How to deal with tremor patients? Flashcards
Case 1:
- 64 M 5yr hx of tremor which is getting worse
- tremor affects both hands and ability to write and hold cup
- O/E bilateral postural tremor with mild head tremor
What are the keys points, what questions should you ask and what is the likely diagnosis?
tremor for at least 5 years, bilateral, symmetrical, actions, bilateral postural tremor, mild head tremor
Ask about alcohol and fam hx
Essential tremor - with these tremors they tend to improve with alcohol
Case 2:
- 64 M 9-12 month hx R arm tremor which is getting worse
- O/E R sided tremor with mild jaw tremor
What are the keys points, what questions should you ask and what is the likely diagnosis?
Unilateral tremor 9-12 months, R sided tremor, jaw tremor
Ask about:
- arm movement, facial expression, tone, writing, slowness in movements, gait, salivation
Parkinson’s disease = rigidity, shuffling gait, micrographia
- usually starts on one side and spreads
What are the key clinical features of essential tremor?
onset - bilateral other features - none body affected by tremor - arms, head, voice type of tremor - action (postural) latency - immediate duration - long (yrs) alcohol- relieves it fam hx - usually positive
most common movement disorder - much more common than PD
usually starts mid- late life but can appear in adolescence (18-20 and 50s = peaks)
What are the key clinical features of parkinsons disease?
onset - unilateral other features - gait, facial expression, rigidity body affected by tremor -arms, legs, jaw type of tremor - rest latency - lag for several seconds duration - short (months) alcohol- no relief fam hx - usually negative
What are the diagnostic tests and treatments for essential tremor?
no diagnostic test, based on clinical diagnosis
no specific treatment needed in some pts
mainstay is beta-blockers - 50% improv on propranolol but can’t be given in asthmatics
primidone used if tolerated
alprazolan - induces drowsiness though
surgical treatment - deep brain stimulation - most decline
What is the pathology of PD?
Loss of pigmented cells in the substantia nigra in midbrain
lewy bodies - intracytoplasmic eosinophilic round inclusions = not diagnostic
diagnosis is confirmed only at post-mortem
What are the key signs of parkinson’s disease?
lack of swing in arms shuffling gait arms flexed at elbow and wrist hips and knees flexed asymmetry - may only swing one arm micrographia
What are the motor and non-motor clinical features of PD ?
Motor = main symptoms
- tremor
- bradykinesia
- rigidity
- postural instabilities
Non-motor - these tend to occur as the disease progresses
- cognitive impairment
- psychiatric complications
- behavioural dysfunction
- sleep disturbance
- autonomic dysfunction
depression and anxiety are common in the early stages
When is vascular parkinsonism more likely to occur?
with a hx of hypertension
What drugs can induce parkinsons?
neuroleptics
antiemetic drugs
sodium valporate
salbutamol - posture tremor
What is parkinson’s +++?
less common
progressive supranuclear palsy
multiple system atrophy
How can PD be diagnosed?
DaTscan
- helps to differentiate between a PD tremor and other tremors
= single photon emission computed tomography, look for dopamine transporters
What are the treatment options for PD?
L-DOPA (+ decarboxylase e.g. sinemet) and COMT inhibitors (entacapone and opicapone) = stalevo, sastravi dopamine agonists (ropinirole and pramipexole) MAOB inhibitors (selegine, rasagiline, safinamide)
nurse practitioner
physical and occupational therapist
speech therapist
dietician
How is cognitive impairment treated?
treat the dementia - rivastigmine
How are psychiatric complications treated?
hallucinations and psychosis - modify anti-PD drugs and quetiapine
