Parkinson disease
What famous celebrity developed Parkinsons in 1991 at age 29? Does he have dementia yet?
Michael J. Fox
What sports/occupations are associated with chronic traumatic encephalopthy?
in retired boxers- CTE with CNS lesions > 17 %
prof football
prof hockey
prof soccer?
military personnel- those hospitalized with TBI with LOC x>24hrs had 4X rate of dementia
What workup should be done in a patient with MCI, or new onset dementia?
vision and hearing assessment
review of medications- stopping possible contributors
Geriatric Depression Score; GAD-7
Consider CBC, TSH, CMP, VDRL or RPR, HIV, folic acid, Vit B12 or MMA
Consider genetic referral if FH +, early onset typical AD,
Consider neuroimaging
Consider lumbar puncture if <age 55, or rapid progression, or relevant STI hx
Consider neuropsych testing if diagnosis is uncertain, or pattern of deficits unusual
Consider referral for biomarker testing or research participant interest
What is the difference between Wernicke's encephalopathy and Korsakoff Syndrome?
Wernicke is acute triad of confusion, ataxia, and eye abnormalities from acute thiamine deficiency, often with lethargy.
Korsacoff is the chronic form of thiamine deficiency-
amnesia for recent events
apathy
confabulation to fill in memory deficits
What are the 3 acetylcholinesterase inhibitors?
donepezil [Aricept, Adlarity]
galantamine [Razadyne, Reminyl]
rivastigmine [Exelon]
What are common early symptoms of PD?
often years of gradual worsening of movement disorders. later onset cognitive, behavioral, or mental health sxs.
Rest Tremor, esp onset in one hand first
Micrographia- difficulty fine finger movements
Stooping gait with difficulty initiating gait. not swing arms when walking
Autonomic dysfunction- Constipation and low blood pressure/dizzyness
Masked facies
Low, soft voice, or drooling. Slur or repeat words, monotonous voice
Bradykinesia
What types of dementia occurs with history of TBIs
FTD
AD
with Parkinsonian traits
What % of patients with MCI meet criteria for dementia within 5 years?
50%
What does the triad ... suggest?
decrease cognition
slowed gait
urinary incontinence
Normal Pressure hydrocephalus
What are 3 important adverse effects of acetylcholinesterase inhibitors?
nausea, vomiting, diarrhea, anorexia, bradycardia, syncope
donepezil- ulcers, seizures
galantamine- can worsen asthma, Steven's Johnson
rivastigmine- occult GI bleeding, interactions B-blockers and oxybutynin and metoclopramide
What are 5 Cardinal Symptoms of Parkinson Disease?
Resting tremor- pill rolling hands [feet,jaw,face]
Masked facies
Bradykinesia
Cog wheel rigidity- muscle stiffness getting out of a chair rolling over in bed
Postural instability- balance and coordination
What % of the US population lives with disability as a consequence from a hx of TBI [repeat or severe]?
2%
What FDA approved drugs prevent progression of MCI to dementia?
none
What are 3 infectious causes of dementia?
HIV
syphilis
prion disease [Mad Cow, Creutzfeld Jacob, etc]- rapid cognitive decline, prominant behavioral ad sleep disturbance, myoclonus or cerebellar deficits
What is the NMDA receptor antagonist used for Alzheimer Disease and what are common side effects?
memantine [Namenda]
dizzyness, sleepiness, headaches, constipation, and SOB
What are common signs of Parkinson's Dementia?
REM sleep disturbances
Tiredness
Depression and Anxiety
Psychosis in later stages in 1/3 of patients
Sensory changes- lose sense of smell. Numbness, tingling prickling in the skin
Changes in perception of pain [increased or reduced]
Compare and contrast CTE and AD
CTE AD
Early depression or mood swings Early memory
Parkinsonism late in course
Suicidal behaviors
Substance abuse
NFT in layers II and III NFTs in V and VI
What is the annual rate of progression of MCI to dementia?
10-15%
What are 2 fatal, genetic untreatable dementias?
Huntington Chorea- onset usually age 30-50. twisting,writhing,akinesia. live 15-20 years after dx
ALS- gradual onset motor deficits. average time to diagnose 1 yr. respiratory death in 2-5yrs.
What are the two Monoclonal Anitibody infusions approved for Alzheimer Disease?
Lecanemab [Leqembi, Lemi] >20k yr, q 2 wk infusion. need mild MCI or dementia, + biomarker test, amyloid PET scan, or LP for amyloid and tau, can't use if on anticoagulation
Donanemab [Kisunla, Cassunla], >>>20k/yr, monthly infusion
What 3 walking tips can you give people with Parkinson disease to reduce the risk of falls?
1.Focus on putting heel [not toes] down first
2. Look ahead, rather than at the feet
3. Practice large purposeful steps to reduce shuffling
4. Avoid carrying things while walking
5. Consider using a cane or walker to increase stability
How does chronic subdural hematoma present? Who is at risk?
Can be asymptomatic. headache. cognitive deficit
Elderly. Alcoholics. Fallers on anticoagulants
What 2 general categories of MCI are there and what are the ramifications of delineating them?
amnestic- if memory deficit present more likely progression to AD
non-amnestic- other cognitive or behavioral domains progress more commonly to FTD, VD, DLB
How does progressive supranuclear palsy present?
tilting head in order to see up and down since vertical gaze is impaired
postural instability with falls
behavioral and mood changes- apathy, disinhibition, dysphoria, anxiety
What is the Anticholinesterase inhibitor that is approved also for Parkinson Dementia?
Does ginkgo biloba, NSAIDs, Vit E or omega-3s slow the progression of dementia?
Rivastigmine
No