Parkinsons disease Flashcards by Georgia Leggett

What is Parkinsons disease?

Neurodegenerative disease resulting from loss of dopaminergic neurones in the substantia nigra

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When does Parkinson’s become clinically apparent?

Not until >,50% of dopaminergic cell activity has been lost

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What is Parkinsonism?

Umbrella term for the clinical syndrome involving bradykinesia plus at least 1 of tremor, rigidity, +/or postural instability.

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Excluding PD, list 5 causes of Parkinsonism

Drug-induced parkinsonism
Cerebrovascular disease
Lewy body dementia
Multiple system atrophy
Progressive supranuclear palsy.

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Name 2 drugs that can cause Parkinsonism

Antipsychotics
Metoclopramide

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What triad of symptoms characterises Parkinson’s?

Resting tremor
Bradykinesia
Rigidity

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What are the aetiological causes of Parkinson’s?

Idiopathic (most common)
Genetic (minority)

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Describe epidemiology of Parkinsons

Mean age ~65y
M > F

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Describe 3 features of bradykinesia in Parkinsons disease

Short, shuffling steps + reduced arm swing
Difficulty + slowness initiating movement
Poverty of movement (hypokinesia)

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Describe the tremor in PD

Most marked at rest, 3-5 Hz
Worse when stressed or tired
Improves with voluntary movement/ action/ mental concentration
“Pill rolling”: thumb + index finger
Usually asymmetrical

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Describe the rigidity in Parkinson’s disease

Lead-pipe: constant resistance felt when limb is passively flexed in the presence of hypertonia without tremor
OR
Cogwheel: regular intermittent relaxation of tension felt when limb is passively flexed in the presence of tremor + hypertonia.

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List 6 autonomic/ non-motor symptoms seen in Parkinsons

Postural hypotension + falls
Constipation
Urinary frequency/ urgency
Dribbling of saliva
Sexual dysfunction
Anosmia

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How can you screen for postural instability?

Pull test
Tendency to fall backwards after a sharp pull from the examiner.

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Give 2 ways in which energy/ sleep if affected in Parkinson’s

REM sleep behaviour disorder
Fatigue

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List 5 signs of Parkinsons

Mask like facies/ Hypomimia
Flexed posture
Quiet voice
Smaller hand writing (micrographia)
Drooling of saliva

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Describe the gait in PD

Stooped  
Shuffling  
Small-stepped gait 
Reduced arm swing  
Difficulty initiating walking

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What 2 features describe the onset of PD?

INSIDIOUS
Unilateral

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What is meant by the terms “on” and “off” in relation to a PD patient?

ON: moving well, may have dyskinesias
OFF: stiff + bradykinetic

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What psychological pathologies may arise with PD?

Depression
Dementia
Psychosis

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How does drug-induced Parkinsonism differ?

Motor Sx are usually rapid onset + bilateral
Rigidity + rest tremor uncommon

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Describe diagnosis of PD

Refer urgently to a specialist
Clinical dx
Response to dopaminergic therapy is supportive

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What neuroimaging investigation can be used to differentiate PD from essential tremor?

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DaTSCAN: single photon emission computed tomography (SPECT) using
123 I‑FP‑CIT

List 5 drug classes for managing PD

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Levodopa + dopa-decarboxylase inhibitor
Dopamine agonists
MAO-B inhibitors
COMT inhibitors
Anticholinergics

What is the first line treatment if the motor symptoms are affecting the patient’s quality of life in PD?

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Levodopa + carbidopa

What is the first line treatment if the motor symptoms are NOT affecting the patient's quality of life in PD?

Dopamine agonist (non-ergot derived) or Levodopa or Monoamine oxidase B (MAO‑B) inhibitor

Why must a dopamine decarboxylase inhibitor be given with Levodopa?

Prevents peripheral metabolism of levodopa to dopamine outside of the brain + hence reduces side effects

Give 3 advantages of Levodopa treatment

Most effective Tx for motor Sx More improvement in ADLs Fewer adverse effects e.g. excessive sleepiness, hallucinations, + impulse control disorders

Give a disadvantage of Levodopa treatment

More motor complications e.g. dyskinesia

List 5 common adverse effects of Levodopa

Dry mouth Anorexia Palpitations Postural hypotension Psychosis

Which adverse effects are due to the difficulty in achieving a steady dose of levodopa?

End-of-dose wearing off: Sx worsen towards end of dosage interval= decline of motor activity On-off phenomena: large variation in motor performance (normal function during on vs weakness + reduced mobility during off) Dyskinesias at peak dose: dystonia, chorea + athetosis

If a patient acutely cannot take levodopa orally, what must be given? Why?

Dopamine agonist patch as rescue medication To prevent acute dystonia

Name 2 monoamine oxidase B inhibitors

Selegiline Rasagiline

Give 2 advantages of MAO B inhbitors

Less motor complications Less adverse effects e.g. excessive sleepiness, hallucinations, + impulse control disorders

Give a disadvantage of MAO B inhibitors

Less improvement in motor Sx + daily functioning

What is the MOA of MAO-B inhibitors?

Inhibit breakdown of dopamine secreted by the dopaminergic neurons

Name 2 dopamine agonists (non-ergot)

Ropinirole Pramipexole

Give an advantage of dopamine agonists (non ergot)

Less motor complications

Give 2 disadvantages of dopamine agonists (non ergot)

Less improvement in motor Sx + daily functioning More adverse effects e.g. excessive sleepiness, hallucinations, + impulse control disorders

Why are ergot dopamine agonists no longer used first line? Name 2

Risk of pulmonary, retroperitoneal + cardiac fibrosis with long-term use and need for additional monitoring. Cabergoline, Bromocriptine

If ergot derived dopamine receptor agonists are used in PD, what must be performed?

Echocardiogram, ESR, creatinine + CXR obtained prior to Tx Patients should be closely monitored

Which drugs can be used as adjuncts to levodopa if a patient continues to have symptoms or has developed dyskinesia?

Dopamine agonist MAO‑B inhibitor Catechol‑O‑methyl transferase (COMT) inhibitor Amantadine

Name 2 COMT inhibitors

Entacapone Opicapone

What is the mechanism of action of COMT inhibitors?

prevent peripheral degradation of levodopa, allowing a higher concentration to cross the BBB hence used as adjunct

What are the benefits of adjunctive COMT in PD?

More improvement in motor Sx + daily functioning Lower risk of hallucinations than other drug classes.

What are the disadvantages of adjunctive COMT in PD?

More adverse effects such as excessive sleepiness + impulse control disorders

What is the probable mechanism of action of amantidine?

Increases dopamine release Inhibits uptake at dopaminergic synapses

List 6 side effects of Amantadine

Confusion Constipation Dizziness Dry mouth Slurred speech Livedo reticularis

What complications can arise due to missing/ not absorbing Parkinson's medication?

Acute akinesia Neuroleptic Malignant Syndrome

Give 3 factors increasing risk for impulse control disorders

Dopamine agonist therapy Hx of previous impulsive behaviours Hx of alcohol consumption and/or smoking

What drug can be used to manage drooling in Parkinson's?

Glycopyrronium bromide

Describe management of excessive daytime sleepiness in PD

No driving Medication adjustment Modafinil if alternative strategies fail.

Describe management of orthostatic hypotension in PD

Medication review If Sx persist: Midodrine (acts on peripheral alpha-adrenergic receptors to increase arterial resistance)

What class of drugs can be used to treat drug-induced parkinsonism? What do they do? Give 2 examples

Anti-muscarinics, block cholinergic receptors Help reduce tremor + rigidity Procyclidine Benzotropine

Parkinsons disease Flashcards

(53 cards)