Parkinson's disease

Question 1

Parkinson’s disease criteria

Answer 1

Gradual onset progressive:
1) Bradykinesia: slow initiation with reduced speed and amplitude of repetitive actions eg. finger or foot tapping

2) Or hypokinesia: poverty of movement:
- reduced facial expression, arm swing, blinking
- difficulty with fine movements - doing buttons, jars, micrographia.
- slow, shufflingg gait, freezing gait or difficulty turning in bed

+ >1:
1) Stiffness or rigidity: led pipe/cogwheel (if with tremor)

2) Rest tremor: improves on moving/concentrating/during sleep. Can be pill-rolling or affect wrist, leg, lips, jaw, head

3) Balance problems/gait disorder:: stooped, pull test - falls backwards

Non-motor:
1) Depression. anxiety
2) Anosmia
3) Cognitive impairment
4) Sleep disturbance
5) Constipation

Question 2

Drug induced Parkinsonism

Answer 2

Typically rapid onset, bilateral and without rigidity, possibly action tremor.

1) Antipsychotics (within 10 weeks): 1st generation (haloperidol, chlorpromazine, penthixols) > 2nd generation (amisulprode, aripiprazole, olanxapine, quetiapine, risperidone)

2) Anti-emetics: prochlorperazine, metoclopramide

Less commonly: SSRI, CCB, amiodarone, lithium, donepezil, memantime, sodium valproate, methyldopa

Question 3

Progressive supra nuclear palsy

Answer 3

Early dysphagia, gaze palsy, recurrent falls

Question 4

Multiple system atrophy

Answer 4

Severe autonomic involvement eg. postural hypotension or cerebellar ataxia

Question 5

Wilson’s disease

Answer 5

Kayser-Fleischer rings, tremor, ataxia, dystonia, liver disease

Question 6

Essential tremor

Answer 6

Bilateral, symmetrical

Worsens with stress, caffeine, sleep deprivation

Improves with alcohol and BB

Use SPECT if can’t differentiate essential tremor from tremor in PD

Question 7

Driving in Parkinson’s disease

Answer 7

Must notify DVLA

G1: may drive if safe

G2: may drive if safe, review annually

Question 8

Medical management of Parkinson’s disease - motor symptoms

Answer 8

1) Levodopa + co-beneldopa/careldopa to prevent peripheral metabolism of LD and reduce SE
- LD improves motor symptoms, but can cause motor complications eg. dyskinesias

2) MAO-B inhibtitors (selegiling, rasagiline, safinamide)
- less improvement in motor fumnction, but less motor complications

3) Oral dopamine agonists (praipexole, ropinirole, rotigotine)
- less improvement in motor symptoms, less motor complications, more adverse effects (sleepiness/halls/impulse control)

4) Ergot derived dopamine agonists (cabergoline, pergolide)
- risk of cardiac fibrosis with long-term use therefore not used 1st line

Adjuvant treatments:
1) COMT inhibitor (entacapone, opicapone) - with levodopa if develops dyskinesia or motor fluctuations despite optimal LDopa therapy

2) Amantadine - for dyskinesia

3) S/C apomorphine - for freezing episodes on optimal treatment

4) DBS

Question 9

Nausea & vomiting in PD

Answer 9

If medication related should settle, take with food.

Avoid metoclopramide or prochlorperazine

Consider low dose domeridone (increased risk of VT and also QT prolongation with apomorphine)

Specialists may increase proportion of co-careldopa to L-Dopa

Question 10

Which PD medication is best for motor symptoms?

Answer 10

Levodopa

Question 11

Which PD medication is best for ADLs?

Answer 11

Levodopa

Question 12

Which PD medication has most motor complications?

Answer 12

Levodopa

Question 13

Which PD medication has most adverse events - excessive sleepiness, hallucinations, impulse control disorders

Answer 13

Dopamine agonists (pramipexole, ropinirole, rotigotine). Increased risk if history of alcohol/smoking or impulsive behaviours

Impulse control disorders - gambling, hyper sexuality, binge eating, obsessive shopping - can offer CBT if modifying DA therapy not effective

Question 14

First line treatment in early PD if motor symptoms impact on QoL?

Answer 14

Levodopa

Question 15

First line treatment in early PD where motor symptoms do not impact on QoL?

Answer 15

Choice of levodopa, DA agonists, MAO-B inhibitors

Question 16

Which medication is not offered first line in PD?

Answer 16

Ergot-derived DA agonists (bromocriptine, pergolide, cabergoline)

Question 17

Managing day-time sleepiness in PD

Answer 17

1) Inform DVLA, stop driving

2) Modafinil (CI in pregnancy)

Question 18

Managing REM sleep behaviour disorder (?+ restless leg syndrome) in PD

Answer 18

Cloazepam or melatonin

Question 19

Managing noturnal akinesia in PD

Answer 19

Levodopa or DA agonists

Consider rotigotine patch if levodopa and/or PO DA agonists not effective

Question 20

Managing orthostatic hypotension in PD

Answer 20

Causes: anti-HTN, dopaminergic, anticholinergics, antidepressants

Consider midodrine (monitor for supine HTN)

If midrodrine CI/not tolerated - consider fludrocortisone

Question 21

Managing hallucinations and delusions in PD

Answer 21

If not tolerated by patient and family consider quetiapine if no cognitive impariemt

If not effective, offer clozapine

Lower doses of quetiapine and clozapine are needed in PD

Do not offer olanzapine
Phenothiazines and butyrophenones can worsen motor features

Question 22

Managing PD dementia

Answer 22

Offer cholinesterase inhibitor in mild-moderate dementia (consider in severe dementia)

Rivastigmine capsules are the only one authorised.

can use donepezol, galantamine and rivastigmine off-label

If cholinesterase inhibitors not tolerated /CI consider memantine

Question 23

Managing drooling of saliva in PD

Answer 23

1) SALT

2) If SALT not effective consider glycopyronium bromide

3) If GB not effective or CI (cognitive impairment, hallucinations, delusions, adverse reaction to anticholinergics) - consider Botox

Question 24

PD and physical activity

Answer 24

1) early physio

2) disease specific physio

3) Alexander Technique if balance/motor function problems

Question 25

PD and diet

Answer 25

If on levodopa with motor fluctuations - recommend most of protein eaten in final main meal of the day

Take vitamin D

Question 26

Levodopa side effects

Answer 26

1) dry mouth
2) anorexia
3) palpitations
4) postural hypotension
5) psychosis
6) dyskinesias at peak dose - dystonia, chorea, athetosis

Question 27

Ergot derived DA agonsits side effects

Answer 27

Pulmonary, retroperitoneal and cardiac fibrosis

ECG, Cr and CXR proor to treatment

Question 28

Amantadine side effects

Answer 28

Ataxia, slurred speech, confusion, dizziness, livedo reticularis