380.2 🩺 國考版

380.2.1 高頻考點

380.2.1.1 TRAP Cardinal Features

  • Tremor (rest, asymmetric, 4-6 Hz)
  • Rigidity (cogwheel)
  • Akinesia/bradykinesia
  • Postural instability (later)

380.2.1.2 Pathology

  • α-synuclein aggregation (Lewy bodies)
  • Loss of dopaminergic neurons SNpc

380.2.1.3 Braak Staging

  • Lower brainstem → SN → cortex

380.2.1.4 Non-Motor Features

  • REM behavior disorder (prodromal — 80% develop)
  • Hyposmia (very early)
  • Constipation
  • Orthostatic hypotension
  • Cognitive impairment (PD-MCI → PDD)
  • Depression, anxiety
  • ICDs (with DA agonists)

380.2.1.5 MDS Diagnostic Criteria

  • Bradykinesia + (rest tremor OR rigidity)
  • Plus supportive
  • No exclusions
  • No red flags

380.2.1.6 Red Flags for Atypical Parkinsonism

  • Rapid progression
  • Early falls (< 1 year)
  • Severe autonomic failure
  • Severe bulbar dysfunction
  • Inspiratory stridor
  • Cerebellar signs
  • Supranuclear gaze palsy
  • Symmetric onset
  • Poor levodopa response

380.2.1.7 DaT-SCAN

  • Distinguishes PD/parkinsonism from essential tremor, vascular, drug-induced, psychogenic

380.2.1.8 Levodopa Side Effects

  • Nausea, hypotension (early)
  • Motor fluctuations + dyskinesias (after years)
  • Behavioral
  • Pulmonary (rare with infusion)

380.2.1.9 Dopamine Agonist Side Effects

  • ICDs (impulse control disorders) — gambling, hypersexuality, eating, shopping — counsel!
  • Sleep attacks
  • Edema
  • Hallucinations
  • Orthostatic

380.2.1.10 MAO-B Inhibitors

  • Selegiline, rasagiline, safinamide
  • Mild benefit
  • Tyramine reaction risk minimal at low doses

380.2.1.11 COMT Inhibitors

  • Entacapone (with each levodopa)
  • Opicapone (once daily)
  • Reduce wearing off
  • Dyskinesias, urine discoloration

380.2.1.12 Amantadine

  • Reduces dyskinesias
  • Gocovri ER FDA-approved

380.2.1.13 Pimavanserin

  • Selective 5HT-2A inverse agonist
  • FDA for PD psychosis
  • No dopaminergic blockade

380.2.1.14 Rivastigmine

  • FDA for PD dementia
  • Cholinesterase inhibitor

380.2.1.15 DBS Targets

  • STN (most common)
  • GPi
  • Vim (tremor)

380.2.1.16 Advanced Therapies

  • DBS
  • LCIG (Duopa)
  • Foslevodopa-foscarbidopa SC (Vyalev) FDA 2024
  • Apomorphine
  • Focused ultrasound (thalamotomy, pallidotomy)

380.2.1.17 Genetic PD

  • LRRK2 (most common AD)
  • GBA (risk allele, also Gaucher)
  • PARKIN, PINK1, DJ-1 (AR, young-onset)
  • SNCA (rare AD)

380.2.2 Specific Treatment Pitfalls

380.2.2.1 Levodopa Wearing-Off

  • Predictable
  • Treatment: more frequent dosing, COMT inhibitor, ER formulations, DA agonist, MAO-B

380.2.2.2 Levodopa Dyskinesias

  • Peak-dose typically
  • Treatment: amantadine, reduce levodopa, DA agonist substitution, DBS

380.2.2.3 Freezing of Gait

  • Difficult
  • Cueing strategies, levodopa response variable

380.2.2.4 Falls

  • Multifactorial
  • PT, home modifications, treat OH

380.2.2.5 Psychosis Management

  • Reduce dopaminergic if possible
  • Pimavanserin
  • Quetiapine, clozapine (avoid typical antipsychotics)