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Management of Neuropsychiatric Disorders > Parkinson's/ Parkinson's plus > Flashcards

Parkinson's/ Parkinson's plus Flashcards

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1
Q

What is the prevalence of Parkinson’s disease?

A

Parkinson’s effect 7 to 10,000,000 people

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2
Q

What percentage of people with Parkinson’s have a comorbid
neuro psychiatric condition? 

A

Approximately 70%

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3
Q

What type of ‘opathy’ is Parkinson’s? 

A

An alphasynucleinopathy

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4
Q

Neuronal degeneration of the cholinergic affects which neurotransmitter?

A

Acetylcholine

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5
Q

Neuronal degeneration of the acetylcholinergic pathway affects which two neurotransmitters

A

Dopamine and norepinephrine

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6
Q

What is the core pathology of PD

A

Central dopamine dysfunction and loss of pigment in the substantia nigra

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7
Q

What is the most common neuropsychiatric manifestation of PD psychosis?

A

Visual hallucinations

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8
Q

What percentage of PD patients experience visual hallucinations

A

8-40%

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9
Q

What are visual hallucinations in PD psychosis like?

A

Complex
Eyes are open and the person is alert
Images are blurry
The content of hallucinations varies
Images are predominantly human or animals
Sometimes hallucinations have an emotional significance 

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10
Q

What time of day are visual hallucinations most common?

A

Night

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11
Q
A
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12
Q

What is the most common cause of hallucinations in PD psychosis

A

Medication

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13
Q

What is the prevalence of delusions in PD psychosis

A

5%

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14
Q

What are the most common types of delusions in PD psychosis

A

Othello syndrome
Persecution
Theft
Abandonment

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15
Q

True or false: delusions can occur without visual hallucinations

A

True

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16
Q

What are benign hallucinations

A

Knowing that you are hallucinating

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17
Q

What percentage of PD pt lack insight into their hallucinations

A

Approximately 5%

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18
Q
A
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18
Q

What is PD psychosis a potential biomarker for?

A

Staging
Disease distribution
Progression

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19
Q

What are early symptoms of PD psychosis?

A

Hallucinations
Illusions
Formed hallucinations of people and animals
Unidentified figures 

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20
Q

What are late symptoms of PD psychosis?

A

Loss of insight
Delusions
Themes
Misidentification
Other sensory hallucinations 

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21
Q

What are hallucinations of unidentified figures associated with?

A

Executive dysfunction

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22
Q

What are sensory hallucinations are experienced in PD psychosis?

A

Tactile
Auditory
Olfactory

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23
Q

What percentage of patients without hallucinations at baseline experience multimodal hallucinations by 10 to 12 years of follow-up?

A

60%

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24
What are the risk factor factors for PD psychosis?
Eye thinning of retinal ganglion layer Visual perception difficulties Executive functioning specifically poor Stroop performance, response, inhibition and verbal fluency 
25
What is the pattern of deterioration in cognition across the psychotic spectrum?
Progressive
26
What is PD psychosis associated with?
Depression RBD Vivid dreams
27
What is the relationship between psychosis and cognitive decline?
Psychosis predicts cognitive decline. Visual hallucinations are associated with an increased risk of dementia at eight years
28
What does the progression from minor visual hallucination to fully formed visual hallucinations tell us about neuropathology 
Progression reflects Braak progression of Levy bodies from brainstem to forebrain
29
Widespread cortical levy bodies lead to what?
Multiple modality hallucinations, loss of insight and delusions 
30
True or false: levodopa infusion leads to PD hallucinations?
False
31
What is the mx for PD psychosis?
Exclude delirium Withdraw antiparkinsonian medications Lowest dose of levodopa that maintains motor symptoms Supportive tx Pimavanserin serotonin 2a inverse agonist
32
What is the effect of risperidone and olanzapine
Motor deterioration
33
Which antipsychotic may be beneficial for PD psychosis?
Clozapine
34
What is the effect of Quetiapine on PD psychosis?
Negative results vs placebo at low dose (200mg)
35
What the serotonin hypothesis of visual hallucinations in PD psychosis?
Clozapine and quetiapine (serotonin 2a and 2c receptor agonists) are effective antipsychotic tx Antipsychotic effects occur at low doses Visual hallucinations associated with increased serotonin 2a receptor binding in the ventral visual pathway
36
Pimavanserine for PD psychosis
FDA approved 74% of ps experienced improvement in symptoms Nearly complete resolution in 14% of ps
37
Scale for assessment of positive symptoms in Parkinson’s disease (SAPS-PD)
Pimavanserin associated with significantly decreased occurrence of positive symptoms at day 29 and 43 vs placebo
38
What is the evidence for cholinesterase inhibitors/ memantine to treat PD psychosis?
Rivastigmine did not significantly reduce NPI visual hallucinations sub scale score Memantine had no effect on NPI scores
39
What is the strongest predictor of evolution to institutional care?
PS psychosis
40
What is the prevalence of PD anxiety?
40%
41
What are the most common anxiety disorders in PD anxiety?
Panic disorder Generalised anxiety disorder Social phobia
42
When do panic attack often occur?
Onset of freezing motor symptoms ‘Off’
43
What is the prevalence of depression in PD?
50%
44
Treatment for PD anxiety and depression
Psychotherapy
45
What are the limitations of psychotherapy for PD anxiety and depression
The extent that you can reality test beliefs is limited as belief such as ‘this is going to get worse and I’m going to die’ are true.
46
What are the components of the theoretical model of off period distress proposed by Brown (2015)
Trigger Positive metabeliefs Cognitive attentional syndrome Negative metabeliefs Distress
47
What is the trigger?
Off period
48
What is the positive metabelief?
“Worry helps with problem solving” “Monitoring symptoms enables me to have better control over them”
49
What is cognitive attentional syndrome?
Worry and self focused attention
50
What is the negative metabelief?
“My worry is uncontrollable” “When I have symptoms its impossible to focus on anything else”
51
What are pharmacological tx for PD anxiety and depression?
Selective serotonin reuptake inhibitors Fluoxetine and sertraline (activating; side effects: n&v, anxiety, sexual dysfunction) Paroxetine (mild sedative, anxiolytic; side effects: nausea, dry mouth, sexual dysfunction) Citalopram/ escitalopram (anxiolytic, less risk of drug interactions; side effects; sexual dysfunction)
52
Atypical antidepressants to treat PD anxiety and depression?
Mirtazapine (depression, anxiety and insomnia: side effects : sedation a lower doses, weight gain, dry mouth, less sexual dysfunction) Venlafaxine (anxiolytic , side effects : nausea, dizziness, constipation, sweating; need blood pressure monitoring) Bupropion (apathy, fatigue, poor concentration) Trazodone
53
What are second/ third line tx for PD depression and anxiety? Why?
Tricyclic antidepressants - anticholinergic effects cause confusion - hypotension causes falls - side effects: weight gain, sexual dysfunction Amitriptyline Nortriptyline
54
What is the interaction effects between antidepressants and risagiline/ selegiline
Serotonin syndrome (low risk )
55
What are the symptoms of serotonin syndrome?
Fever Confusion Agitation Stupor Sweating Diarrhoea Delusions Mania Tremor Rigidity
56
What is the prevalence of apathy in PD
17 to 70%
57
Aetiology of apathy in PD?
Dysfunction of the mesocorticolimbic system Deficits in reward processing
58
Impulse control disorders related to dopaminergic (LEVODOPA) medication in PD
Pathological gambling Pathological hypersexuality Compulsive shopping Overeating Punding
59
What is punding?
Peculiar stereotyped behaviours characterised by and intense fascination with a repetitive activity
60
Common punding behaviours?
Sorting collections Grooming Hoarding Knitting
61
What is the aetiology of impulse control disorders in PD?
Dopamine depletion in the motor dorsal striatum Relative preservation of the ventral striatum
62
Treatments for impulse control disorders?
Reduce dopamine replacement therapies CBT (reduced sx from moderate to mild) - global symptom severity reduction vs waiting list controls - reduced caregiver burden and distress
63
Evaluation of deep brain stimulation for ICDs?
De novo occurrence post dbs Able to reduce dopamine replacement therapies Consistent stimulation reduces risks of ICDs
64
Iowa gambling task
74% reduction in dopamine replacement therapy Improved performance on task at 3 months following substantia nigra dbs
65
Burkhard 2004
66
Foncke 2006
67
Causes of suicide (risk factors)
Male Single Previous attempts Substance misuse Depression Anxiety Previous psychiatric admission Physical illness Older age
68
What is the prevalence of dopamine agonist withdrawal syndrome (daws)
8-19%
69
Sx of DAWS?
Anxiety and panic attacks Depression Agitation Irritability Dysphoria Insomnia Fatigue Generalised pain Drug cravings Autonomic signs
70
Early executive dysfunction is associated with what pathology?
Fronto-striatal pathological changes
71
Noradrenergic changes in the locus coeruleus are associated with what cognitive changes?
Early changes in attentional set shifting
72
Later dementia is due to what pathology
Extensive cortical lewy bodies which leads to cholinergic effects
73
What are the hallmarks of Lewy body dementia
Visual hallucinations Fluctuating alertness and attention Visuospatial impairment (drawing)
74
How do pt with Lewy body dementia perform on visuspatial tasks compared to Alzheimer’s
Worse
75
DBS target for Lewy body dementia
Targeting the nucleus basalis of maynert improves attention, concentration and alertness However based on a case report only
76
Phase one trial evidence of nucleus basalis as a target in Alzheimer’s
Low frequency stimulation had an excitatory effect on the cholinergic output of the nucleus basalis of maynert
77
What are Parkinson’s plus syndromes?
Disorders of multiple system degeneration characterised by classic Parkinsonism symptoms
78
What are the classic Parkinsonism symptoms
Tremor Rigidity Postural instability Akinesia/ Bradykinesia
79
What additional features distinguish parkinsonisms from Parkinson’s disease
Symmetrical/ bilateral onset Lack of tremor Negative response to dopamine

Management of Neuropsychiatric Disorders (25 decks)

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