
Duo-dopa - continuous intrajejunal L dopa administration through a gastrojejunostomy
DBS - usually bilateral STN

50
Q

Managing insomnia in PD?

A

Nocturnal dopaminergic drug dose
Clonazepam
Low dose amitriptyline
Sleep hygiene

51
Q

Management of depression in PD?

A

Noradrenergic reuptake inhibitors e.g. Duloxetine

Amitriptyline or nortryptiline

52
Q

Management of REM sleep behaviour disorder in PD?

A

Melatonin

Clonazepam

53
Q

Management of daytime sleepiness in PD e.g. Due to dopamine agonist therapy?

A

Modafinil

54
Q

Management of psychosis in PD?

A

Reduce doses of antiPD drugs, consider clozapine quetiapine or Aripiprazole and cholinomimetics

55
Q

Management of constipation in PD?

A

Macrogol - osmotic laxative

Faecal softeners

56
Q

Management of urinary urgency in PD?

A

Bladder stabilisers e.g. Tolterodine, trospium

Desmopressin if nocturia

57
Q

Management of ED in PD?

A

Sildenafil

58
Q

Management of rigidity/dystonia pain in PD?

A

Clonazepam, Anticholinergics

59
Q

Management of restless legs in PD?

A

Dopamine agonists

60
Q

Management of orthostatic hypotension in PD?

A

Increase water and salt
Fludrocortisone
Ephedrine/midodrine

61
Q

Management of drooling in PD?

A

Atropine eye drops sublingually (0.5%)

Botulinum toxin injections into salivary glands

62
Q

Management of excessive sweating in PD?

A

Propranolol

Propantheline

63
Q

What is Stalevo?

A

L dopa plus carbidopa plus entacapone

64
Q

What is madopar?

A

Co-beneldopa

65
Q

What is sinemet?

A

Co-careldopa

66
Q

What is azilect?

A

Rasagiline

67
Q

What is a commonly used anticholinergic in PD?

A

Trihexiphenidyl

68
Q

How is Parkin PD inherited?

A

AR

69
Q

How does Parkin PD differ to idiopathic?

A

More benign, with restricted SN lesion but not alpha synuclein
Early onset and slowly progressive with no Anosmia, leg presentation and common rest tremor

70
Q

How is LRRK2 PD inherited? What is the mutation? What about its penetrance?

A

AD
G2019S
Incomplete penetrance but a susceptibility gene seen in sporadic PD fairly often

71
Q

How is LRRK2 different to Parkin PD?

A

It is an alpha synucleinopathy so is more like IPD

72
Q

What percentage of PD patients get dementia by terminal stages/over 70 years?

A

40%

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