Degenerative Disease of the CNS Flashcards
(102 cards)
1
Q
Definition of dementia
A
Progressive impairment of multiple domains of cognitive function in an alert patient leading to loss of acquired skills and interference in occupational and social role
2
Q
Parkinsonism is a clinical syndrome with >2 of;
A
Bradykinesia
Rigidity
Tremor
Postural instability
3
Q
Definition of bradykinesia
A
Slowness of movement
4
Q
Where is the pathology in parkinsons?
A
Basal ganglia
5
Q
What is predominately lost is the basal ganglia in parkinsons?
A
Dopamine
6
Q
What is the 2nd most common neurodegenerative disease?
A
Parkinsons
7
Q
Types of late onset (65 +) dementia
A
Alzheimer’s (55%)
Vascular (20%)
Lewy body (20%)
Others (5%)
8
Q
Types of young onset (<65 years old) dementia
A
Alzheimers (33%) Vascular (15%) Frontotemporal (15%) Other (33%) - toxic (alcohol) - genetic (huntingtons) - infection (HIV, CJD) - inflammatory (MS)
9
Q
Treatment causes of dementia
A
Vitamin deficiency - B12
Thyroid disease
HIV
Syphillis
10
Q
What conditions mimic dementia?
A
Hydrocephalus
Tumour
Depression (pseudodementia)
11
Q
Types of parkinsonism
A
Idiopathic parkinsons disease (IPD) Lewy body dementia (LBD) Drug induced (e.g. dopamine antagonists) Vascular parkinsons (lower half) Parkinsons plus syndromes
12
Q
What are some parkinsons plus syndromes?
A
Multiple system atrophy
Progressive supranuclear palsy
Corticobasal degeneration
13
Q
What is examined when looking at cognitive function?
A
Memory Attention Language Visuospatial Behaviour Emotion Executive function Apraxia Agnosias
14
Q
What is ataxia?
A
A motor disorder in which the individual has difficulty with the motor planning to perform tasks or movements when asked, provided that the request or command is understand and he/she is willing to perform the task
15
Q
Definition of agnosia
A
Inability to process sensory information
16
Q
What screening tests are done for cognitive function?
A
Mini mental (MMSE) Montreal (MOCA)
17
Q
What type of dementia has a stepwise progression?
A
Vascular
18
Q
What would dementia with abnormal movements indicate?
A
Huntington’s
19
Q
What type of dementia also has parkinsonism?
A
Lewy body dementia
20
Q
What type of dementia comes with myoclonus?
A
CJD
21
Q
How do you get a definitive diagnosis of parkinsonism?
A
Post morteom
22
Q
Presentation of IPD
A
BRADYKINESIA \+ At least one of the following - tremor - rigidity - postural instability Slowly progressive (>5-10 years) Asymmetric rest tremor
23
Q
Does parkinsons have a good response to dopamine replacement treatment?
A
Yes
24
Q
Treatment of PD
A
Dopamine replacement treatment
- Levodopa (L-dopa) = CO-CARLEDOPA OR CO-BENELDOPA
- dopamine agonists = ROPIRINOLE OR PRAMIPEXOLE OR ROTIGOTINE PATCH
25
Treatment of Alzheimer's (+/- Lewy body dementia)
```
Cholinesterase inhibitors (cholinergic deficit)
- donepezil
- rivastigimine
- galantamine
NMDA antagonist
- memantine
```
26
Treatment for frontotemporal dementia
None
27
Complications for parkinsonism
Drug induced
- motor fluctuations - levodopa wears off
- dyskinesias - involuntary movements (levodopa)
- psychiatric - hallucinations, impulse control
Non drug induced especially non motor
- depression
- dementia
- autonomic; BP, bladder, bowel
- speech, swallow
- balance
28
Late treatment of parkinsonism
```
Prolong levodopa half life
- MAO-B inhibitors
- COMT inhibitor
- Slow release levodopas
Add oral dopamine agonist
Continous infusion
- apomorphine
- duodopa
Functional neurosurgery (Deep brain stimulation)
```
29
What is the commonest neurodegenerative condition?
Alzheimer's disease
30
Mean onset age of Alzheimer's?
70 y/o
31
Presentation of temporo-pareital dementia
Early memory disturbance
Language and visuospatial problems
Personality preserved until later
32
Presentation of frontotemporal dementia
Early change in personality/behaviour
Often change in eating habits
Early dysphagia
Memory/visuospatial relatively preserved
33
Presentation of vascular dementia
Mixed picture
| Stepwise decline
34
What are the degenerative causes of parkinsonism?
IPD
LBD
Parkinsons plus syndromes
35
What are the 2ndry causes of parkinsonism?
Vascular
| Drug induced
36
What is IPD responsive to?
Levodopa
37
Exclusion criteria for PD
History of
- repeated strokes with stepwise progression of parkinsonism features
- repeated head injury
- definite encephalitis
Oculogyric crises
Neuroleptic treatment at onset of symptoms
More than one affected relative
Sustained remission
Strictly unilateral features after 3 years
Supranuclear gaze palsy
Cerebellar signs
Early severe autonomic involvement
Early severe dementia with disturbance of memory, language and praxis
Babinskis sign
Prescence of cerebral tumour or communicating hydrocephalus on imaging study
Negative response to large doses of levodopa in absence of malabsorption
MPTP exposure
38
Supportive prospective criteria for PD
```
Unilateral onset
Rest tremor present
Progressive
Persistent asymmetry affecting side of onset most
Excellent response (70-100%) to levodopa
Severe levodopa induced chorea
Levodopa response for 5 years or more
Clinical course of 10 years or more
```
39
Pathological changes of IPD
Deposits of Lewy bodies
Loss of pigmented dopaminergic neurones in brainstem nuclei
Alpha synuclein changes thought key
Over time changes spread - involving more of brainstem, then cortex etc
40
What is the most common cause of parkinsonism?
IPD
41
What cause of parkinsonism is more likely to have cognitive problems than parkinsonism?
LBD
42
What presymptomatic changes can people get in PD before they get their symptoms?
Anosmia
43
What can be used to assess bradykinesia?
Finger taps
44
What can indicate rigidity?
Loss of arm swing whilst walking
45
What type of signs to start off with indicate IPD?
Unilateral
46
Assessment of parkinsonism
Finger tap
| Full neurological assessment
47
What happens to a finger tap in PD?
Do for 20 seconds, gets slower as time goes on and gets smaller
Worse on DOMINANT SIDE
48
Extra indications of PD
Loss of facial expression
| Micrographia
49
What is micrographia?
Small and tremulous writing
50
Diagnosis of PD
Clinical
51
What must also be asked about in PD?
Non motor symptoms
52
What are the non motor symptoms that may occur in PD?
```
Cognition
Cramps
Restless legs
Constipation
Speech
Mood changes
```
53
When is a Dat-SPECT scan used?
To differentiate essential tremor from parkinsonian tremor
54
When is Dat-SPECT scan +ve?
Degenerative parkinsonian conditions, but DOES NOT tell you which one
55
Drug interactions of Dat-SPECT that decreases the binding
```
Cocaine
Amphetamines
Methylphenidate
Ephedrine
Fentanyl
```
56
Drug interactions of Dat-SPECT that increase the binding
SSRIs
57
Why give levodopa in PD?
Replaces the chemical
58
Why give dopamine agonists in PD?
Boots any chemical left over in the brain
59
What are some other Parkinson therapies?
Apomorphine
| Duodopa
60
What is apomorphine used to treat?
Disabling motor fluctuations - if off spells
61
How is apomorphine given?
SC infusion with pump or pen injection
62
What is depression thought to be in PD?
2ndry to the disease
63
Why may someone with PD need a dietician?
Due to loss of calories due to constant trembling
64
What is duodopa?
Gel for continuous administration into the duodenum or upper jejunum via a pump and tube
65
Triggers of freezing of gait
Different terrain
Doorways
Busy / loud environment
66
When does freezing of gait occur in PD?
Advanced disease
67
What is common in freezing of gait?
On and off spells
68
What make freezing of gait better?
Cueing techniques
- visual
- rhythmic
69
A slow shuffling turn then improves with what?
Walking
70
Features of essential tremor
```
FH
Head can be involved
Action tremor
May have had for many years
Mobility issues/falls/constipation/speech/swallow should NOT be affected
```
71
What may help an essential tremor?
Alcohol
72
What is commonly used to treat an essential tremor?
Propanolol
73
What is drug induced parkinsonism difficult to differentiate from?
IPD
74
Can you still get drug induced parkinsonism if off the meds?
Yes, still may have symptoms for months after
75
DAT SPECT Scan result in drug induced parkinsonism
Negative
76
Can you fully recover after drug induced parkinsonism if stop meds?
Will not progress any further but will not fully recover
77
Top 3 drugs causing drug induced PD
Metoclopradmide (anti emetic)
Prochlorperazine (anti emetic)
Haloperidol (antipsychotic)
78
Causes of drug induced PD
```
Metoclopramide (anti emetic)
Procholrperazine (anti emetic)
Haloperidol
Antipsychotics
Lithium
Amoidarone
Valproate
Cinnarizine
```
79
Features of vascular parkinsonism
```
Legs > arms
Stepwise progression
Sudden onset
Gait affected EARLY
Cognitive impairment EARLY
```
80
Levodopa response in vascular parkinsonism
Poor
81
2 predominant types of multiple system atrophy
1. MSA-P = predominant Parkinson features
| 2. MSA-C = predominant cerebellar features
82
Features of multiple system atrophy
```
Parkinsonism
Autonomic disturbance
- erectile dysfunction (usually early feature)
- postural hypotension
- atonic bladder
Cerebellar signs
```
83
What is the antiemetic choice in PD?
Domperidone
84
Features of PD tremor
Unilateral
| Improves with voluntary movements
85
Parkinsonism with autonomic disturbance points towards what diagnosis?
Multiple system atrophy
86
What can parkinsons lead to and why?
Postural hypotension
| Due to autonomic failure
87
What neurodegenerative condition is associated with MND?
Frontotemporal dementia
88
As well as hands and fingers, what can an essential tremor also affect?
Vocal cords
89
Presentation of progressive supranuclear palsy
```
Impairment of vertical gaze
- down gaze worse than up gaze
- may complain of difficulty reading or climbing stairs
Parkinsonism
Falls
Slurring of speech
Cognitive impairment
```
90
Which treatment of parkinsons has been linked to impulse control disorders?
Dopamine receptor agonists
91
Treatment of vomiting caused by radio / chemotherapy
Ondansteron
92
Treatment of vomiting caused by intracranial causes e.g. raised ICP, direct effect of a tumour
Haloperidol
93
Treatment of vomiting caused by vestibular causes
Prochloperazine
94
Treatment of vomiting caused by GI problems
Metoclopramide
95
What drugs can cause neuroleptic malignant syndrome?
Antipsychotics
| If dopaminergic drugs are stopped or have their dose reduced
96
When does neuroleptic malignant syndrome start?
Within hours to days of starting an antipsychotic
97
Presentation of neuroleptic malignant syndrome
```
Pyrexia
Muscle rigidity
Autonomic lability
- HTN
- tachycardia
- tachypnoea
Agitated delirium with confusion
```
98
What is often raised in neuroleptic malignant syndrome?
Creatinine kinase
99
What may develop in neuroleptic malignant syndrome secondary to raised creatinine kinase?
AKI due to rhabdomyolysis
100
Treatment of neuroleptic malignant syndrome
Stop drug
IV fluids to prevent renal failure
Dantrolene
Bromocriptine (dopamine agonist)
101
What psychiatric condition is the most common in PD patients and what % of them have it?
40%
102
Describe ataxic gait
A wide based gait with loss of heel to toe walking
