Definition Aetiology PD vs Parkinsonism Symptoms and signs
Differentials Investigations Management Prognosis
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1. What is the definition of Parkinsons disease?
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A movement disease characterised by Tremor at rest Rigidity
Bradykinesia
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2. Aetiology of PD
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Degeneration of dopaminergic pathways in the substantia
nigra
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4. What is the difference between PD and Parkinsonism?
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PD is used to describe idiopathic syndrome of Parkinsonism
Parkinsonism is symptoms attributable to an underlying cause
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5. Causes of Parkinsonism
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Drug induced Any drug that blocks dopamine receptors or reduce
storage of dopamine Mainly antipsychotics But also antiemetics such
as metoclopramide Antihistamines eg cyclizine 5HT3 receptor
blockers eg ondansetron Dopamine blockers eg metoclopramide,
domperidone Following encephalitis Exposure to toxins manganese
dust, sever CO poisioning
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6. 3 main features of PD
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Tremor 4-6 hz Seen at rest can be induced by concentration
Usually apparent in one limb or one side first Rigiditiy Increase
in resistance to passive movement Can produce a characteristic
flexed posture Cogwheel rigidity Bradykinesia Slowness of voluntary
movement Reduced arm swing Progressive reduction in amplitude of
repetitive movements
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7. How does PD present
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Insidious onset Peak age of onset is 55-65, slightly more
common in men Impairment of dexterity Progressive disorder
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8. Other symptoms
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Fixed facial expression Infrequent blinking Quiet voice
Micrographia Gait short shuffling steps (festination), difficulty
in initiating movement and in stopping Non motor Anosmia Depression
Dementia Visual hallucinations REM sleep disorders
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9. Differential diagnosis
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Benign essential tremor Far more common worse on movement, rare
at rest Drug or toxin induced
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10. In which type of dementia do patients have PD
symptoms?
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Lewy body dementia Dementia Fluctuating levels of awareness
Signs of mild PD Visual hallucinations Sleep disorgers PD dementia
Dementia occuring >1 year after PD diagnosis Visual
hallucinations Fluctuating lucidity
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11. Diagnosis of PD
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Bradykinesia plus one of following Muscular rigidity Resting
tremor Postural instability Not causes by primary visual,
vestibular, cerebellar or proprioceptive dysfunction
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12. Investigations
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Diagnosis is clinical
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13. Management
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Levodopa Taken with a decarboxylase inhibitor Start with low
dose and build up Keep dose as low as possible N+V/loss of appetite
Dopamine agonists Eg bromocriptine, cabergoline Monotherapy or
adjuvant COMT inhibitors Must be taken with levodopa Eg entacapone,
tolcapone
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MAOBi Prevent dopamine being broken down Selegine Has
amphetamine metabolites hallucinations, nightmares, confusion so
avoid in elderly Rasagiline No amphetamine metabolites
14. Management OT SALT Exercises to strengthen voice/help
control facial expression/swallowing or drooling problems Suggest
communication aids Physio PD nurse Support groups
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15. Common management problems
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Motor fluctuations associated with long term L-dopa On off
fluctuations occur randomly Wearing off phenomenon before next dose
is due Involuntary movements while on dyskinesias Axial problems Do
not respond to treatment Balance, speech and gait Physio, SALT, OT
Associated disease Dementia (20-40%) Depression (45%)
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16. Complications
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Infections Aspiration pneumonia Bed sores Poor nutrition Falls
Contractures Bowel and bladder disorders
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17. Prognosis
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Slowly progressive with mean duration of 15 years Severity is
hugely varied Some show little disability after 20 years Others
severely disabled after 10 years
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Explaining things to patients
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What do they already know Why they need it What will happen
Risks/side effects Do they have any questions? It is fine if you
dont know the answers say you will find out and get back to them
Offer to give them information sheets/leaflets
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References Patient UK Professional Reference NICE guidelines
Parkinsons UK website