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Questions and Answers
What is the main cause of motor symptoms in Parkinson's Disease?
Which medication is considered the most effective for treating motor symptoms in Parkinson's Disease?
What common early complaint in Parkinson's Disease involves a change in handwriting?
Which non-motor symptom is commonly associated with Parkinson's Disease?
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When is the best time to consider starting medication for Parkinson's Disease?
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What factor is a potential side effect of dopamine agonists in older patients?
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What is a common dosage strategy for introducing carbidope/levodopa?
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What is the main purpose of dopaminergic therapy in Parkinson's Disease?
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Which treatments are generally recommended to be avoided in managing depression and anxiety?
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What is the primary goal when dealing with fatigue in patients?
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What contributes to hallucinations in patients with Parkinson's disease?
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What is a common recommendation for managing dementia related to Parkinson's disease?
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Which type of training has shown effectiveness in gait improvement for PD patients?
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What is a crucial aspect of the exercise regimen for patients with Parkinson's disease?
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What medication is FDA approved for dementia associated with Parkinson's disease?
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What is essential for exercises targeting balance and coordination in PD patients?
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What is the typical daily l-dopa dose range for patients?
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Which statement about dopamine agonists is true?
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What complication is commonly associated with mid to late Parkinson's Disease?
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Which of the following non-motor symptoms is NOT commonly associated with Parkinson's Disease?
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Which treatment option may provide temporary improvement of symptoms in Parkinson's Disease?
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In what situation might a patient experience OFF periods in the management of Parkinson’s Disease?
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What should be monitored in patients using dopamine agonists, especially older or demented patients?
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How can motor symptoms in Parkinson's Disease evolve?
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Study Notes
Parkinson’s Disease
- Usually idiopathic, meaning the cause is unknown.
- Degeneration in the substantia nigra causes a dopamine deficiency in the striatum, leading to motor symptoms.
- Dopaminergic therapy helps relieve motor symptoms.
Common Early Complaints
- Resting tremor
- Difficulty writing and buttoning due to smaller handwriting
- Slowness, weakness, and limb dysfunction
- Stiffness or achiness in limbs
- Stooping, shuffling gait, dragging legs
- Difficulty getting out of chairs or turning in bed
- Low or soft voice
- Non-motor symptoms include anosmia (loss of smell), dream enactment, constipation, anxiety, depression, and passiveness.
Medications for Motor Symptoms
- L-dopa (with carbidopa) is the most effective and generally well-tolerated medication.
- Dopamine agonists, such as ropinirole and pramipexole, are also used.
- Other medications, such as MAO-B inhibitors, anticholinergics, and amantadine, offer modest benefits.
Early PD: When to Start Medications?
- Medications are symptomatic and do not protect or damage neurons.
- The level of patient function is the best indicator for starting medication.
- Response to dopaminergic therapy, particularly L-dopa, serves as the best available test for PD.
- Exercise is crucial and should not be overlooked.
Which Treatment to Start
- L-dopa is most effective for motor symptoms like bradykinesia, tremor, and gait changes.
- Family physicians can initiate levodopa treatment.
- Dopamine agonists can cause more non-motor side effects and are best avoided in patients over 70 years old.
Treatment Pearls in Early PD
- L-dopa should not be feared; delaying it offers no long-term benefit.
- Focus on treating symptoms and function rather than solely on appearance.
- Generic medications are acceptable.
- Allow adequate dosage and time for the medication to work before concluding treatment failure or misdiagnosis.
- Resting tremor may not respond to medication in some patients, which should not be interpreted as a misdiagnosis.
Levodopa
- Most effective overall for motor symptoms.
- A good option for initial PD therapy.
- Almost always needed in mid-to-late disease.
- Non-motor side effects include nausea, orthostasis, sleepiness, and hallucinations, but less frequent than with other PD drugs.
- Dyskinesias are a potential motor side effect.
Carbidopa/Levodopa Dosing
- The most common preparation is 25/100mg.
- Start with one pill, gradually increasing to 1.5 pills and then 2 pills.
- Taking medication with meals can reduce nausea.
- Allow two weeks between dosage increases to assess the effect.
- If there is no response, at least 900mg per day is necessary to rule out PD.
- Some patients require more frequent dosing.
- Typical daily L-dopa dosage ranges from 300mg to 1500mg.
Dopamine Agonists
- Can be used as monotherapy in early disease, but L-dopa is usually needed in mid-to-late stages.
- Can be added to L-dopa to reduce OFF time.
- Frequent side effects include nausea, sleep attacks, hypotension, compulsive behaviors, and lower extremity edema.
- More likely than L-dopa to cause hallucinations and confusion, especially in older or demented patients.
Mid-to-Late PD
- More motor complications, including dyskinesias and ON-OFF fluctuations.
- More drug-resistant motor symptoms, such as balance impairment and falls.
- More non-motor symptoms, especially dementia and hallucinations.
- More medications, leading to increased side effects.
- Managing these complexities requires experience.
“Motor Complications” as PD Progresses
- Fluctuations: Medication wears off before the next dose, with OFF periods worsening as the disease progresses.
- Dyskinesias: Typically occur at the peak of ON periods.
- Need for higher and/or more frequent medication dosages or combinations of drugs.
- Deep brain stimulation is an option for some patients with medically refractory motor complications.
Some Motor Symptoms May Not Respond to Medication Adjustments
- Postural instability and falls
- Freezing of gait
- Fatigue
- Dysarthria (difficulty speaking) and dysphagia (difficulty swallowing)
- Some tremor
Management
- Surgical: Stereotactic thalamotomy can temporarily improve symptoms, and deep brain stimulation is an option.
- Physiotherapy: Reduces rigidity and corrects abnormal posture.
- Speech Therapy: Addresses dysarthria and dysphonia.
- Neuropsychiatric: Manages associated psychiatric and cognitive issues.
Non-Motor Symptoms
- Psychiatric: Depression and anxiety.
- Autonomic: Blood pressure, genitourinary, and gastrointestinal issues.
- Sleep: REM behavior disorder, insomnia, hypersomnia, and sleep apnea.
- Fatigue
- Cognitive: Psychosis and dementia.
Why Non-Motor Symptoms?
- PD affects many parts of the nervous system.
- Early involvement occurs in the gut nerve plexus, lower brainstem, and olfactory bulb.
- Pathology spreads upwards through the brainstem and affects serotonergic, noradrenergic, and cholinergic nuclei.
- Non-motor symptoms, such as anosmia, constipation, and dream enactment, often precede motor symptoms.
Depression and Anxiety
- Not solely due to the stress of diagnosis.
- Motor symptoms and medication wearing off can impact mood and anxiety levels.
- "Poker face," a common symptom in PD, can be misinterpreted as depression.
- SSRIs can be effective, while benzodiazepines should be avoided.
Depression and Anxiety: Other Considerations
- Support services and psychotherapy for patients and caregivers are crucial.
- Geriatric psychiatrists generally have more expertise in this population.
Fatigue
- Characterized by feelings of tiredness, exhaustion, and lack of energy.
- Can be caused by sleepiness, medication wearing off, motor symptoms, mood, or other factors.
- Isolated fatigue can be debilitating.
- No established treatment, although antidepressants and stimulants have been tried.
- Encourage light exercise, hobbies, and other activities.
- Effective treatments for fatigue are urgently needed.
Hallucinations and Dementia in PD
- Complications in many long-standing PD cases.
- Hallucinations are usually visual.
- Contributing factors include disease progression, age, and medication.
- Older patients are at higher risk.
- Marker for increased morbidity, mortality, and institutionalization.
Hallucinations and Dementia in PD: Assessment and Management
- Assess medical state for vitamin B12 and TSH levels.
- Simplify medication regimen, prioritizing the elimination of anticholinergics and dopamine agonists. Reduce L-dopa as a last resort.
- Rivastigmine (a cholinesterase inhibitor) is FDA-approved for PD dementia.
- Antipsychotics, while off-label and with a black-box warning, can be used with caution, with quetiapine and clozapine being least likely to worsen parkinsonism.
Exercises
- Focus on range of motion, gait, balance, antirigidity, and activities of daily living (ADLs).
- Leg strength exercises involving equipment and resistive bands.
- Balance and sway exercises using foam pads and retropulsion tests.
- Strengthening trunk muscles for respiration and posture.
- Weight shifting exercises.
- Transfer exercises.
- Stretching exercises are essential:
- Posterior direction: reaching backwards, walking backwards.
- Extension exercises.
- Throwing/kicking a ball.
- Push-ups.
- Passive range of motion (PROM).
- Proprioceptive neuromuscular facilitation (PNF).
- Respiration exercises.
- Relaxation exercises, including yoga and Tai Chi.
- Energy conservation techniques.
Balance Training and High-Intensity Resistance Training
- PD patients exhibit dyssynchrony of leg muscles during movement initiation.
- Reduced peak torque production in knee extension, flexion, and ankle dorsiflexion.
- Lower extremity weakness impairs postural responses to balance challenges.
- High-intensity resistance training of knee extensors, flexors, and ankle plantarflexors using devices like Nautilus machines and cycle ergometers.
Treadmill Training
- Numerous studies have demonstrated the effectiveness of treadmill training for gait training.
- At initial sessions, all patients could walk without freezing phenomenon at higher treadmill speeds.
- Improvement in gait speed and number of steps.
- Effects sustained for up to four months.
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Description
This quiz provides an overview of Parkinson’s disease, including its idiopathic nature, early symptoms, and available medications. Test your knowledge about the causes, motor and non-motor symptoms, and treatment options for this neurodegenerative condition.
