Rapid review of BASIC Pearls on Parkinsonism for MRCP

Parkinsonism

1.       Parkinsonism= Parkinson's disease(Idiopathic),Drug induced Parkinsonism, Parkinson plus syndrome, Wilson's disease

2.       Parkinson Plus Syndrome= Progressive Supranuclear palsy, Multi System Atrophy, Cortico-basal degeneration, Lewy body dementia

3.       Parkinsonism= (Bradykinesia+resting Tremor+Rigidity )+ Postural instability+ Depression+( Psychosis+REM sleep behaviour disorder)

4.       Parkinson's disease, mean age of onset= 65 years

5.       Bradykinesia= decrease movement, short shuffling step, decrease arm swinging, difficulty in initiating movement

6.       Tremor= resting+ 3-5 Hz + increased in stress/movement/emotion

7.       Rigidity= Lead pipe@ elbow+ Cog wheel@ wrist

8.       Postural instability= Fall = Propusion+Retropulsion

9.       Psychiatric features= DEPRESSION+ psychosis

10.   Psychosis due to disease process, and/or treatment side effects

11.   Degeneration of nigrostriatal pathway→↓Dopamine release→Parkinsonism

12.   Idiopathic/Parkinsonism= Asymmetrical resting tremor+ rigidity+ decrease arm swing: well response to levodopa

13.   Drug induced = Bilateral+ symmetrical+rapid+ bradykinesia, but tremor+rigidity less common: less response to levodopa

14.   Parkinson's disease(PD) treatment: Delay upto onset of  Disabling symptoms

15.   PD treatments drugs= DRA,Levodopa/L dopa, COMTi,Amantadine, Anticholinergic, MAO-Bi

16.    Sinemet= levodpa+carbidopa, Medopar=levodopa+benserazide ; carbidopa/ benserazide/COMTi decrease conversion of  levodopa to dopamine @ periphery 

17.   Young,less than 65 years, treatment of  PD  = Dopamine receptor agonist(DRA) = Ropinirole

18.   Elderly= Levodopa

19.   efficacy of  Levodopa is MORE than DRA

20.   DRA= improves bradykinesia

21.   DRA= Day time somnolence+ Impulsive disorder(ICD)+Psycosis(hallucination)+Postural hypotension+nasal congestion

22.   DRA= fibrosis, so before DRA, Echo+ESR+CXR+Creatinine must, close monitoring during treatment

23.   Levodopa= fLuctuation+Dyskinesia(LID)+Psycosis(hallucination)+Postural hypotension

24.   Levodopa: decrease effectiveness after 2 years, no use in neuroleptic induced parkinsonism

25.   LID treatment= decrease dose of levodopa, then,if refractory, deep brain stimulation (DBS) 

26.   ⇛DBS ↑suicidal risk , cause unknown

27.   Fluctuation=on-off(Off= freezing, bradylinesia, rigidity

28.   fLuctuation treatment= add COMTi with Levodopa

29.   Refractory 'off'( after long term levodopa) treatment= Subcutaneous Apomorphine= test bolus, then infusion, with antiemetic must

30.   Amantadine= NMDA antagonist;  increase dopamine release+ decrease uptake @ dopaminergic synapses

31.   Amantadine A/E= Ataxia+slurring+dizziness+CONFUSION+livedo reticularis

32.   Anticholinergic is used to treat tremor, best= benzhexol(trihexyphenidyl)

33.   Tremor , 1st line= Procyclidine, Benzhexol, Orphenadrine, 2nd line= ABC= Amntadine, BB ( propanolol) , Clozapine

34.   Refractory Tremor = DBS

35.   COMTi= decrease dopamine breakdown, decrease fLuctuation, but increase dyskinesia , TOLcapone= TOxic to Liver 

36.   MAO-Bi= decrease BREAKDOWN of dopamine, not as monotherapy, always adjunct at PD, Rasagiline is commonly used, Once daily dose

37.    PD+ executive dysfunction+ visuospatial dysfunction (after 12 months of  PD)= Parkinson's disease dementia (PDD)

38.   LBD=  (any 2 of 3)1.Parkinsonism (within 12 months)+2.(Visual+vivid HALLUCINATION)+3.Fluctuating Cognitive impairement,   also falls+syncope+delusion can be there

39.   LBD inv= SPECT/ Dat scan 

40.   Lewy body= alpha synuclein+ ubiquitin @ neocortex+paralimbic+subtantia nigra, can be present in ALzheimer's disease also

41.   PDD Rx= Rivastigmine ( reversible anticholinesterase)

42.   LBD Rx= Rivastigmine ( reversible anticholinesterase)

43.   Multi system atrophy= Olivo-ponto cerebellar atrophy(OPCA), Shy drager syndrome

44.   OPCA= pyramidal+cerebellar

45.   SHY  drager =  erectyle dysfunction+ other autonimic( postural hypotension)