Parkinson's disease Flashcards Preview

Alasdair - Neurology > Parkinson's disease > Flashcards

Flashcards in Parkinson's disease Deck (33):
1

Signs of Parkinson's disease on general inspection

Asymmetrical resting tremor: 5Hz - exacerbated by counting backwards
Hypomimia (reduced facial expression)
Extrapyramidal posture

2

Signs of Parkinson's disease in the arms

Bradykinesia
Tone: cogwheel rigidity, may be enhanced by performing an action with the other limb
Normal power and reflexes
Coordination: abnormal if MSA

3

Signs of Parkinson's disease in the eyes

Nystagmus: MSA
Vertical gaze palsy: PSP
Saccades: slow initiation and movement

4

Definition of cogwheel rigidity

Tremor superimposed on increased tone

5

Gait signs in Parkinson's disease

Slow initiation
Shuffling (preceded by reduced stride length)
Hurrying = festination
Absent arm swing

6

Extra signs in Parkinson's`

Glabellar tap (Myerson's sign)
Write sentence and draw spiral (micrographia)
BP lying and standing

7

Completion of Parkinson's exam

MMSE
Drug chart review
Abdominal examination: hepatomegaly + signs of CLD (DDx hepatic encephalopathy)

8

Causes of Parkinsonism

Idiopathic PD
Parkinson Plus Syndromes:
Progressive Supranuclear Palsy (PSP)
Multiple system atrophy (MSA)
Lewy-body dementia
Corticobasilar degeneration
Multiple infarcts in the substantial nigra
Wilson's disease
Drugs: neuroleptics, metoclopramide

9

Specific history for Parkinsonism

Symptoms: tremor, rigidity, akinesia
Autonomic: postural hypotension, urinary problems, constipation, hypersalivation
ADLs:
Handwriting, buttons, shoelaces
Getting in and out of a car
Sleep:
Turning in bed, insomnia, daytime sleepiness
Complications:
Depression
Drug SEs esp. motor fluctuation
Cause:
Sudden onset?
Eye or balance problems
Visual hallucinations, reduced memory
DHx
FHx

10

Investigations for Parkinsonism

Bloods: caerulopasmin (low in Wilson's)
Imaging: CT/MRI to exclude vascular cause
DaTscan: ioflupane I123 injection binds to domapinergic neurones and allows visualisation of substantial nigra - can exclude other causes of tremor e.g. benign essential tremor.

11

General management of Parkinsonism

MDT
Assess disability e.g. using UPDRS (Unified Parkinson's Disease Rating Scale)
Physiotherapy: postural exercises
Depression screen

12

Specific medical treatment of Parkinson's

Choice of treatment depends on balance between improvement in motor symptoms and motor and psychiatric side-effects.
MAO-B: selegiline, rasagiline.
Oral/transdermal dopamine agonist: ropinirole, pramipexol.
Levodopa (most effective symptomatic drug)
For more advanced disease:
Apomorphine SC as a rescue agent for severe 'off' episodes.
Amantadine or an antimuscarinic e.g. procyclidine.
COMT inhibitors e.g. tolcapone.

13

Use of levodopa in Parkinson's

Given with a peripheral dopa-decarboxylase inhibitor. Preparations e.g. Sinemet.
Use lowest effective dose.
Long term use may cause weight loss.
Side effects (N+V) are rare.

14

Use of dopamine agonists in Parkinson's

Effective in controlling motor symptoms, used early in disease. Fewer motor side-effects and weaker effect cf long-term levodopa, therefore used more in younger patients. All eventually require levodopa.

15

Adjunct medications in Parkinson's

Domperidone: nausea
Quetiapine: psychosis
Citalopram: depression

16

Epidemiology of idiopathic Parkinson's disease

Mean onset 65 yoa
2% prevalence

17

Pathophysiology of Parkinson's disease

Destruction of dopaminergic neurones in pars compact and substantial nigra
Beta amyloid plaques
Neurofibrillary tangles: hyperphosphorylated tau

18

Features of Parkinson's disease

Asymmetric onset: side of onset remains worst
TRAPPS PD
Tremor (increased by stress, reduced by sleep)
Rigidity (lead pipe, cog-wheel)
Akinesia (slow initiation, difficulty with repetitive movement, micrographia, monotonous voice, mask-like face)
Postural instability (stooped gait, festination)
Postural hypotension (plus other autonomic dysfunction)
Sleep disorders (insomnia, excessive daytime sleepiness, obstructive sleep apnoea, RBD)
Psychosis esp visual hallucinations
Depression / Dementia / Drug SEs

19

Sleep disorder in Parkinson's Disease

Affects ~90% of PD patients
Insomnia + frequent waking leads to excessive daytime sleepiness (EDS)
Due to: inability to turn, restless legs, early morning dystonia (drugs wearing off), nocturne, obstructive sleep apnoea
REM Behavioural sleep Disorder (RBD): loss of muscle atone during REM sleep, violent enactment of dreams
Dopamine side effects: insomnia, drowsiness, EDS

20

Autonomic dysfunction in Parkinson's disease

Combined effects of drugs and neurodegeneration
Postural hypotension
Constipation
Hypersalivation (dribbling d/t reduced ability to swallow saliva)
Urgency, frequency, nocturne
Erectile dysfunction
Hyperhidrosis

21

L-DOPA side-effects

DOPAMINE
Dyskinesia
On-off phenomena = motor fluctuations
Psychosis
Autonomic BP problems (orthostatic hypotension)
Mouth dryness
Insomnia
N/V
Excessive daytime sleepiness

22

Motor fluctuations with levodopa treatment

End-of-dose (wearing off): progressively decreased benefit
On-off effect: unpredictable fluctuations in motor performance unrelated to timing of dose

23

Pathology of multi system atrophy

Papp-Lantos Bodies: alpha-synuclein inclusions in glial cells

24

Features of multi system atrophy

Autonomic dysfunction: postural hypotension
Parkinsonism
Cerebellar ataxia

25

Differentiating MSA from Parkinson's

Main differentiating factor is in MSA parkinsonism does not improve with levodopa

26

Name of MSA if autonomic features predominate

Shy Drager Syndrome

27

Features of progressive supranuclear palsy (PSP)

Postural instability leading to falls
Vertical gaze palsy
Pseudobulbar palsy (speech and swallowing problems)
Parkinsonism (but: symmetrical onset, tremor is unusual)

28

Features of corticobasilar degeneration

Unilateral parkinsonism, esp rigidity
Aphasia
Astereognosis: cortical sensory loss
Alien limb phenomenon: autonomous arm movements

29

Pathology of Lewy-Body Dementia

Alpha synuclein and ubiquitin Lewy Bodies in brainstem and neocortex

30

Features of Lewy-Body dementia

Fluctuating cognition
Visual hallucinations
Parkinsonism

31

Features of Parkinsonism

Sudden onset
Parkinsonism worse in legs than arms
Pyramidal signs
Prominent gait abnormality

32

Causes of tremor

Resting tremor: parkinsonism
Intention tremor: cerebellar
Postural tremor (worse with arms outstretched): Benign essential tremor, hyperthyroidism, alcohol withdrawal, beta agonists, anxiety.

33

Features of benign essential tremor

Autosomal dominant
Occurs with movement and worse with anxiety, caffeine
Doesn't occur during sleep
Better with EtOH