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Flashcards in NEURO - Parkinson's Deck (25)
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(4) What are the Motor Features of Parkinson Disease?

•Postural instability


What do you expect to find on neurological examination in Parkinson's disease?

- Reduced speed, stride length
-Narrow base of support
- Forward trunk flexion
- Reduced arm swing Short, shuffling steps
- festination or freezing
- Difficulty turning, changing direction, stepping over or moving around objects
- dyskinesia/dystonia

- Pull test positive (staggers backwards multiple steps when pulled – retropulsion)


What are Dyskinesia and Dystonia?

- a category of movement disorders that are characterized by involuntary muscle movements
•Reversible levodopa-induced motor complication
•Present in 30-40% of patients on levodopa for 5 year, nearly 60% by 10 years
•Abnormal involuntary movements (choreic, dystonic, ballistic, myotonic)
•Treat by adjusting levodopa dosing

- Involuntary muscle contraction involving abnormal movements and postures
- More sustained abnormal posture than dyskinesia
- Can be an undertreated PD motor symptom OR a complication of levodopa treatment


What is Levodopa?
- Mechanism of Action
- Effects
- Common combinations

•Mainstay of PD treatment
•Replacement of dopamine via prodrug (levodopa)
•Most effective for hypokinetic motor symptoms, also tremor and rigidity
•Less effective for postural instability + it can even cause postural hypotension!
•Always combined with peripheral decarboxylase inhibitor to minimise peripheral conversion to dopamine (adverse effects) e.g. Sinemet/Kinson (Levodopa/carbidopa) or Madopar (levodopa/benserazide)

If started too early, it can actually cause degeneration of dopaminergic neurons. (controversial)


SE of parkinson's medications

•Nausea, abdominal cramping, diarrhea
•Dizziness and headache
•Confusion, hallucination, delusions, agitation and psychosis
•Orthostatic hypotension


(4) Levodopa-related complications in Parkinson's disease

Motor fluctuations

~ 50% of patients on levodopa for five years experience motor fluctuations and dyskinesia

4 types:
1. Wearing-off: end-of-dose effect

2. On-Off syndrome: Episodes of unpredictable ‘off’, alternating with ‘on’ (+/- dyskinesia)

3. Failure to turn ‘on’, (‘no-on’ response to levodopa)
-Due to excessively prolonged or severe ‘off’ period

4. Acute akinesia
-sudden exacerbation of PD,
-akinetic state lasting for days and not responding to antiparkinson medications


(6) Types of Parkinson's disease medications

• Levodopa
•COMT inhibitors
•Selective Monoamine Oxidase Type B inhibitors (MAO-I)
•Dopamine agonists (DA) e.g. Sifrol -> huge side effects (e.g. hypersexuality, impulsive acts etc)


(5) What are Non-Motor Features of Parkinson Disease?

•Orthostatic hypotension
•Urine frequency (usually at night -> huge problem when not very mobile due to off period at night -> risk of falls)
•Constipation -> Movocol (commonly used)


What is the difference between GEM & Rehabilitation?

•GEM (Geriatric Evaluation & Management): ‘slow stream’ multidisciplinary rehab under geriatrician

•Rehabilitation:‘fast-stream’ rehab with daily intensive multidisciplinary therapy under rehab physician


What are the criteria for rehabilitation (not GEM)?

•Wants to participate
-Consent, motivated

•Can participate, can learn
-Tolerate 3 hours of therapy per day
-Medically stable, psychiatrically stable
-Cognitive ability to learn and carry over

•Has goals
-Working towards something, functional gains in set time-frame


What are rehabilitation goals?

•Prevent complications
•Maintain/optimise function, mobility and self-care skills
•Educate patient and carers, provide counseling and support
•Facilitate community reintegration


Comment on the use of multidisciplinary team in Parkinson's disease

- working on posture, gait, balance, general fitness, setting up Home exercise program

Occupational therapist
- increase safety & ease in pADLs; provide adaptive aids, compensatory strategies
- functional cognitive screen

Speech therapist
- manage dysphagia, any aspiration concerns, hypokinetic dysarthria.
- modify food texture, optimise head & neck position

- input for nutrition

Social worker
- work on psychological & social aspects; social isolation, inability to drive decreasing access, loss of role.
- offer counselling, carer support, recommend services (home help, Shopping assistance, half price taxi card)
- information re PD support group


What (4) psychological aspects should you consider in Parkinson's disease?

(~ 50% PD pts, can trial SSRI)
(~ 29-38% PD pts, often the result of inadequate information, advice and counseling)
•Apathy and abulia
(Loss of motivation, diminished speech, motor activity and emotional expression, ascribed to frontal lobe dysfunction and basal ganglia lesion)
•Sleep disturbance


What is Parkinson's disease?

PD is a chronic neurodegenerative disorder that affects a person’s physical, psychological, and social function


Pathogenesis of Parkinson's disease

Degeneration/Loss of dopaminergic neurons in substantia nigra (basal ganglia)


Risk factors for Parkinson's disease

- FMHx
- Pesticide exposure (not published yet)
- brain injury -> Parkinsonism (not PD)


What is the difference in the causes of cogwheel rigidity vs. lead pipe rigidity?

Cogwheel rigidity - Parkinson's. (can be asymmetrical. Rigidity due to drugs are more bilateral)

Lead pipe rigidity - UMN lesion


Characteristic gait of PD

Shuffling, festinating gait (shorter gaits & faster -> ends up in a fall), en bloc turning


Slightly turned in feet, knees slightly bent, arm swing reduced, rigid posture, walk shorter & slower. Stooped posture

If tremor is exacerbating by walking: it is due to PD.


(2) Effects of PD on eyes

- reduced blink rate
- impaired saccades (rapid movement b/w fixation points): hypometric saccades


What should you check on examination in a PD pt?

- oculomotor function (siccades)
- hypomimia
- cogwheel rigidity (asymmetrical?)
- foot tapping
- gait


Treatment goals & Rx in PD

- Motor symptoms Mx: dopamine agonist, movement chart, DBM (in young pts) etc
- Hydration & nutrition
- infection
- constipation
- reconditioning, improve mobility, function
- Psychological support


Orthostatic hypotension Mx in PD
- when does it occur
- non-pharm Mx
- pharm Mx

-Occurs late. 58% PD patients

Non-pharmacological Mx (PT/OT/nursing)
•Teach profiling strategies (rise slowly from a supine/sitting position)
•Avoid sudden postural changes, prolonged recumbence
•Elevate head of bed
•Use of compressive garments, elastic stockings or abdominal binders
•Avoid excessive alcohol and large meals, warm temperature and excessive straining

Pharmacological Mx
•Salt supplements, fludrocortisone


Mx of Bowel/Bladder dysfunction in PD

•Small regular meals, adequate fibre and water
•Regular bowel program, with aperients/suppository

Urinary frequency
•Treat underlying UTI, Check Post Void Residual Volume
•Timed voiding
•Fluid regulation
•Commode by bed

Sexual dysfunction
•Education re sexual function being affected by PD autonomic dysfunction and/or psychological factors
•Intimacy training, sexual counseling and strategies (posture, timing of meds)


Mx of communication, swallowing & nutrition in PD

Speech pathology review

•Modified food texture (soft), optimise head and neck position when swallowing
•Speech exercises
- emphasize breath and rate control, improving (exaggerating) articulation, and improving volume
•Ongoing dietetics input - nutrition


How should you follow up a PD pt?

•Movement Disorder Clinic follow-up
•Rehabilitation Clinic follow-up
•Liaison with LMO
•RDNS to monitor/maintain apomorphine pump
•Contact number for PD nurse
•Dietician follow-up
•Outpatient community based physiotherapy – exercise group to maintain gains

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