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62 Cards in this Set

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Dr. James Parkinson first described Parkinson's in 1817 in this essay
An Essay on the Shaking Palsy
Mean age of onset for PD between ___-___ years
58-62 years
- Bradykinesia/Akinesia
- Resting Tremor
- Rigidity or increased "stiffness"
- Postural instability
- Dystonia
Cardinal Motor Signs of parkinsonism
Area of the brain involved in self-initiated movements
- when not enough activation, people have difficulty initiating voluntary movement and have to use other ares of their brain --> prefrontal area (executive functioning - thinking about what they want to do so they can activate SMA--> Premotor Area)
- Very fatiguing because everything is an effort
Supplementary Motor Area
Slowness of movement; inability to initiate adn execute a movement; "freezing" episodes
Bradykinesia/Akinesia
Affects proximal musculature early, with spread to muscles of face and extremities
- Types: Cogwheel, Leadpipe
- Leads to decreased ROM, slowness, and fatigue
- no trunk movement during gait
- "en bloc" - no dissociation between LE and trunk
- reduced ability to turn/rotate trunk
Muscle Rigidity
jerky, ratchetlike resistance to passive movement as muscles alternately tense and relax
Cogwheel Rigidity
Constant, uniform resistance to passive movement
Leadpipe Rigidity
Slowness and difficulty maintaining voluntary movement
- impaired ability to initiate and execute a movement (akinesia)
- slowness and reduction in movements lead to prolonged time to complete ADLs
- May experience "freezing" episodes
- Reflex movements may be impaired (eg. blinking and facial movements) so that they require concentrated volitional effort = "masked expression"
Bradykinesia
Present in 70% at initial dx
- usually begins unilaterally, affecting hand and UE
- Slow (4-7 Hz), pill-rolling
- Generally disappears with action or intention and sleep
- Stress and anxiety increase it
Resting Tremor
Loss of balance or lack of recovery of balance when perturbed
- respond to instability with abnormal muscle coactivation patterns
- difficulty with feed-forward postural control
- some pt's with PD have an abnormal gait with retropulsion, leading to backward falls
- rapid, festinating gait in combination with a stooped posture leads to forward falls
Postural Instability
- Fatigue
- Shuffling gait with decreased arm swing
- Decreased facial expression
- Muscle aches or cramps
- soft voice with poor annunciation
- Decreased hand dexterity
- Micrographia (smaller writing)
- Dysphagia
- Depression
- Feelings of fear and anxiety
- Memory problems
- confusion/dementia
- sialorrhea
- sleep disturbances (life-like nightmares)
- urinary problems
- constipation
- sexual dysfunction
S/S of PD
Idiopathic PD = 78% of all parkinsonism cases
Primary Parkinsonism
- Brain injur from strokes, toxins, trauma (boxing), infections (encephalitis, HIV), metabolic abnormalities (hypo- or hyper-thyroidism or parathyroidism, liver failure), drug-induced
Secondary Parkinsonism
- Progressive Supranuclear Palsy
- Multiple System Atrophy
- Corticobasalganglionic Degeneration
Parkinson-Plus Syndromes
Loss of balance or lack of recovery of balance when perturbed
- respond to instability with abnormal muscle coactivation patterns
- difficulty with feed-forward postural control
- some pt's with PD have an abnormal gait with retropulsion, leading to backward falls
- rapid, festinating gait in combination with a stooped posture leads to forward falls
Postural Instability
- Fatigue
- Shuffling gait with decreased arm swing
- Decreased facial expression
- Muscle aches or cramps
- soft voice with poor annunciation
- Decreased hand dexterity
- Micrographia (smaller writing)
- Dysphagia
- Depression
- Feelings of fear and anxiety
- Memory problems
- confusion/dementia
- sialorrhea
- sleep disturbances (life-like nightmares)
- urinary problems
- constipation
- sexual dysfunction
S/S of PD
Idiopathic PD = 78% of all parkinsonism cases
Primary Parkinsonism
- Brain injur from strokes, toxins, trauma (boxing), infections (encephalitis, HIV), metabolic abnormalities (hypo- or hyper-thyroidism or parathyroidism, liver failure), drug-induced
Secondary Parkinsonism
- Progressive Supranuclear Palsy
- Multiple System Atrophy
- Corticobasalganglionic Degeneration
Parkinson-Plus Syndromes
- Most common of hte Parkinson-plus syndromes
- Damage in basal ganglia, brainstem, thalamus, and frontal cortex
- Sx include: postural instability leading to falls within first year of disease onset, supranuclear opthalmoplegia (vertical gaze paresis, especially in the downward direction)
- Prognosis - 9.7 year median survival from onset of sx
Progressive Supranuclear Palsy (PSP)
- postural instability leading to falls within the first year of disease onset
- supranuclear opthalmoplegia - vertical gaze paresis, especially in the downward direction
Sx of Progressive Supranuclear Palsy (PSP)
- Progressive, idiopathic degenerative process begining in adulthood
- Sx: varying degress of parkinsonism, autonomic failure, cerebellar dysfunction, and pyramidal signs (UMN, corticospinal)
- Poorly responsive to levadopa or dopamine agonists
- orthostatic hypotension develops in 66% of pts
- prognosis: median survival in one study was 6.2 years with a range of 0.5-24 years
Multiple System Atrophy (MSA)
Varying degrees of parkinsonism, cerebellar dysfunction, autonomic failure, pyramidal signs, orthostatic hypotension, festination of speech
Sx of Multiple System Atrophy (MSA)
- Cortical atrophy of the frontal and parietal lobes and loss of dopamine in the substantia nigra
- Sx: focal rigidity, bradykinesia, tremor, marked dystonia (usually in one arm), often have limb apraxia
- Prognosis - severe disability and death within 10 years
Corticobasalganglionic Degeneration (CBGD)
Focal rigidity, bradykinesia, tremor, marked dystonia (usually in one arm), limb apraxia
Sx of Corticobasalganglionic Degeneration (CBGD)
Can't produce a movment upon request (motor planning)
Apraxia
- Begins slowly, usually on one side of the body and then involves the other side
- Slow, variable rate of progression, lasting between 20-30 years after onset
- May have normal lifespan because it begins so late in life and progresses slowly
- Progression of disability assessed using: Hoehn and Yahr Classification of Disability and/or United Parkinson Disease Rating Scale (UPDRS)
Clinical Course for Idiopathic Parkinson's Disease
Five stages within Stage 1 indicating minimal disease involvement to Stage 5, indicating severe involvement
Hoehn and Yahr Classification of Disability (for PD)
Contains: 1) Mentation, Behavior, and Mood, 2) ADL and 3) Motor scales
United Parkinson Disease Rating Scale (UPDRS)
- Postural Instability Gait Disturbed (PIGD)
- Tremor Predominant
- Early Frontal Dementia with Bradykinesia and Rigidty
Variants of Primary PD
Dominant sx include postural instability and gait disturbance
Postural Instability Gait Disturbed (PIGD)
Tremor is the main sx; few problems with bradykinesia or postural instability
Tremor Predominant PD
PD Pathology
- Disease affects melanin-containing monoamine neurons of the brain, particularly the dopamine neurons in the ______ of the brainstem
- Results in decreased dopamine levels in other parts of the basal ganglia with immportant motor functions (putamen and caudate = striatum)
substatia nigra pars compacta (SNpc)
- a pathologic hallmark of PD
- round, intracytoplasmic inclusions consisting mainly of misfolded alpha-synuclein protein found in monoamine neurons
- found in abnormally increased amount
Lewy Bodies
Dopamine is excitatory - selects movements you want to do
Direct Pathway (D1)
Dopamine is inhibitory - stops movements you don't want to do
Indirect Pathway (D2)
- Sporadic PD
- Familial PD
- Environmental
- Combination of Cellular Mechanisms
Etiology of Primary PD
- Experimental model for production of Parkinsonism in animals. ____ is structurally similar to certain pesticides
- Metabolism of ____ in astrocytes and metabolite is taken up by dopaminergic neuron mitocondria.
- Metabolite inhibits complex I (NADH-CoQ1) fo the mitochondrial respiratory chain --> ATP production falls --> cell death
MPTP - Environmental Toxin model
- At least 2 out of 4 cardinal sx: resting tremor, bradykinesia, rigidity, postural instability
- Absence of secondary causes (drugs, metabolic, etc)
CT scan or MRI used to r/o other disorders
- Definitive only at autopsy
Diagnosis of PD
According to Honolulu-Asia aging study
- Olfactory deficits
- Obesity
- Constipation
- Slow Reaction Times
factors associated with getting PD or having Lewy Bodies in brain were midlife:
Mean survival after onset of PD is ____ years
- longer in non-demented PD (tremor predominant are at less risk for dementia than PIGD)
- Longer with L-dopa use, especially if drug started early in disease
15 years
- Older age at onset (>57 yrs)
- Rigidity/hypokinesia as presenting sx
- PIGD
Worse prognosis in PD
- Resting tremor
- Bradykinesia
- Rigidity
- Postural Instability
4 Cardinal Sx of PD
Pulmonary complications, UTIs, complications of falls and fractures
Most common cause of death in PD
_____ drugs improve motor funciton, reduce both the morbidity and mortality of PD, and improve quality of life
Dopaminergic Drugs
- First developed in the 1960s; most clinically effective drug for the Sx of PD
- Still the "gold standard" for PD medications
Levadopa
Combination of levadopa and carbidopa that crosses the BBB
- turned into dopamine within the nerve cell
- alleviates bradykinesias and rigidity with less effect on tremor
Sinemet
Orhtostatic hypotension, dyskinesias, hallucinations, sleepiness
Side Effects of Sinemet/Levodopa
- Action - directly stimulate dopamine receptors
- Brands - Mirapex (pramipexole), Requip (ropinirole), Upima (apomorpine)
Dopamine Agonists
- Actions - potentiate levadopa; prevent degredation by COMT
- Brands - Comtan (Entacapone), Stalevo (Levadopa and Entacapone), Tasmar (tolcapone)
COMT Inhibitors
-Actions- reduce overactivity of ACh; inhibit DA reuptake in striatum - good for tremors
- Brands - Artane (trihexyphenidyl HCl), Cogentin (benztropine mesylate), Kemadrin (procyclidine hydrocloride)
Anticholinergics
Action - Inhibits MAO-B that degrades DA
- often used earlier; neuroprotective effect
- Brands - Eldepryl (selegiline hydrochloride), Azilect (rasagiline)
Selegiline/Rasagiline
- Action - releases DA; decreases DA reuptake; DA agonist
- Brands - Symmetrel (amantadine hydrochloride)
amantadine
- Shorter tx horizon; lower risk of long-term complicatoins; comorbidities
- Levadopa well tolerate; effective; sedating adjunctive medications avoided
- some DA-agonist drugs aren't well tolerated in this population
Initial Therapy for the Elderly PD patient
- Long-term tx horizon; increased risk of long-term complications
- Levadopa-sparing/neuroprotective strategies (eg. selegiline, DA agonists)
Initial Therapy in the Young PD patient
Surgery permanently destroys overactive globus pallidus internus (GPi) to eliminate rigidity and significantly reduce contralateral tremor, bradykinesia, and balance problems
Pallidotomy
Destroys part of the VL thalamic nucleus to relieve contralateral tremors
Thalamotomy
- Many pts experience reduction of their PD sx (tremors, rigidity, bradykinesias, dyskinesias) and can greatly reduce their medications
- reduction in meds leads to significant improvement in side effects such as dyskinesias
Benefits of Deep Brain Stimulation (DBS)
- Most pts must still take medications
- amoutn of reduction in sx varies
- non-motor sx (gait and balance) of PD not affected - still have issues with postural instability
Limitations of Deep Brain Stimulation (DBS)
Grafting of fetal cells or autotransplantaiton with the pt's own adrenal medullary cells to replace the dopamine-producing cells inthe substantia nigra. Remans controversial
- mixed results - some benefited, others worse
Fetal Cell Transplantation
Research to try to make human embryonic stem cells into dopamine-producing neurons that can be used to tx PD
Stem Cell Research