Parkinson's Disease Flashcards by Jack Wildman

What is the annual incidence of PD?

1/8000

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What is the prevalence of PD?

1/800

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What percentage of over 65s are affected by PD?

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What is the median age of onset of PD?

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What is roughly the time from PD disease onset to death?

15 years

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What is the classical pathology of PD? Be specific

Loss of pigmented neurons in ventrolateral tier of SNPC with alpha synuclein inclusions in surviving nigral neurons (Lewy Bodies)

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What percentage of PD cases present before age 45?

Roughly 15%

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How much more likely are non-smokers to get PD than smokers?

Twice as likely

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What is the major environmental toxin linked loosely to a PD like picture?

MPTP

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9 major iatrogenic (drug) causes of Parkinsonism?

Antipsychotics
Prochlorperazine 
Metaclopramide 
Several CCBs
Amiodarone
Valproate
Lithium
Ciclosporin
Chloroquine

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5 major degenerative differentials for PD?

PSP
MSA
Vascular Parkinsonism - diffuse subcortical white matter ischaemia
DLB
Acute vascular Parkinsonism

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What are the 4 key diagnostic features of PD?

Fatiguable bradykinesia with slowing of initiation of movements
Postural instability
Rigidity
Coarse, slow resting tremor (pill rolling)

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What are the 4 major differentials for the PD rest tremor?

Severe essential
Holmes tremor/rubral tremor
Dystonic tremor
Neuropathic tremor

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How might rigidity in early PD manifest as a complaint?

Muscle stiffness and aching discomfort

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How would you describe the rigidity in PD?

Lead pipe

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What early complaints might be heard in PD?

Difficulty with fine motor - doing up buttons, stirring, wiping, brushing teeth, getting things out of pockets…
Muscle aches and stiffness
Dragging or slowness of a limb
Tremor

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What defines early onset in PD?

Less than 40 (/45)

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What prodromal features of PD may be seen?

Major depressive illness or stress may unmask
Fatigue
Bradykinesia, mental inflexibility
Autonomic Sx
Frozen shoulder, low back pain (?due to mobility problems)
REM sleep behaviour disorder
Anosmia

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What is Braak’s hypothesis?

That PD begins in the peripheral autonomic system, olfactory bulb and dorsal nucleus of vagus before spreading rostrally in a prion like mechanism

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What is the name of the hypothesis that PD starts in the autonomic and olfactory system?

Braak’s hypothesis

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What autonomic Sx may be seen early in PD?

Thermodysregulation
Dribbling saliva e.g. At night onto pillow
Colonic motility disturbance and constipation
Erectile dysfunction

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What does vertical saccadic slowing suggest in the context of Parkinsonism?

PSP

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What does delay in initiation of vertical saccades in the context of Parkinsonism suggest?

CBD

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What do horizontal square wave jerks and gaze evoked nystagmus suggest in the context of Parkinsonism?

MSA

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How may speech differentiate types of Parkinsonism?

Monotonous and quiet in PD Growly and slow in PSP Nasal and whining in MSA

What eyelid signs may suggest PSP?

Eyelid apraxia | Near-absent spontaneous blinking

What should babinski signs in Parkinsonism without cervical spondylotic myelopathy/prev stroke make you think about?

Is it MSA (maybe PSP) Genetic pallidopyramidal syndrome e.g. Hallervorden-Spatz (PKAN) or another NBAI such as Kufor-Rakeb syndrome or PLA2G6 neuroaxonal dystrophy

Why is lying and standing BP after 2 mins important in assessing PD?

Postural hypotension of over 20 systolic may suggest increasing risk of falls if starting on dopaminergic meds

What should significant orthostasis preceding Parkinsonism make you think about?

Is it MSA-P

What might be a useful way to distinguish between PD and essential tremor on exam?

Get patient to hold arms/hands outstretched - latent interval of a few seconds before tremor appears in PD vs tremor present straight away in essential

What is the possibly arbitrary definition of DLB?

Dementia occurring within the first year of onset of Parkinsonism or before onset

What rating scales may be useful in analysing disease response for PD especially early on?

UPDRS (parts 2 and 3)

What might make you reconsider a presumptive PD diagnosis?

Poor response to therapy (750mg/day LDopa) at 4 months, having doubled dose at 3 months

What constitutes a formal acute levodopa challenge?

250mg of levodopa/benserazide with finger tapping and timed walking tests at baseline and 1 hour then 2 hours With all PD meds stopped overnight beforehand and domperidone if nauseous

What should be done for a bradykinetic-rigid predominant phenotype of presumed PD that hasn't responded to initial LDopa therapy? Looking for what?

MRI Hot cross bun sign in pons, pontocerebellar atrophy, hyperintense putaminal rim on T2 - MSA Midbrain and superior cerebellar peduncle atrophy (hummingbird/penguin sign) - PSP Vascular Parkinsonism - subcortical white matter ischaemia and striatocapsular infarcts Secondary Parkinsonism e.g. Basal ganglia calcification

What might be a good investigation for predominantly tremulous patients with suspected PD?

DAT scan, as normal DAT excludes PD

2 important surgical causes of Parkinsonism?

Supratentorial meningiomas | Communicating hydrocephalus

What is the middle cerebellar peduncle sign and what does it suggest?

Increased white matter T2 signal in middle cerebellar peduncle With tremor, ataxia and Parkinsonism suggests fragile X premutation (FRXTAS) esp if FH/male patient

What is ephedrone toxicity and what can it cause? Where is it a major problem?

Subacute bradykinesia, severe dysarthria, dystonic posturing and walking and severe postural instability with backwards falls Due to illicit ephedrone IV injection, made from sudafed (pseudoephedrine) Big in Eastern Europe

What is the initial maintenance dose of L dopa?

50mg TDS | /62.5mg TDS if with a DDCI (carbidopa/benserazide)

What is the max L dopa dose per day with aim to reduce long term side effects?

600mg/day

What is the main role of L dopa sparing agents?

To avoid on-off phenomena and end of dose deterioration, and also peak dose choreoathetosis

What is the best drug to reduce dyskinesias in PD?

Amantadine

What drugs might be useful for off-period dystonia in earlier onset PD patients?

Anticholinergics

Commonly used MAO-B inhibitors in PD?

Selegiline | Rasagiline

What are commonly used COMT inhibitors?

Entacapone | Tolcapone

What are commonly used dopamine agonists?

Rotigotine - patch Ropinerole Pramipexole Apomorphine

What might be a reasonable starting drug for patients with mild motor disability only in PD?

Rasagiline - a MAO-B inhibitor

What are the 3 best methods of managing refractory motor fluctuations for PD?

Apomorphine subcut administration Duo-dopa - continuous intrajejunal L dopa administration through a gastrojejunostomy DBS - usually bilateral STN

Managing insomnia in PD?

Nocturnal dopaminergic drug dose Clonazepam Low dose amitriptyline Sleep hygiene

Management of depression in PD?

Noradrenergic reuptake inhibitors e.g. Duloxetine | Amitriptyline or nortryptiline

Management of REM sleep behaviour disorder in PD?

Melatonin | Clonazepam

Management of daytime sleepiness in PD e.g. Due to dopamine agonist therapy?

Modafinil

Management of psychosis in PD?

Reduce doses of antiPD drugs, consider clozapine quetiapine or Aripiprazole and cholinomimetics

Management of constipation in PD?

Macrogol - osmotic laxative | Faecal softeners

Management of urinary urgency in PD?

Bladder stabilisers e.g. Tolterodine, trospium | Desmopressin if nocturia

Management of ED in PD?

Sildenafil

Management of rigidity/dystonia pain in PD?

Clonazepam, Anticholinergics

Management of restless legs in PD?

Dopamine agonists

Management of orthostatic hypotension in PD?

Increase water and salt Fludrocortisone Ephedrine/midodrine

Management of drooling in PD?

Atropine eye drops sublingually (0.5%) | Botulinum toxin injections into salivary glands

Management of excessive sweating in PD?

Propranolol | Propantheline

What is Stalevo?

L dopa plus carbidopa plus entacapone

What is madopar?

Co-beneldopa

What is sinemet?

Co-careldopa

What is azilect?

Rasagiline

What is a commonly used anticholinergic in PD?

Trihexiphenidyl

How is Parkin PD inherited?

How does Parkin PD differ to idiopathic?

More benign, with restricted SN lesion but not alpha synuclein Early onset and slowly progressive with no Anosmia, leg presentation and common rest tremor

How is LRRK2 PD inherited? What is the mutation? What about its penetrance?

AD G2019S Incomplete penetrance but a susceptibility gene seen in sporadic PD fairly often

How is LRRK2 different to Parkin PD?

It is an alpha synucleinopathy so is more like IPD

What percentage of PD patients get dementia by terminal stages/over 70 years?

40%

Parkinson's Disease Flashcards

(72 cards)