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TREMORS AND PARKINSON’S DISEASE
Dr Naomi WarrenConsultant NeurologistRVIMarch 2017
CONTENT Is it tremor? Tremor cases Parkinson’s Disease
MOVEMENT DISORDERSToo much or too little?
Too little
Bradykinesia
PD Other parkinsonisms
Too much
Tremor
Myoclonus
Dystonia
Chorea
Tics
video
video
TREMOR Rhythmical oscillatory movement Ask about…
Duration of history Symmetry when occurs ADL FH Alcohol Drugs Associated features
HELPFUL CLUES - EXAMINATION Description
Rest, posture, action, intention Frequency & amplitude Which body part?
Gait Arm swing
Rigidity? Bradykinesia? Draw Archimedes spiral, writing
CASE 1 55 yr old man R handed Background psychotic depression many yrs Tremor hands R>L When holding cups, doing DIY Some difficulty with dexterity Sense smell normal Smoker Medication
Olanzapine 20mg many years, amlodipine O/E
symmetrical tremor Mild rigidity and bradykinesia
DIFFERENTIAL DIAGNOSIS Drugs
Da blocking drugs Antipsychotics Antiemetics
Inhalers – B agonists Ca channel blockers Li Valproate Digoxin
etc
PD
Thyrotoxicosis Check TFTs
Anxiety
ET
Dystonic
DIAGNOSIS Drug induced parkinsonism and tremor Can be immediate or delayed effect. Post synaptic blockade Da receptors
DaT scan normal (presynaptic receptors)
Clues Symmetry Smoker No non-motor features
CASE 2 85 yr old man R handed 5-6 years tremor R >L hand Carrying cups + holding paper Head tremor ? Started same time Sleeps well Gait – L TKR last year Alcohol no effect Mother – tremor Tried propranolol – initial effect, topiramate
and gbp – s/e, primidone – no effect
VIDEO
DIFFERENTIAL DIAGNOSIS Essential tremor
Dystonic tremor
Parkinson’s disease
Investigations? Consider DaT
ESSENTIAL TREMOR Activity Bimodal age onset ½ alcohol benefit ½ FH Postural/action, symmetrical 4-12 Hz +/- head (late), jaw, voice Treatment
Propranolol LA 80mg – 240mg, Topiramate 25mg – 100mg
primidone, gbp. Rarely: deep brain stimulation
VIDEO
DYSTONIC TREMOR Asymmetric Can look like PD Neck/head (often in isolation), arm, hand Jerky Task/posture specific Sensory trick Tx Bo tox head, try propanolol
VIDEO
CASE 3 76 yr old man R handed 3 years tremor L hand (C4 decompression) More recent R hand temor Slowness L hand – no limitation ADL Occ feels stumbling Sleeps poorly, REM sleep behaviour disorder PMH HTN, on lisinopril Non-smoker No FH
video
DIFFERENTIAL DIAGNOSIS
PD Dystonic Asymmetrical ET
Any Investigations? No need for Brain Scan unless atypical
features Consider DaT if unsure
DAT SCAN
DopaminereceptorsDopamineDOPA
The The DopaminergicDopaminergic Terminal Terminal
MAO-B COMT
Metabolites
Dopamine Transporter
[123I]FP-CIT SPECT (DAT SCAN)
Normal Abnormal
caudate
putamen
PARKINSON’S DISEASE Older age mostly Rest Non-motor features
Smell, RBD, depression Examination
Rest mostly, asymmetric, 4-6Hz +/- legs Jaw – not head Parkinsonism
NEWCASTLE PD SERVICE Movement disorder clinic (CRESTA, CAV)
Prof Nicola Pavese, Dr Naomi Warren + Dr Paul Goldsmith
Care of Elderly Dr Jane Noble (CAV) Dr Alison Yarnell (FRH)
3 x Parkinson’s disease nurses (RVI)
Referral form Fax See within 6 weeks
NEW DIAGNOSIS PD Explanation and information
PDUK website
PD nurse
DVLA + insurance
Consider Physiotherapy
Consider Research
TREATMENT Refer in untreated Treat if affects ADLs First line:
MAOB-I ( rasageline, selegiline) Da Agonist (ropinirole, pramipexole, rotigotine
patch) L Dopa (sinemet, madopar)
If elderly/severe symptoms – L dopa
CONTINUOUS DOPAMINERGIC THERAPY Aim for smooth drug delivery
Less long term comps Multiple drugs in low doses Long acting Da agonists Da agonist patch If wearing off – add entacapone (COMT-I)
Stalevo Later …. Dyskinesias……..Amantadine
PD TREATMENT – OTHER OPTIONS Apomorphine
Injections, infusion Duodopa
Into Jejenum Surgery
Deep brain stimulation Mostly STN Thalamus for tremor
NON-MOTOR SYMPTOMS Sleep problems
RBD Clonazepam
Restless legs PLMS
Bowel/bladder Drooling
Anticholinergics, bo tox Pain Depression/anxiety Dementia
ESTABLISHED PD - CHALLENGES Side effects medication
Impulse control disorders/psychosis (Da agonists) Avoid antiemetics (domperidone/ondansetron)
Infections/surgery Can worsen symptoms Keep meds same Physio
Dementia/depression/psychosis Common Avoid most antipsychotics (use clozapine/quetiepine) Cholinesterase inhibitors SSRI, SNRI, mirtazepine
REMINDER …..CAUSES Exaggerated physiological Metabolic/drugs Essential tremor Parkinson’s disease Dystonic tremor Rarer:
Cerebellar, rubral, functional….etc…..
WHO/WHEN TO REFER Uncertain diagnosis PD – untreated ET – unresponsive to propranolol +/-
topiramate Functional Cerebellar
CONCLUSIONS Common Challenging Think about the company they keep
Questions????