Parkinson’s/movement disorder

Question 1

Definition of Parkinsons Disease

Answer 1

• Progressive
Neurodegenerative disease from loss of dopaminergic neutrons in nigro-strial pathway of basal ganglia 
• onset gradual, manifesting as bradykinesia, rigidity and tremor 
• Motor /Non-motor
/Neuropsychiatric
manifestation
• Incidence increase after age
60

Question 2

Parkinson’s Disease: Describe Bradykinesia

Answer 2

• loss of normal arm swing while walking
• decreased blinking of eyelids
• loss of ability to swallow
• blank expression
• difficulty initiating movement

Question 3

Parkinson’s Disease: Describe Rigidity

Answer 3

• Increased resistance to passive movement, may led to pain and stiffness
• cog wheel, Jerky slow movement

• 75-90 % of PD pts
• Begins unilaterally on same side as tremor, may progress bilateral
• Cogwheel rigidity (tremor
superimposed on increased tone)
• Bed side test–muscle tone

Question 4

Parkinson’s Disease: Describe Tremor

Answer 4

• commonly in hands and arms
• pill rolling motion with the fingers
• Occurs most often at rest
• may involve diaphragm, tongue, lips and jaw
• increased with stress

Question 5

Parkinson’s Disease: Non-Motor Symptoms

Answer 5

Olfactory dysfunction, constipation, depression, REM sleep disorder may present before motor symptom

Question 6

Parkinson’s Disease: Neuropsychiatric Manifestations

Answer 6

• Cognitive dysfunction –Executive/Dementia-I year after PD Dx
• DDx -Lewy Body Dementia-Dementia begin before or concurrently with PD
symtoms–DLB)
• Psychosis / Hallucinations-drug related /PD
• Mood disorder - depression /anxiety, apathy, Fatigue

Question 7

Parkinson’s Disease: Autonomic Manifestations

Answer 7

orthostatic hypotension, urinary symptoms, sexual dysfunction, constipation, GI dysfunction dysphagia

Question 8

Differential Diagnosis for parkinsonian syndrome (Bradykinesia plus Tremor or Rigidity)

Answer 8

Idiopathic PD 
Benign essential tremor
Drug induced
Pressure from Hydrocephalus or Chronic Subdural
Metabolic –Wilsons
Lewy Body Dementia
Parkinson plus syndrome
Multisystem atrophy
Progressive Supranuclear Palsy

Question 9

Clinical features suggesting a parkinsonian syndrome is not due to Idiopathic Parkinson’s disease

Answer 9

• History of severe cerebral trauma, stroke ,exposure to
Neurotoxins or Anti dopaminergic drugs
• No rest Tremor –
• Symmetrical signs
• Associated ophthamoplegia,pyramidal or cerebellar signs
• Associated severe autonomic dysfunction
• Rapid disease progression
• Poor response to levodopa

Question 10

Diagnosis of Parkinson’s

Answer 10

• Primarily clinical.
• Diagnosis uncertainty, can use presynaptic dopaminergic imaging, DaT Scan, to establish the correct diagnosis.
• Brain MRI exclude PD mimics: stroke, hydrocephalus

Question 11

What is a DAT Scan?

Answer 11

Imaging of dopamine transporter density that will be abnormal in any process that reduces this density.

For example, will be abnormal: neurodegenerative disorders, neurogenetic disorders (some spinocerebellar ataxias, Wilson’s disease), cerebrovascular disease

Will be normal if pathology does not reduce dopamine transporters: essential tremor, dystonic tremor or other dystonia, drug-induced parkinsonism, functional parkinsonism and/or tremor

Question 12

7 types of drugs available for the treatment of Parkinson’s motor symptoms

Answer 12

• Levodopa
• Dopamine agonists
• MAO inhibitors
• COMT inhibitors
• Anticholinergic
• Amantadine – weak antiparkinsonism drug
• Peripheral decarboxylase inhibitors

Question 13

Risks of sudden withdrawal of Parkinson’s drugs

Answer 13

Both L-dopa and DA risk of parkinsonian hyperpyrexia syndrome (Neuroleptic Malignant Syndrome )

Question 14

What drugs must be avoided in Parkinson’s disease?

Answer 14

–avoid phenothiazine for anti-sickness, such as prochloperizine/metochlopromide
• Use Domperidone

Question 15

Side Effects of L-Dopa and DA for Parkinsons

Answer 15

GI upset, sleepiness, postural hypotension, confusion, hallucination

Question 16

Name two MAO B Inhibitors used to treat Parkinson’s

Answer 16

• Selegiline/Rasagiline
• Modest symptomatic benefit
as monotherapy
• Caution with SSRI /Amitryptyline

Question 17

What is the indication for anti-cholinergics in Parkinson’s disease

Answer 17

• Mainly for disturbing tremors
• < 70
• Do NOT Use in older age /dementia /without tremor

Question 18

What is the indication for COMT inhibitors in Parkinson’s disease

Answer 18

Entacapone
• Add on therapy for motor fluctuation
• Use as Ldopa extensor –stable prolong therapeutic effect- to deal with end of dose dyskinesia
• SE: Diarrhoea/Yellow colour urine /Monitor LFT

Question 19

Non pharmacological management of Parkinson’s

Answer 19

• Education/Support for patient and family
• Exercise – Physiotherapy /
• Physical therapy – orthopaedic complication of abnormal posture
• Speech therapy-dysphonia /hypophonia - Speech volume and Quality
• High fibre and adequate hydration-Constipation

Question 20

Device-assisted treatment options for management of Parkinson’s

Answer 20

• Deep brain stimulation (DBS)
• Continuous levodopa-carbidopa intestinal gel (LCIG) infusion
delivered through a percutaneous gastrojejunostomy tube
• Continuous subcutaneous apomorphine infusion

Question 21

How should psychosis be treated in a patient with Parkinson’s?

Answer 21

• Psychosis - visual hallucinations and delusions-treat underlying cause of delirium
• Reduced or stop Anti PD drugs in reverse order of potency and effectiveness if disabling hallucinations start with anticholinergic drugs, followed by amantadine, then (COMT) inhibitors, and dopamine agonists. Levodopa should be the last of a drug combination to be reduced, since it is essential in almost all patients with PD in which it is being used.
• Treatment with clozapine, or pimavanserin is an option if all other measures fail