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Flashcards in Parkinson 1 Deck (19):
1

• Idiopathic PD

• Parkinson’s plus
– Multiple system atrophy (aka Shy-Drager syndrome)
– Progressive supranuclear palsy
– Lewy body disease

• Parkinsonism
– Postencephalitic,
– Drug-induced, toxin-induced
– Vascular

• Idiopathic PD

• Parkinson’s plus
– Multiple system atrophy (aka Shy-Drager syndrome)
– Progressive supranuclear palsy
– Lewy body disease

• Parkinsonism
– Postencephalitic,
– Drug-induced, toxin-induced
– Vascular

2

Parkinson’s disease, paralysis agitans, shaking palsy

• Idiopathic,
• Degenerative
• CNS disorder
• with 4 characteristic features
1. ____________
2. ____________
3. ________
4. _______

Parkinson’s disease, paralysis agitans, shaking palsy

• Idiopathic,
• Degenerative
• CNS disorder
• with 4 characteristic features
1. Slowness & poverty of movement
2. Muscular rigidity
3. Resting tremor
4. Postural instability

• POSTURAL INSTABILITY :
late feature
• Must exclude drug-induced disease
• Definitive diagnosis on autopsy

3

Based on clinical signs, physical examination, history
• 2 of the 3 cardinal signs must be present
– Tremor : resting tremor (disappears with movement), increases with stress
– Rigidity : “ratchet”-like stiffness (cogwheel rigidity); also leadpipe rigidity
– Akinesia /bradykinesia : subjective sense of weakness, loss of dexterity, difficulty using kitchen tools, loss of facial expression, reduced blinking, difficulty getting out of bed/chair, difficulty turning while walking.

Based on clinical signs, physical examination, history
• 2 of the 3 cardinal signs must be present
– Tremor : resting tremor (disappears with movement), increases with stress
– Rigidity : “ratchet”-like stiffness (cogwheel rigidity); also leadpipe rigidity
– Akinesia /bradykinesia : subjective sense of weakness, loss of dexterity, difficulty using kitchen tools, loss of facial expression, reduced blinking, difficulty getting out of bed/chair, difficulty turning while walking.

4

Diagnosis
• Non-motor symptoms at presentation
______________________

Diagnosis
• Non-motor symptoms at presentation
– Pain
– Urinary frequency
– Anxiety, depression
– Constipation
– Hyposmia (olfactory dysfunction)

5

Clinical presentation of PD

Micrgraphia
Hypomimia
Hypophonia
Hyperhidrosis
Decrease blink rate
Orthostatic hypotension
Psychosis
Sleep disturbance
Confusion
Dementia
Festination

6

Idiopathic PD – features at initial presentation

• Asymmetric
• Positive response to levodopa or apomorphine
• Postural instability (& falls) - not present
• Less rapid progression (rapid = H&Y 3 in 3 years)
• Autonomic dysfunction – not present
• Neuroimaging - ??
• Impaired olfaction (?)

7

Morbidity

• Unable to perform ADLs
• Choking
• Pneumonia
• Falls

8

Pathology

• Loss of dopaminergic neurons in the substantia nigra
– About 80% loss --> clinical symptoms

• Age-related loss of neurons?
• Environmental toxin / insults?
– MPTP-MPP+
– Pesticides, herbicides

• Genetics?
– Predisposition to toxins / insults
– Genetic abnormalities

9

Stage One
– Signs and symptoms on one side only
– Symptoms mild
– Symptoms inconvenient but not disabling
– Usually presents with tremor of one limb
– Friends have noticed changes in posture, locomotion and facial expression

Stage One
– Signs and symptoms on one side only
– Symptoms mild
– Symptoms inconvenient but not disabling
– Usually presents with tremor of one limb
– Friends have noticed changes in posture, locomotion and facial expression

10

• Stage Two
– Symptoms are bilateral
– Minimal disability, able to walk
– Posture and gait affected

• Stage Two
– Symptoms are bilateral
– Minimal disability, able to walk
– Posture and gait affected

11

Stage Three
– Significant slowing of body movements
– Early impairment of equilibrium on walking or standing – Generalized dysfunction that is moderately severe

Stage Three
– Significant slowing of body movements
– Early impairment of equilibrium on walking or standing – Generalized dysfunction that is moderately severe

12

Stage four
– Severe symptoms
– Can still walk to a limited extent
– Rigidity and bradykinesia
– No longer able to live alone
– Tremor may be less than earlier stages

Stage four
– Severe symptoms
– Can still walk to a limited extent
– Rigidity and bradykinesia
– No longer able to live alone
– Tremor may be less than earlier stages

13

Stage Five
– Cachectic stage
– Invalidism complete
– Cannot stand or walk
– Requires constant nursing care

Stage Five
– Cachectic stage
– Invalidism complete
– Cannot stand or walk
– Requires constant nursing care

14

“Measuring” PD - Hoehn and Yahr
• Assesses mobility
• If on treatment, should be assessed when the person is in the “ON” and also in the “OFF” state

“Measuring” PD - Hoehn and Yahr
• Assesses mobility
• If on treatment, should be assessed when the person is in the “ON” and also in the “OFF” state

15

“Measuring” PD – Unified Parkinson’s Disease Rating Scale
(1) Mentation, Behaviour, Mood – E.g. intellectual impairment, depression
(2) Activities of Daily Living – E.g. speech, salivation, swallowing, dressing, hygiene, walking
(3) Motor Examination – E.g. facial expression, tremor at rest, gait
(4) Complications of Therapy – E.g. dyskinesias, clinical fluctuations

“Measuring” PD – Unified Parkinson’s Disease Rating Scale
(1) Mentation, Behaviour, Mood – E.g. intellectual impairment, depression
(2) Activities of Daily Living – E.g. speech, salivation, swallowing, dressing, hygiene, walking
(3) Motor Examination – E.g. facial expression, tremor at rest, gait
(4) Complications of Therapy – E.g. dyskinesias, clinical fluctuations

16

Early/young onset PD

- ~40YO
• Slower disease progression
• Features
– < cognitive decline
– earlier motor complications
– dystonia is common initial presentation vs falls & freezing in late-onset
• Dopamine agonists used in preference to levodopa

Early/young onset PD

- ~40YO
• Slower disease progression
• Features
– < cognitive decline
– earlier motor complications
– dystonia is common initial presentation vs falls & freezing in late-onset
• Dopamine agonists used in preference to levodopa

17

Goal of treatment
X Replace dopamine
X Cure

✔Manage symptoms
✔Maintain function & autonomy

Goal of treatment
X Replace dopamine
X Cure

✔Manage symptoms
✔Maintain function & autonomy

18

Treatment modalities

• Pharmacological
– INCREASE central dopamine, dopaminergic transmission
• Levodopa
• Dopamine agonists
• MAO B inhibitors
• COMT inhibitors

– Correct imbalance in other pathways
• Reduce cholinergic activity with anticholinergics
• NMDA antagonists

Treatment modalities

• Pharmacological
– INCREASE central dopamine, dopaminergic transmission
• Levodopa
• Dopamine agonists
• MAO B inhibitors
• COMT inhibitors

– Correct imbalance in other pathways
• Reduce cholinergic activity with anticholinergics
• NMDA antagonists

19

Nonpharmacological

– Physiotherapy
• Stretching, transfers, posture, walking

– Occupational therapy
• Mobility aids, home & workplace safety

– Speech & swallowing
• Vocal exercises

– Surgery
• Deep brain stimulation (DBS)