2.5 Neuro Cases 2 Flashcards
What is a tremor?
“An involuntary, rhythmic, oscillatory movement of a body part and is the most common movement disorder seen in primary care clinics.”
What are the (7) major classifications of tremors?
- Resting
- Action
- Enhanced physiologic
- Essential
- Parkinsonism
- Cerebellar
- Psychogenic
Describe a:
Resting Tremor
Occurs in body part that is relaxed and completely supported against gravity
Enhanced by mental stress or movement of another body part
DIMINISHED by voluntary movement of that body part
Describe a:
Action Tremor
(describe the three subtypes)
Postural tremor : maintaining a position against gravity (i.e. arm elevation)
Isometric tremor : muscle contraction against a rigid stationary objects (i.e. making a fist)
Kinetic tremor : associated with voluntary movement and includes intention tremor, which is produced w/ target-directed movement (i.e. reaching for a pen)
Describe a:
Enhanced physiologic tremor
EVERYBODY has an asymptomatic physiologic tremor
(low amplitude, high frequency at rest and during activity)
Enhanced by anxiety, stress and certain medications
***If pt.s have tremors that come and go with anxiety, med use, caffeine intake or fatigue, they don’t need further testing
What is the most common pathological tremor?
Essential tremor
What are some telltale signs that your patient has an essential tremor?
Caffine and fatigue make worse
ALCOHOL can lessen symptoms
Common in hands/wrists
What is the mechanism of parkinsons?
Low dopamine
What is the most common form of parkinsons?
Idiopathic Parkinson’s Disease (PD)
What is the classic “parkinsonian” tremor?
“Pill rolling” tremor
What is a classic symptom of parkinsons?
Bardykinesia
(Difficulty rising from a seated position, micrographia, reduced arm swing while walking)
Describe a:
Cerebellar tremor
Low-frequency, slow-intention or postural tremor
Caused by MS with cerebellar plaques, stroke or brainstem tumors
What is particularly challenging about diagnosing a psychogenic tremor?
It can be VERY difficult to differentiate from organic tremor
What are some telltale signs of a psychogenic tremor?
Abrupt onset
Spontaneous remission
Changing tremor characteristics
Increase with attention and extinction w/ distraction
CLINICAL PEARLS
What would a family hx of neurologic disease suggest?
Genetic component
COMMON IN ESSENTIAL TREMORS
CLINICAL PEARLS
What would a tremor in an older patient w/ gradual onset suggest?
Probably…
PD or essential tremor
CLINICAL PEARLS
What would a sudden onset tremor most likely indicate?
Psychogenic tremor
Related to meds use/Toxin exposure
Brain tumor
What are the common symptoms associated with PD?
- Tremor
- Decreased arm swing
- Soft voice
- Sleep disturbances
- Decreased sense of smell
- Symptoms of autonomic dysfunction
- Decreased facial expression
- Malaise
- Depression/anhedonia
- Slowness in thinking
What has a strong correlation to family history:
PD or Essential tremor
Essential tremor
What is the difference in writing patterns between PD and Essential tremor?
PD: Micrographia
Essential tremor: Tremulous
What is the symmetry difference in distrubution b/w PD and Essential Tremor?
PD: Asymmetrical
Essential tremor: Symmetrical
Writing sample:
Most likely PD or Essential tremor?
PD:
Small, can be illegible
Writing sample:
Most likely PD or Essential tremor?
Essential tremor
Large, tremulous, can be illegible
what is the most common type of tremor?
action: postural, isometric, kinetic, or intention
most common type of pathologic tremor?
essential tremor
What is a common death related to dementia patients?
Some sort of infection or complication of injury b/c they dont have safety reminders
CLINICAL PEARL for Parkinsons disease?
70% of these patients have a resting tremor as presenting symptom
-also “masking face”, shuffling gait
what is an “organic” tremor?
a tremor that is real and not under patient control
What are examples of complex attention that is affected by dementia?
- Normal tasks taking longer
- difficulty multi tasking
- difficulty remembering a phone number while dialing
- work requires more overview than before
What are examples of executive function deficits with dementia?
- difficulty completing familiar multistep tasks (like making a meal)
- easily distracted
- no long wanting to participate in activities of the home
- less enjoyable to be social
What are language deficits with dementia?
- difficulty finding the correct words
- using general pronouns instead of names
- mispronunciation
- problems understanding verbal and written communication
What are learning and memory deficits associated with dementia?
- forgetting to buy items or buying the same items multiple times
- repetition in conversations
- difficulty recalling recent events
- relying on lists of tasks to complete
- forgetting to pay bills
What are perceptual-motor deficits associated with dementia?
- difficulty in using familiar technology, tools, or kitchen appliances
- getting lost in familiar environments
What are social cognition deficits associated with dementia?
- apathy
- increase in inappropriate behaviors
- loss of empathy
- impaired judgement
What history should we include for patients with neurocog disorder?
- Education, timeline of symptom presentation and speed of progression
- Medication review for those that may affect cognition (Beers criteria for older adults)
- Recent hospitalization? Infection? Delirium should be on the differential, also cardiometabolic risk factors for cognitive impairment.
PE findings are usually normal in dementia, but what lab values should you look into for reversible causes of dementia?
–Hypothyroidism
–Vitamin deficiencies
–Intracranial tumors
–Noremal. Pressure hydrocephalus
–Depression
–Hypoperfusion from heart failure
Brief Initial Screening Test for Cognitive Impairment
- Mini-Cog
- Ascertain Dementia 8 Item Informant Questionnaire
- General Practioner Assessment of Cognition
How do you perform a mini-cognition test?
Paient asked to repeat three unrelated words, perform a clock drawing test then recall the three words
*This tool demonstrates better performance in pateints with dementia than mild cognitive impairment
what is the scoring for mini-cognition test?
- One point for each word remembered. 2 points for good clock (numbers correct, clock hands have arrow marks, arm length doesn’t matter)
- Score of 3, 4 or 5 indicates lower likelihood of dementia but doesn’t. exclude some element of cognitive impairment
What is the major DSM-5 criteria for neurocognitive disorders?
significant cognitive decline in at least 1 cognitive domain interfering with activities of daily living
8 questions in the AD8 Dementia Screening Interview
- problem with judgement
- loss of interest with hobbies
- repeats same things over
- trouble learning how to use tool, appliance, gadget
- forgets correct month or year
- trouble handling financial affairs
- trouble remembering appointments
- daily problems with thinking and/or memory
If there is a positive brief initial screening test for cognitive impairment, what should be performed next?
- mini-mental state examination (MMSE): high sensitivity and specificity
- montreal cognitive assessment (MOCA): score higher than 24
- or the St. Louis University Mental Status Exam
