parkinson's

Question 1

what is parkinson’s

Answer 1

progressive idiodegeneration of the dopaminergic pathways in the substantia nigra

loss of dopaminergic neurones in the substantia nigra that leads to inadequate dopamine transmission.

Question 2

characteristic neuropathological finding

Answer 2

lewy body formation in affected neurones

Question 3

gold standard for diagnosis for parkinsons

Answer 3

brain bank criteria

Question 4

brain bank criteria for the diagnosis of Parkinson’s disease

Answer 4

step 1:
clinical syndrome involving bradykinesia (+rigidity important

plus at least one of

• tremor - 4-6 Hz - corase, pill-rolling, disappears during voluntary movement, asymmetrical
• rigidity
• postural instability

step 2: exclude other potential conditions

step 3
PLUS 3 OR MORE

• Unilateral onset
• stooped posture
• loss of arm seing
  • Rest tremor present
  • Progressive disorder
  • 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 ten years or more

Question 5

Other parkisonian features apart from the triad

Answer 5

• Depression, anxiety, and fatigue.
• Reduced sense of smell.
• Cognitive impairment.
• Sleep disturbance.
• Constipation.
• lack of facial expression
• lsck of spontanrous movements
• greasy skin - autonomic dysfunction
• decreased blinking
  tibulation - nodding head involuntarily
• dribbling of saliva
• festinating gait
• stooped posture
• increased tone
• impotence
• sweating

Question 6

what is lead pipe rigidity

Answer 6

constant resistance felt when a limb is passively flexed in the presence of increased tone without tremor,

Question 7

what is cogwheel rigidity

Answer 7

regular intermittent relaxation of tension felt when a limb is passively flexed in the presence of tremor and increased tone.

Question 8

what may be seen when examining a parkinson patient

Answer 8

reduced facial expression
slow
shuffling, festinating gait

pill rolling
‘pull test’ - tendency to fall back when pulled by examiner

Question 9

other causes of parkinsonism

Answer 9

drug-induced parkinsonism

antipsychotics
antiemetics
- prochlorperazine
- metocloperamide

amiodarone
antidepressants - SSRIs

wilson’s
repeated head injury
cerbrovascular disease

Question 10

other causes of tremor

Answer 10

1) essential tremor
- bilateral stress, caffeine, sleep deprivation

exaggerated psychological tremor

dystonic tremor

hyperthyroidism

drugs - B2 agonists

2) intention - cerbellar

Question 11

name of scales used to assess progression of parkinson

Answer 11

Hoehn and Yahr

Unified Parkinson’s Disease Rating Scale

Question 12

classification of Unified Parkinson’s Disease Rating Scale

Answer 12

Part 1: non-motor experiences of daily living
Part 2: motor experiences of daily living
Part 3: motor examination
Part 4: motor complications

Question 13

drugs available for parkinson

SEs

Answer 13

levodopa - pass thru BBB - converts levodopa into dopamine

neuroepileptic malignant syndrome

monomine oxidase B inhibitors - dizzy, insomnia, orthostatic hypotension, joint pain

and COMT - coloured urine, diarrhoea, liver damage, impulsive and compulsive behaviours

stop breakdown of dopamine

Question 14

4 phases of parkinson

Answer 14

1. Early stage - Soon after diagnosis, symptoms are mild and normal life possible
2. Maintenance stage - Good response to treatment and no major disability
3. Advanced stage - Poor response to drugs with motor side effects
4. Palliative stage - Unable to live independently and in need of multidisciplinary support

Question 15

clinical features of vascular pseudoparkinsonism

Answer 15

• bilateral symmetrical rigidity;
• bradykinesia, predominantly involving - lower limbs
• postural instability; shuffling gait
• falls;
• dementia
• corticospinal findings.
  resting tremor maybe absent

Question 16

clinical features of benign essential tremor

Answer 16

Begin gradually, usually more prominently on one side of the body

Worsen with movement
Usually occur in the hands first, affecting one hand or both hands

Can include a “yes-yes” or “no-no” motion of the head

May be aggravated by emotional stress, fatigue, caffeine or temperature extremes

Question 17

dementia with lewy bodies

Answer 17

cognitive symptoms develop within the year whereas IPD is after a year

Question 18

features of progressive supranuclear palsy

Answer 18

postural instability and falls
— patients tend to have a stiff, broad-based gait

impairment of vertical gaze (down gaze worse than up gaze - patients may complain of difficultly reading or descending stairs)

parkinsonism
— bradykinesia is prominent

cognitive impairment
— primarily frontal lobe dysfunction

pseudobulbar palsy

supranuclear opthalmoplegia

Question 19

progressive supranuclear palsy ?

Answer 19

brain cells in certain parts of the brain are damaged as a result of a build-up of a protein called tau

Question 20

features of multiple system atrophy

Answer 20

alpha synuclein build up

parkinsonism + autonomic disturbance

• erectile dysfunction: often an early feature
• postural hypotension
• atonic bladder

POOR RESPONSE TO LEVODOPA

• rapid progression
• pronounced autonomic failure

cerebellar signs

autonomic NS affected

bladder problems
low BP

Problems with co-ordination, balance and speech
slow moving and feeling stiff

Question 21

types of multiple system atrophy

Answer 21

1) MSA-P - Predominant Parkinsonian features

2) MSA-C - Predominant Cerebellar features

Question 22

first line treatment for parkinson

Answer 22

if the motor symptoms are affecting the patient’s quality of life: levodopa

if the motor symptoms are not affecting the patient’s quality of life: dopamine agonist (non-ergot derived), levodopa or monoamine oxidase B (MAO‑B) inhibitor

Question 23

impulse control disorders more significant

features

Answer 23

• dopamine agonist therapy
• a history of previous impulsive behaviours
• a history of alcohol consumption and/or smoking

Question 24

SEs of levodopa

Answer 24

dyskinesia (involuntary writhing movements), ‘on-off’ effect, dry mouth, anorexia, palpitations, postural hypotension, psychosis, drowsiness

Question 25

what happens if you stop levodopa acutely

Answer 25

acute dystonia

Question 26

examples of dopamine receptor agonists

Answer 26

bromocriptine, ropinirole, cabergoline, apomorphine

Question 27

SEs fo dopamine receptor agonists

Answer 27

(bromocriptine, cabergoline) have been associated with pulmonary, retroperitoneal and cardiac fibrosis. impulse control disorders excessive daytime somnolence more likely to cause hallucinations comapred to levodopa nasal congestion postural hypotension

Question 28

examples of monoamine oxidase B inhibitors

Answer 28

e.g. selegiline | inhibits the breakdown of dopamine secreted by the dopaminergic neurons

Question 29

SEs of amantadine

Answer 29

ataxia, slurred speech, confusion, dizziness and livedo reticularis

Question 30

COMT eg

Answer 30

entacapone, tolcapone | COMT is an enzyme involved in the breakdown of dopamine, and hence may be used as an adjunct to levodopa therapy

Question 31

antimuscarinics?

Answer 31

block cholinergic receptors now used more to treat drug-induced parkinsonism rather than idiopathic Parkinson's disease help tremor and rigidity e.g. procyclidine, benzotropine, trihexyphenidyl (benzhexol)

Question 32

DDx fro parkinson

Answer 32

vascular pseudoparkinsonism benign essential tremor parkinsonism + syndromes drugs antipsychotics toxins - CO, MPTP depression

Question 33

What is meant by on/off fluctuations in patients who are taking levodopa preparations and why do they occur?

Answer 33

Unpredictable fluctuations in motor function due to “wearing off”.

Question 34

causes of parkinsonism

Answer 34

``` Parkinson's disease drug-induced e.g. antipsychotics, metoclopramide* progressive supranuclear palsy multiple system atrophy Wilson's disease post-encephalitis dementia pugilistica (secondary to chronic head trauma e.g. boxing) toxins: carbon monoxide, MPTP ```

Question 35

excessive daytime sleepness remedy

Answer 35

modafinil reviewed every 12 months cant drive infrom DVLA

Question 36

orthostatic hypotension remedy

Answer 36

midodrine hydrochloride then fludrocortisone acetate

Question 37

drooling of saliva

Answer 37

glycopyrronium bromide 2nd line botulinum toxin A

Question 38

Managing motor Sx of parkinsons

Answer 38

offer levodopa w carbedopa or benserazide in early stages of parkinson's disease whose motor Sx impact their quality of life QOL not affected OFFER levodopa, non-ergot-derived dopamine-receptor agonists (pramipexole, ropinirole or rotigotine) or monoamine-oxidase-B inhibitors (rasagiline or selegiline hydrochloride). ADJUVANT THERAPY Patients who develop dyskinesia or motor fluctuations despite optimal levodopa therapy should be offered a choice of - non-ergotic dopamine-receptor agonists (pramipexole, ropinirole, rotigotine) - MAOI (rasagiline or selegiline hydrochloride) - COMT inhibitors (entacapone or tolcapone) as an adjunct to levodopa. ergot-derived dopamine-receptor agonist (bromocriptine, cabergoline or pergolide) should only be considered as an adjunct to levodopa if symptoms are not adequately controlled with a non-ergot-derived dopamine-receptor agonist. If dyskinesia is not adequately managed by modifying existing therapy, amantadine hydrochloride should be considered.

Question 39

What info should be given when starting Mx for motor Sx

Answer 39

impulse control disorders esp w dopamine agonists excessive sleepiness sudden onset of sleep w dopamine agonists Psychotic Sx THESE 3 Sx more likely to be seen with dopamine receptor agonists Levodopa treatment is associated with motor complications, including response fluctuations and dyskinesias. Response fluctuations are characterised by large variations in motor performance, with normal function during the ‘on’ period, and weakness and restricted mobility during the ‘off’ period.

Question 40

Long term problems of parkinsons

Answer 40

50-90% of people who have received L-dopa for 5-10 years may experience the following - motor fluctuations-> when the dose is wearing off, "on" may experience involuntary movements DYSKINESIAS - Axial problems are balance, speech and gait disturbance which do not respond to Parkinson's disease medication -> Due to degeneration outside the substantia nigra where dopamine is not the NT -> Mx- SALT and physio, OT Parkinson's dementia -> occurs more than one year after diagnosis of Parkinson's - Presence of Parkinsonism in the limbs. - Frequent visual hallucinations. - Frequent fluctuations in lucidity.

Question 41

Mx of nocturnal akinesia

Answer 41

levodopa or oral dopamine-receptor agonists should be considered 2nd line -> rotigotine

Question 42

Mx of psychotic Sx

Answer 42

No CI -> quetiapine to treat hallucinations and delusions. above ineffective -> clozapine offered

Question 43

Mx of rapid eye movement sleep behaviour disorder

Answer 43

clonazepam | melatonin

Question 44

Mx of advanced parkinson's disease

Answer 44

apomorphine hydrochloride w domperidone if they ahve N/V chech ECG due to cardiac effects deep brain stimulation - IF DRUG DO NOT WORK

Question 45

what is impulse control disorders

Answer 45

compulsive gambling, hypersexuality, binge eating, or obsessive shopping on dopaminergic therpay modify Mx