Parkinson's

Question 1

Define Parkinson’s

Answer 1

A chronic, progressive neurodegenerative condition resulting from the loss of the dopamine-containing cells of the substantia nigra.

Worse but not better

Question 2

RRB

Parkinson’s classic triads

Answer 2

• Resting Tremor
• Rigidity
• Bradykinesia

Question 3

Parkinson’s presentations

Answer 3

• Micrographia
• Unilateral resting tremor (4-6 Hertz
• Hypertonia (cogwheel)
• Shuffling gait

Question 4

Parkinson’s aetiology

Answer 4

• Idiopathic
• Environment

Question 5

Condition presented in similar way of Parkinson’s

Answer 5

Parkinsonism’s

Question 6

Parkinson’s pathophysiology

Answer 6

• Loss of dopaminergic neurones in the substantia nigra
• Dopamine deficiency in the basal ganglia leading to motor dysfunction
• Presence of Lewy bodies (alpha-synuclein
  aggregates)
• Imbalance between direct and indirect motor
  pathways in the basal ganglia disrupting the

Question 7

What is the purpose of the direct / indirect pathway

Answer 7

To refine movement - in Parkinson’s this is imbalanced

Question 8

Parkinson’s imbalance in PD

Answer 8

Direct pathway: dopamine stimulates the DP - as dopamine is reduced there is less dopamine available –> difficult to initiate movements
Indirect pathway: dopamine is also required for inhibition for movement refinement –> as dopamine is reduce this path cannot be exacuted

Question 9

Parkinson’s non-motor Sx

Answer 9

• Cog impairment
• Psych: depression
• Autonomic dysfunc: constipation, postural hypotension
• Sleep disturbance
• Ansomia, fatigue, pain

Question 10

Parkinson’s autonomic features

Answer 10

• Weight loss
• Dysphagia
• Constipation
• Erectile Dysfunction
• Orthostatic hypotension
• Excess sweating
• Drooling

Question 11

Parkinson’s examination findings

Answer 11

Observation
* Resting pill-rolling tremor
* Masked facies
* Reduced blink rate
Motor
* Bradykinesia
* Rigidity due to increase tone
* Postural instability (late sign)
* Ask to do repetitive hand / foot movements.
* Ensure power, reflexes and planters normal
Gait assessment
* Shuffling gait
* Festination
* Turning difficulty
Pull test – assess postural stability
* Pull on shoulder from behind. No loss of balance / one-step / two-step / requires assistance

Question 12

Parkinson’s definitive Dx

Answer 12

Post-mortem

Question 13

Parkinson’s Dx criteria

Answer 13

1. Bradykinesia + (Resting tremor, rigidity, postural instability)
2. Exclusion criteria
   * Drug-induced Parkinsonism
   * Vascular Parkinsonism
   * Normal pressure hydrocephalus
   * Parkinson Plus Syndromes
   * Infection, neoplasms, toxic exposures, or trauma.
3. Establish Diagnosis
4. Look for additional supportive features
   * Unilateral onset
   * Progressive course
   * Good response to Levodopa
   * Dysautonomia
   * Cognitive dysfunction

Question 14

Parkinson’s Tx

Answer 14

1. Levodopa (synthetic precursor to dopamine) + Carbidopa (Gold standard)
2. Dopamine Agonists – Pramipexole, Ropinirole, Rotigotine (SEs: HTN, psych effects)
3. MAO-B inhibitors – Selegiline, Rasagiline (for mild Sx)
4. COMT inhibitors – Entacapone, Tolcapone
5. Catechol-O-Methyltransferase enzyme breaks down dopamine.
   Used as adjunct to levodopa

Question 15

Parkinson’s other Mx

Answer 15

• SALT
• Physio
• OT

Question 16

Parkinson’s Long-term Mx

Answer 16

• 5-2-1 assessment
• Medication adjustments over time
• Addressing motor fluctuations (on-off phenomenon)
• Psychosocial support, caregiver education
• Role of palliative care in advanced cases

Question 17

PD VS LBD

Answer 17

PD: Motor Sx first and then Cog sx presented at late stage
LBD: Cog Sx first and then Motor Sx presented much later

Answer 18

antipsychotic inhibits D2 receptor causing less dopamine available for connection

Question 19

Parkinson’s gait freatures

Answer 19

• Freeze and festinating
• Shuffling gait
• Slow initiation
• Difficult on turning