NEURO - Parkinson's Flashcards
(4) What are the Motor Features of Parkinson Disease?
- Tremor
- Bradykinesia
- Rigidity
- Postural instability
What do you expect to find on neurological examination in Parkinson’s disease?
Gait:
- 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?
Dyskinesia:
- 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
Dystonia:
- 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
- Somnolence
- 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
- On-Off syndrome: Episodes of unpredictable ‘off’, alternating with ‘on’ (+/- dyskinesia)
- Failure to turn ‘on’, (‘no-on’ response to levodopa)
- Due to excessively prolonged or severe ‘off’ period - 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)
- Anticholinergics
- Amantadine
(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)
- Hypomimia
- Hyposmia
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
Physiotherapist
- 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
Dietitians
- 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?
•Depression
(~ 50% PD pts, can trial SSRI)
•Anxiety
(~ 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)
