TEST 4- STUDY GUIDE 3

Question 1

Parkinson’s- What are the 3 cardinal manifestations of Parkinson’s disease?

Answer 1

-Bradykinesia- slowness of movement
-Rigidity
-Rest tremor

Question 2

What do patients with Parkinsons disease look like?

Answer 2

stooped posture:
-Cogwheeling
-tremor
-maslike face (hypomimia)
-soft speech (hypophonia)
- small, slow handwriting (micrographia)
-dysphagia
-cognitive decline

Question 3

John, a 68-year-old man, presents to the clinic with complaints of difficulty in movement and maintaining balance. Over the past year, he has noticed a tremor in his right hand, especially at rest, and a significant reduction in his handwriting size. His family reports that he has developed a stooped posture and shows little facial expression. He occasionally experiences moments of confusion and mild hallucinations. John also reports ongoing issues with constipation and recent difficulty with speaking softly.

Question 1: Identifying Core Symptoms

Q: What are the core manifestations of Parkinson’s Disease observed in John’s presentation?

Answer 3

A: Bradykinesia, rest tremor, rigidity, stooped posture, hypomimia (masklike face), micrographia, and hypophonia.

Rationale: PD commonly presents with a combination of motor symptoms such as bradykinesia, rest tremor, and rigidity alongside additional features like hypomimia, hypophonia, and micrographia, all of which are observable in John’s symptoms.

Question 4

*Q:** What non-motor symptoms associated with Parkinson’s Disease does John exhibit?

Answer 4

Constipation, soft speech (hypophonia), cognitive changes, confusion, and hallucinations.

Rationale: Non-motor symptoms, including autonomic dysfunction, cognitive decline, and psychiatric symptoms such as hallucinations, are prevalent in PD patients and can significantly impact the patient’s quality of life.

Question 5

hich non-pharmacological strategies could potentially help manage some of John’s symptoms, such as constipation and balance issues?

A: Dietary modifications, increased fluid and fiber intake for constipation, physical therapy to improve balance and movement, and possibly speech therapy for hypophonia.

Answer 5

Rationale:** Implementing lifestyle changes and therapies can be beneficial in managing some aspects of PD. Physical therapy can help improve mobility and balance, while dietary changes often help relieve constipation issues.

Question 6

Considering John’s hallucinations, why might it be important to review his current medication regimen?

A: Certain PD medications can contribute to or exacerbate hallucinations, necessitating a review to adjust doses or switch medications under medical guidance.

Answer 6

Rationale:** Medication-induced hallucinations are common in PD, particularly with dopaminergic treatments. Adjusting these treatments could help manage these psychiatric symptoms.

Question 7

How might autonomic dysfunction be further evaluated in John to clarify its extent, especially given his bowel and bladder symptoms?

A: Comprehensive questioning about urinary habits, thorough review of bowel movement patterns, clinical tests for orthostatic hypotension, and possible referral to gastroenterology or urology.

Answer 7

Rationale:** Evaluating the full scope of autonomic dysfunction is important for overall management, involving direct inquiry, clinical examination and specialist input if necessary.

Question 8

True or False many patients with Parkinsons disease exhibit behavioral changes?

Answer 8

True:
-apathy
-anxiety
-depression
-agitation
-hallucinations

Question 9

Common problems in parkinsons disease?

Answer 9

-constipation
-bladder dysfunction
-sexual dysfunction
orthostatic hypotension

Question 10

What are the core manifestations of Parkinson’s Disease observed in John’s presentation?

A: Bradykinesia, rest tremor, rigidity, stooped posture, hypomimia (masklike face), micrographia, and hypophonia.

Answer 10

Rationale:** PD commonly presents with a combination of motor symptoms such as bradykinesia, rest tremor, and rigidity alongside additional features like hypomimia, hypophonia, and micrographia, all of which are observable in John’s symptoms.

Question 11

What non-motor symptoms associated with Parkinson’s Disease does John exhibit?

A: Constipation, soft speech (hypophonia), cognitive changes, confusion, and hallucinations.

Answer 11

Non-motor symptoms, including autonomic dysfunction, cognitive decline, and psychiatric symptoms such as hallucinations, are prevalent in PD patients and can significantly impact the patient’s quality of life.

Question 12

Manage some of John’s symptoms, such as constipation and balance issues?

A: Dietary modifications, increased fluid and fiber intake for constipation, physical therapy to improve balance and movement, and possibly speech therapy for hypophonia.

Answer 12

Rationale:** Implementing lifestyle changes and therapies can be beneficial in managing some aspects of PD. Physical therapy can help improve mobility and balance, while dietary changes often help relieve constipation issues.

Question 13

Considering John’s hallucinations, why might it be important to review his current medication regimen?

A: Certain PD medications can contribute to or exacerbate hallucinations, necessitating a review to adjust doses or switch medications under medical guidance.

Answer 13

Rationale:** Medication-induced hallucinations are common in PD, particularly with dopaminergic treatments. Adjusting these treatments could help manage these psychiatric symptoms.

Question 14

How might autonomic dysfunction be further evaluated in John to clarify its extent, especially given his bowel and bladder symptoms?

A: Comprehensive questioning about urinary habits, thorough review of bowel movement patterns, clinical tests for orthostatic hypotension, and possible referral to gastroenterology or urology.

Answer 14

Evaluating the full scope of autonomic dysfunction is important for overall management, involving direct inquiry, clinical examination and specialist input if necessary.

Question 15

Onset of Parkinsons disease

Answer 15

Preclinical stage [6]
Constipation
Anosmia
Sleep disturbances
REM sleep behavior disorder (RBD)
Restless leg syndrome
Excessive daytime sleepiness
Mood disorders (most commonly depression, apathy, and/or anxiety)

Question 16

Parkinsonism TRAPs the patient: Tremor, Rigidity, Akinesia, and Postural instability.

Question 17

Levodopa challenge test: performed to support the diagnosis of PD or as part of the evaluation prior to implantation of a deep brain stimulator

Answer 17

Question 18

Parkinson’s Disease: Follow-up and Referral

Answer 18

Refer to specialist
As the disease progresses, especially in the area of tremor, it may become necessary to refer the patient to a movement disorder neurologist or to a stereotactic neurosurgeon to consider surgical treatment options, such as deep brain stimulation.

Rating scales are frequently used to evaluate and monitor a patient’s response to medications.

The Unified Parkinson’s Disease Rating Scale (UPDRS) is a comprehensive evaluation tool that assesses mental, historical, and motor features and the complications of dopaminergic therapy.

A subscale of the UPDRS is the Activities of Daily Living Scale, which assesses speech, salivation, swallowing, handwriting, cutting food, handling utensils, hygiene, turning in bed, falling, freezing, walking, tremor, and sensory symptoms

Question 19

The ___ Scale (UPDRS) is a comprehensive evaluation tool that assesses?

**tools monitor the patients response to medications

Answer 19

Unified Parkinson’s Disease Rating Scale (UPDRS)

-Mental
-Historical
-Motor features
-Complications of dopaminergic therapy

Question 20

What is the sub scale of the UPDRS is the___

Answer 20

Activities of Daily Living scale (parkinson disease evaluation)

-speech
-salivation
-swallowing
-handwriting
-cutting food
-handling utensils
-hygiene
-turning in bed
-falling
-freezing
-walking
-tremor
-sensory symptoms

Question 21

When should a patient with Parkinson’s Disease be referred to a movement disorder specialist or a stereotactic neurosurgeon?

A. When there is a first diagnosis of Parkinson’s Disease.

B. When non-motor symptoms such as constipation appear.

C. When dopaminergic medications no longer control symptoms effectively or if surgical options like deep brain stimulation are considered.

D. When initial symptoms of tremor and rigidity are first observed.

Answer 21

*Answer:** C. When dopaminergic medications no longer control symptoms effectively or if surgical options like deep brain stimulation are considered.

Rationale: Referral to a specialist or neurosurgeon is typically indicated when the patient’s symptoms are not adequately managed by medications alone, and surgical interventions might be explored to alleviate symptoms such as tremor.

Question 22

Which rating scale is specifically used to evaluate and monitor a patient’s response to Parkinson’s medications and assess mental, historical, and motor features?

A. Montreal Cognitive Assessment (MoCA)

B. Mini-Mental State Examination (MMSE)

C. Unified Parkinson’s Disease Rating Scale (UPDRS)

D. Geriatric Depression Scale (GDS)

Answer 22

Answer:** C. Unified Parkinson’s Disease Rating Scale (UPDRS)

Rationale: The UPDRS is a subjective and objective tool specifically designed for comprehensive assessment of Parkinson’s Disease, including response to medications, mental status, motor skills, and complications.

Question 23

The Activities of Daily Living Scale, a subscale of the UPDRS, assesses which of the following activities?

A. Cognitive functions and memory

B. Sleep patterns and anxiety levels

C. Speech, salivation, swallowing, and handling utensils

D. Vision acuity and hearing ability

Answer 23

*Answer:** C. Speech, salivation, swallowing, and handling utensils

Rationale: The Activities of Daily Living Scale within the UPDRS focuses on practical and physical tasks that can be significantly impacted by Parkinson’s Disease, such as speaking, swallowing, personal hygiene, and using utensils.

Question 24

Aside from motor symptoms, Parkinson’s Disease often presents with autonomic dysfunctions. Which symptom is NOT typically associated with autonomic dysfunction in Parkinson’s Disease?

A. Constipation

B. Bladder dysfunction

C. Insomnia

D. Orthostatic hypotension

Answer 24

*Answer:** C. Insomnia

Rationale: While insomnia can occur in Parkinson’s due to other factors like medication side effects, it is not directly categorized under autonomic dysfunction, which includes symptoms like constipation, bladder issues, and orthostatic hypotension.

Question 25

MAO- B medications Delays the metabolism of dopamine - Correct.-inhibitors work by blocking the enzyme monoamine oxidase B, which breaks down dopamine, thus prolonging dopamine's availability in the brain.

Answer 25

MAO-B inhibitors don't directly activate dopamine receptors; they work by preventing dopamine breakdown.--- THEY DO NOT TRIGGER DOPAMINE RECEPTORS MAO-B inhibitors- inhibit dopamine metabolism.

Question 26

MAO-B MEDICCATIONS TRUE OR FALSE Converts levodopa to dopamine - Incorrect. This is the function of dopa decarboxylase, not MAO-B inhibitors.

Answer 26

FALSE

Question 27

MAO-B inhibitors delay the metabolism of dopamine. WE DO NOT WANT DOPAMINE TO BE METABOLIZED BECAUSE DOPAMINE HELPS IN FUNCTION. SO THE DELAY IS A GOOD THING This mechanism helps maintain higher dopamine levels in the brain, which is beneficial for Parkinson's Disease patients who have depleted dopamine levels.

Answer 27

This mechanism helps maintain higher dopamine levels in the brain, which is beneficial for Parkinson's Disease patients who have depleted dopamine levels.

Question 28

Identify a drug that inhibits MAO-B to slow the metabolism of dopamine in the brain? 1. Rasagilline 2. Bromocriptine 3. Carbidopa 4. Tolcapone 5. Levodopa

Answer 28

Rasagiline is a drug that inhibits monoamine oxidase-B (MAO-B) to slow the metabolism of dopamine in the brain. By doing so, it can help manage the symptoms of Parkinson's disease and related movement disorders by increasing the availability of dopamine and reducing motor symptoms. Rasagiline is often used alongside other medications and therapies as part of a comprehensive treatment plan aimed at improving the quality of life for those living with Parkinson's disease and related conditions.

Question 29

What is the class of these medications? Rasagilline

Answer 29

1. MAO-B Inhibitors

Question 30

Bromocriptine class of med?

Answer 30

Dopamine receptor agonists. It treats hyperprolactinemia by decreasing the amount of prolactin in the body. It treats acromegaly by decreasing the amount of growth hormone in the body. It treats Parkinson's disease by stimulating the nerves that control movement.

Question 31

Rasagiline belongs to a class of medications called MAO-B inhibitors, which are used to manage the symptoms of Parkinson's disease and other related movement disorders.

Answer 31

The drug works by selectively inhibiting MAO-B, preventing the breakdown of dopamine and increasing its availability in the brain. This helps to alleviate the motor symptoms associated with low dopamine levels, such as tremors, rigidity, and bradykinesia (slowness of movement).

Question 32

What class is carbidopa?

Answer 32

Dopaminergic Medications

Question 33

What drug class is Tolcapone?

Answer 33

Catechol-O-methyl transferase inhibitor class of drugs. (COMT)

Question 34

What drug class is levodopa?

Answer 34

Dopamingeric Medication

Question 35

L-DOPA (Levodopa) in Parkinson's Disease Treatment L-DOPA (levodopa) is a precursor to dopamine that, unlike dopamine itself, can cross the blood-brain barrier. Once in the brain, it's converted to dopamine by DOPA decarboxylase in presynaptic neurons, primarily activating D2 receptors. Key characteristics?

Answer 35

Most effective medication for reducing Parkinson's disease symptoms, particularly bradykinesia (slow movement) Typically first-line treatment, especially for older patients Usually administered with decarboxylase inhibitors (like carbidopa) to reduce peripheral conversion and side effects Should be taken between meals (30 minutes before eating) to improve absorption, as high-protein foods can interfere with uptake

Question 36

What are side effects of levodopa?

Answer 36

Immediate: nausea, vomiting, orthostatic hypotension (reduced by carbidopa) Psychiatric: hallucinations, anxiety Motor complications with long-term use: hypokinesia (reduced movement), dyskinesia (involuntary movements), and potentially akinetic crisis (severe immobility)

Question 37

The primary challenge with L-DOPA is that while initially highly effective,

Answer 37

long-term use often leads to motor complications that can significantly impact quality of life, creating a treatment dilemma in Parkinson's management.

Question 38

Which of the following statements best describes how Levodopa helps to manage the motor symptoms of Parkinson’s disease? a. Levodopa is synthesised in the brain into dopamine resulting in dyskinesia to counteract the bradykinesic symptoms. b. Levodopa crosses the blood-brain barrier and is converted to dopamine resulting in an improvement in symptoms. c. Levodopa is unable to cross the blood-brain barrier so prevents further increases in dopamine resulting in and improvement in symptoms. d. Levodopa blocks the conversion of dopamine resulting in an improvement in symptoms.

Answer 38

b. Levodopa crosses the blood-brain barrier and is converted to dopamine resulting in an improvement in symptoms. Levodopa is a prodrug that is converted to dopamine by DOPA decarboxylase and can cross the blood-brain barrier. When in the brain, levodopa is decarboxylated to dopamine and stimulates the dopaminergic receptors, thereby compensating for the depleted supply of endogenous dopamine seen in Parkinson's disease.

Question 39

MAO-B inhibitors (such as selegiline and rasagiline) are monoamine oxidase inhibitors. This means that they inhibit the breakdown of dopamine in the brain. This allows L-DOPA to be more effective and to last longer.

Question 40

L-DOPA (levodopa) is an important medication in the treatment of Parkinson's Disease. Why is it used instead of dopamine, and how can its effectiveness be extended using other drugs?

Answer 40

is used to instead of dopamine because dopamine itself does not cross the blood - brain barrier . is a precursor to dopamine ,which means that it is converted to dopamine once it enters the brain. This allows to increase dopamine levels in the brain, which is necessary to treat the symptoms of parkinson's disease. How to extend the effectiveness of L-DOPA using other drugs: Explanation: There are a number of drugs that can be used to extend the effectiveness of . These drugs work in different ways, but they all aim to increase the amount of that reaches the brain and/or to slow down its breakdown.

Question 41

COMT inhibitors (such as entacapone and tolcapone) are inhibitors. This means that they inhibit the breakdown of dopamine and

Question 42

L-DOPA risk of ?

Answer 42

severe motor dysfunction. with longterm use

Question 43

What is the function of L-DOPA?

Answer 43

is converted to dopamine by DOPA decarboxylase at the presynaptic neuron → direct dopaminergic effect (especially at D2 receptors) L-DOPA, in contrast to dopamine, can cross the blood-brain barrier. Predominantly controls bradykinetic symptoms

Question 44

Initial treatment option for most patients with PD, especially older patients?

Answer 44

levodopa

Question 45

What are some adverse effects of dopamingeric medications? Levodopa

Answer 45

-Nausea -H/A -Orthostatic hypotension -Confusion -hallucinations -peripheral edema -compulsive behavior Administer between meals (e.g., 30 minutes before a meal) to increase gastrointestinal absorption (→ avoid high-protein diets)

Question 46

Decarboxylase inhibitors Carbidopa Benserazide

Answer 46

Always administered alongside L-DOPA

Question 47

COMT inhibitor monotherapy is ineffective; therefore, it should always be combined with L-DOPA and carbidopa.

Question 48

NMDA antagonists Amantadine

Answer 48

Drug of choice during akinetic crisis

Question 49

Anticholinergic agents

Answer 49

Benztropine Trihexyphenidyl Biperiden Useful as monotherapy in patients < 65 years of age with tremor as the main symptom Beneficial regarding tremor and rigidity but does not improve bradykinesia Usually avoided in patients > 65 years because they are more prone to anticholinergic side effects (e.g., urinary retention, delirium, constipation)

Question 50

To remember that anticholinergics like benztropine and trihexyphenidyl are used in the treatment of Parkinson disease, think of “A Benz for a trip to the park.”

Question 51

To remember the main drugs used to treat Parkinson disease, think of A2 B2 C2 D2: Antimuscarinics and Amantadine; Bromocriptine and MAO-B inhibitors; COMT inhibitors and Carbidopa; L-DOPA and nonergot Dopamine agonists.

Question 52

Open-angle glaucoma: Levodopa (and anticholinergics) should be used with caution.

Question 53

Closed-angle glaucoma: Levodopa (and anticholinergics) are not recommended.

Question 54

Akinetic crisis

Answer 54

Definition: condition caused by severe dopamine deficiency (e.g., after discontinuation of L-DOPA therapy or insufficient L-DOPA absorption) Clinical features: complete inability to move , incomprehensible speech, possibly hyperthermia → increased risk of dehydration, deep-vein thrombosis, and pneumonia Treatment: intensive medical care, volume substitution, administration of L-DOPA, apomorphine, amantadine

Question 55

Levodopa (L-DOPA), a dopamine precursor, is the most effective medication for controlling the motor symptoms of Parkinson disease. Primary effects of L-DOPA are achieved by stimulating D2-receptors in the substantia nigra and striatum. However, overstimulation of D2-receptors by levodopa may also induce psychosis and hallucinations (usually visual). The risk for developing psychiatric symptoms increases with age, other psychiatric conditions, long duration of levodopa treatment, and high doses. Since this patient has been taking levodopa for 3 years and is elderly, her symptoms are most likely the result of levodopa therapy. Other adverse effects of L-DOPA therapy include dizziness, somnolence or insomnia, anxiety, and aggressive behavior.

Question 56

Trihexyphenidyl is a muscarinic antagonist that reduces cholinergic activity in the CNS. Initial monotherapy with an anticholinergic (e.g., trihexyphenidyl, benztropine, biperiden) can be considered in patients with PD who are ≤ 65 years of age if the main symptom is resting tremor and there is no evidence of cognitive impairment, significant bradykinesia, or gait disturbance. Alternative pharmacotherapy for patients with PD who are ≤ 65 years of age includes nonergot dopamine agonists, MAO-B inhibitors, COMT inhibitors, and/or levodopa/carbidopa.

Answer 56

Anticholinergics should be avoided in patients > 65 years of age (particularly those with dementia) because they may worsen psychiatric symptoms and cause urinary retention.

Question 57

Propranolol is a first-line treatment of benign essential tremor. This patient likely has a family history of essential tremor (his father developed head bobbing at an older age). However, unlike the asymmetric resting tremor seen in this patient, essential tremor is symmetrical, worsens with voluntary movements, and resolves completely at rest.

Question 58

Amantadine is a weak NMDA receptor antagonist that can improve motor symptoms (tremor, rigidity, akinesia) in patients with mild forms of Parkinson disease, or it can be combined with levodopa to reduce dyskinesia in patients with advanced disease. Livedo reticularis and peripheral edema, which are seen in this patient, occur as adverse effects in up to 5% of patients who take amantadine

Question 59

A non-ergot dopamine agonist such as pramipexole or ropinirole is the typical first-line treatment for Parkinson disease in young patients (< 65 years) without cognitive impairment. If symptoms are severe, combination treatment of levodopa with carbidopa and/or a COMT inhibitor (e.g, entacapone) can be initiated. Levodopa is more effective than dopamine agonists. However, levodopa therapy is usually reserved for elderly patients or patients with cognitive impairment. MAO-B inhibitors (e.g., selegiline) or amantadine can be used as monotherapy in patients with minimal symptoms that do not affect quality of life, or as an adjunct with dopamine agonists or levodopa in more severe cases.

Question 60

Direct dopamine receptor agonists (e.g., pramipexole, ropinirole) are the first-line treatment for Parkinson disease patients < 65 years of age. They are, however, associated with the development of impulse control disorders (e.g., compulsive gambling, hypersexuality, excessive spending of money), which occurs in up to 50% of patients with long-term use. This adverse effect is presumably due to decreased neuronal activity in brain areas responsible for impulse and inhibitory control. Risk factors include high doses, long duration of treatment, young age, and male sex. Other common side effects of dopamine agonists include nausea, drowsiness, orthostatic hypotension, confusion, and hallucinations. Patients may also develop compulsive use of these drugs (termed dopaminergic dysregulation syndrome). A withdrawal syndrome resembling cocaine withdrawal (e.g., anxiety, depression, sweating, nausea, fatigue, and drug craving) may occur if the drug is abruptly discontinued.

Question 61

Entacapone is a peripherally acting COMT inhibitor that reduces the methylation of levodopa and dopamine, thus allowing a more stable and long-lasting plasma concentration of the drug. This results in fewer periods of end-of-dose akinesia and less variability of symptoms during the day. Tolcapone is a centrally acting COMT inhibitor that is used for refractory Parkinson disease. Motor fluctuations increase during long-term therapy with levodopa because the neurons gradually lose their capacity to store and release dopamine. The severity of symptoms is directly related to the drug dose.

Question 62

Following administration, L-DOPA is absorbed into the systemic circulation where it is partially converted to dopamine by the enzyme DOPA decarboxylase. The remaining L-DOPA is then transported across the blood-brain barrier and enters the central nervous system to produce the desired effects. Carbidopa reduces the peripheral (systemic) conversion of L-DOPA to dopamine, thereby mitigating the peripheral side effects, including orthostatic hypotension, nausea, and vomiting. Although the combination of carbidopa-levodopa significantly improves drug compliance, many patients still experience some degree of these side effects.

Question 63

Amantadine increases dopamine release, decreases dopamine reuptake, and inhibits the N-methyl-D-aspartate (NMDA) receptor. It can be used as initial short-term monotherapy in patients with mild symptoms of Parkinson disease, mainly for those with prominent tremor.

Answer 63

amantadine is associated with anticholinergic-like side effects (e.g., dry mouth, constipation), prolonged QT interval, and psychological disorders (e.g., hallucinations, anxiety).

Question 64

DAs) such as ropinirole may lead to impulse control disorders (ICDs), irrespective of the underlying disease. Patients taking DAs should be aware of this adverse effect and regularly monitored, because ICDs may have debilitating effects on their work and social functioning. If the patient shows signs of ICDs, the dose should be slowly tapered or discontinued until symptoms resolve. Abrupt discontinuation of DAs can lead to dopamine agonist withdrawal syndrome. Although most patients with ICDs due to DA therapy respond well to discontinuation of the medication, ICDs may persist in some patients. Other adverse effects of DAs include restlessness, nausea, orthostatic hypotension, drowsiness, hallucinations, and psychosis.

Question 65

-Doapa- (gel form to use with gastrostomy tube)

Answer 65

Dopaminergic Medications

Question 66

-Parcopa- (oral dissolving tablet)

Answer 66

Dopaminergic Medications

Question 67

Inbrija (inhaled)

Answer 67

Dopaminergic Medications This med can be used as a rescue medication

Question 68

For dopaminergic medications what med should be used if there is a swallowing dysfunction?

Answer 68

Parcopa (oral disintegrating tablet)

Question 69

What are some adverse effects of dopamine agonists? Pramipexole (mirapex) Ropinirole Apomorphine

Answer 69

-nausea -sleepiness -orthostatic hypotension -confusion -hallucinations -peripheral edema -compulsive behavior

Question 69

What dopamine agonist can be used as a rescue therapy for its quick onset of action?

Answer 69

apomorphine

Question 70

What meds are only beneficial with carbidopa/levodopa & with motor functions that wear off?

Answer 70

emtacapone (Comtan) opicapone (omgentys)

Question 71

What are some side effects of COMT inhibitors?

Answer 71

-diarrhea -orange urine **can worsen adverse effects of levodopa

Question 72

What are adverse effects of anticholinergic drugs? Trihexypenidyl benzotropine mesylate

Answer 72

-confusion -hallucinations -dry mouth -urinary retention

Question 73

Side effects of antiviral medications? amantadine

Answer 73

unknown mechanism of action in PD can treat dyskinesia -ankle edema -confusion -hallucinations

Question 74

What migraine triptan medication is used as an injection and nasal spray?

Answer 74

Imitrex

Question 75

When should triptans not be used?

Answer 75

Ischemic heart disease or cardiovascular disease

Question 76

What are some side effects of triptans?

Answer 76

-paresthesia -asthenia -nausea -dizzness -neck or chest tightness -heaviness -somnolence

Question 77

When should you not use ergot meds?

Answer 77

-PVD -CAD -HTN -hepatic -renal disease

Question 78

The ergot med migranal is also available as a ?

Answer 78

nasal spray IV route preferred for fast acting relief

Question 79

NSAIDS risk factor?

Answer 79

mild to moderate pain, GI bleed with alcohol

Question 80

Combo analgesics

Answer 80

not 1st line for treatment of migraines -drowsiness, dizziness, GI butalbital

Question 81

Opiates

Answer 81

sedation resp failure constipation addiction

Question 82

Medrol dose pack dexamethasone IM/IV

Answer 82

adjunct therapy for severe refractory migraine headaches

Question 83

beta blockers

Answer 83

preferred HTN, angina Do not use in asthma sinus bradycardia 2nd or 3rd AV block increased by alcohol causes weight loss asthenia mental fuzziness

Question 84

antidepressants -venlafaxne nortriptyline amitryline

Answer 84

can cause sedation- amitryline nighttime dosing

Question 85

Calcium channel blocker verapamil

Answer 85

takes a long time (several months to be effective) DO NOT USE IN PREGNANCY side effects: -somnolence -dizziness -asthenia give seizure disorders and diabetic peripheral neuropathy

Question 86

Resting tremor

Question 87

action tremor

Question 88

intention tremor

Question 89

Benign essential tremor what is the best treatment?

Answer 89

1st propranolol line agent then primidone- sedative hypnotic drug barbiturate

Question 90

first line medications. All medications are started at a low dose and titrated to achieve the desired effect; the effective dose varies widely between patients. Propranolol DOSAGE. Some authors recommend a starting dose of 20 mg twice daily or 10 mg twice daily in older adults. Primidone DOSAGE. Some authors recommend a starting dose of 25 mg once daily at bedtime for older adults. Alternative medications (if propranolol and primidone are ineffective or contraindicated) Other beta blockers (e.g., atenolol, metoprolol) Other anticonvulsants (e.g., topiramate, gabapentin) Benzodiazepines (e.g., alprazolam, clonazepam)

Answer 90

beta blockers can mask symptoms of hypoglycemia hyperlipidemia weight gain propranolol treats akathisia inability to sit still. contraindications of propranolol Symptomatic bradycardia Cardiogenic shock and hypotension Pheochromocytoma: administration of beta blockers before alpha blockers → unopposed α-adrenoceptor mediated vasoconstriction → hypertensive crisis (except nonselective beta blockers with α-antagonism, such as carvedilol and labetalol) Decompensated heart failure Combination with calcium channel blockers (diltiazem or verapamil): can precipitate AV block Sick sinus syndrome (without a pacemaker); heart block greater than first-degree