Parkinson/Extrapyramidal Disease Flashcards

1
Q

What is the classical triad of Parkinsonism?

A

Tremor
Rigidity
Bradykinesia

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2
Q

What are the features of the Parkinsonian tremor?

A

4-7Hz
‘Pill-rolling’ movements w/ thumb & finger
Occurs at rest, decreases w/ action, increases w/ anxiety
-increased if clench opposite hand
Positive glabellar tap sign (excessive blinking)

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3
Q

What are the features of Parkinsonian rigidity?

A

Increased tone throughout range of limb movement

Equal in opposing muscle groups - ‘lead pipe’

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4
Q

What are the features of Parkinsonian bradykinesia?

A

Difficulty initiating movement
Progressive reduction in speed/amplitude of actions
Spontaneous blinking rate reduced
Hypomimia +/- hypersalivation

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5
Q

What is cogwheeling?

A

Jerky resistance to passive movement

-rigidity + tremor

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6
Q

What are the causes of Parkinson’s?

A
Idiopathic - PD
Drug induced
Vascular - Multiple cerebral infarcts
Toxin - Wilson's disease
Post-encephalopathy
Parkinson's plus syndromes
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7
Q

What are the drug induced causes of Parkinson’s?

A
Neuroleptics
Prochlorperazine
Metoclopramide
TCAs
Methyldopa
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8
Q

What are the Parkinson’s plus syndromes?

A

Rare alternative causes of PD, screen before diagnosing as idiopathic PD

  • Progressive supranuclear palsy
  • Multiple system atrophy
  • Lewy body dementia
  • Vascular Parkinsonism
  • Corticobasal degeneration
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9
Q

What are the features of Progressive Supranuclear Palsy?

A
Symmetrical onset, tremor unusual
Early postural instability/speech problems
Dementia develops early
Vertical gaze palsy present
   -limitation of movement in down gaze
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10
Q

What are the features of Multiple System Atrophy?

A
Early autonomic features (postural hypotension, bladder dysfunction, excess sweating)
Cerebellar signs (nystagmus in horizontal gaze)
Pyramidal signs (extensor plantar, hyperreflexia)
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11
Q

What are the features of Lewy Body Dementia?

A

Early dementia w/ fluctuating cognition & visual hallucinations
Symmetrical motor signs

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12
Q

What are the features of Vascular Parkinsonism?

A

Strokes affecting basal ganglia
Sx worse in legs than arms
Pyramidal signs present

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13
Q

What are the features of Corticobasal degeneration?

A

Akinetic rigidity involving 1 limb

Cortical sensory loss

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14
Q

What is the underlying pathology of Parkinson’s?

A

Degeneration of nigrostriatal neurones w/ Lewy Body formation
Reduced dopamine activity w/i corpus striatum of basal ganglia

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15
Q

What additional features are present in Parkinson’s?

A
Postural changes
Gait changes 
Speech changes 
GI/urological sx
Dermatological sx
Psychological sx
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16
Q

What are the postural changes present in Parkinson’s?

A

Characteristic swoop

Fixed flexion of all joints (apart from PIPJ/DIPJ)

17
Q

What are the gait changes present in Parkinson’s?

A

Gait becomes quicker (festinant)
Narrow based, shuffling, reduced arm swing
Slow/unsteady on turn (may freeze)
Falls common

18
Q

What are the speech changes present in Parkinson’s?

A

Monotonous pronunciation

Progresses to slurring dysarthria/anarthria

19
Q

What are the GI/urological sx present in Parkinson’s?

A

Dysphagia
Constipation
Urinary frequency

20
Q

What are the dermatological sx present in Parkinson’s?

A

Excessive sweating

Greasy skin

21
Q

What are the psychological sx present in Parkinson’s?

A
Cognition preserved til late stages
Dementia develops later in disease
Depression common (1/3)
REM behavioural sleep disorder
Insomnia
22
Q

What is the management of Parkinson’s?

A

MDT care
Social care assessment
Levodopa
Adjuncts - dopamine receptor agonists, MAO-B inhibitors, COMT inhibitors

23
Q

How does Levodopa work?

A

Precursor of dopamine, crosses BBB

Combined w/ carbidopa to prevent conversion peripherally

24
Q

What are the common side effects of Levodopa?

A

N/V (treat w/ Domperidone)
Confusion
Visual hallucinations (treat w/ Olanzapine)
Chorea

25
Q

What are the late side effects of Levodopa?

A

After 2-5yrs pts develop late side effects

  • motor fluctuations
  • dyskinesias
  • dystonias
26
Q

What are motor fluctuations?

A

Response to a given dose is shorter lived
Rapid ‘on-off’ switching from well controlled state to akinesia
Seemingly unrelated to dosage

27
Q

What is dyskinesia?

A

Abnormal, involuntary, uncontrolled movements

Peak dose dyskinesias due to high dopamine levels

28
Q

What is dystonia?

A

Painful muscle spasms

Painful ‘wearing off’ dystonia as dopamine levels fall

29
Q

How are dopamine receptor agonists used to treat Parkinson’s?

A

Adjuncts to L-dopa
Less effective but fewer unwanted dyskinesias
-ergot derivatives (bromocriptine, cabergoline)
-d2 agonists (ropinirole)
-d2/3 agonists (pramipexole)

30
Q

What are the common side effects of dopamine receptor agonists?

A

Vomiting
Haemolytic anaemia
Ergot derivatives cause pulmonary/pericardial/retroperitoneal fibrosis

31
Q

How do MAO-B & COMT inhibitors work?

A

Both prevent breakdown of dopamine by respective enzymes

  • MAO-B inhibitors (selegline, rasagline)
  • COMT inhibitors (entacapone)
32
Q

What is the main side effect of MAO-B inhibitors?

A

Exacerbate postural hypotension

33
Q

How can anticholinergic agents be used to treat Parkinson’s?

A

Address dopamine/ACh imbalance in substantia nigra
Help tremor
Can cause confusion/anti-cholinergic effects in elderly

34
Q

What are the surgical options for the management of Parkinson’s?

A

Thalotomy/deep brain stimulation to interrupt overactive vasal ganglia circuits

35
Q

What is the prognosis of Parkinson’s?

A

If untreated pts will die due to complications w/i 10yrs