Lecture 5: Neuro Cases 2 Flashcards
What is a tremor?
- An involuntary, rhythmic, oscillatory movement of a body part
- Most common movement disorder seen in primary care clinics
What are the major classifications of tremors?
- Resting
- Action
- Enhanced physiologic
- Essential
- Parkinsonism
- Cerebellar
- Psychogenic
Describe a resting temor.
- 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 an action tremor.
-
Postural tremor: maintaining a position against gravity
- Ex: arm elevation
-
Isometric tremor: muscle contraction against a rigid stationary objects
- Ex: making a fist
-
Kinetic tremor: associated with voluntary movement and includes intention tremor, which is produced w/ target-directed movement
- Ex: reaching for a pen
Describe an 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 patients have tremors that come and go with anxiety, medication use, caffeine intake or fatigue, they do not need further testing
Describe an essential tremor.
- Most common pathological tremor
- Most common in hands and wrists, can also affect head, LEs and voice
- Usually bilatera
- Can be inherited, tends to progress with age
- •5% of those affected retire early or modify career path
- Caffeine and fatigue exacerbate these tremors, alcohol can help symptoms
What is the most common form of Parkinson’s Disease?
Idiopathic Parkinson’s Disease (PD)
What is the classic “parkinsonian” tremor?
“Pill rolling” tremor
What is a classic symptom of Parkinson’s?
Bradykinesia: 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 with distraction
What would a family history of neurologic disease suggest?
Genetic component
(common in essential tremors)
What would a tremor in an older patient with gradual onset suggest?
Parkinson’s Disease or Essential Tremor
What would a sudden onset tremor most likely indicate?
- Psychogenic tremor
- Related to medication use or toxin exposure
- Brain tumor
What are the common symptoms associated with Parkison’s Disease?
- 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 is the difference in writing patterns between PD and Essential tremor?
- Parkinson’s Disease: micrographia
- small, illegible
- Essential tremor: tremulous
- large, illegible
What is dementia?
- Loss of cognitive functioning and behavioral abilities that can interfere with a person’s daily life and activities
- Memory
- Language skills
- Visual perception
- Problem solving
- Self-management
What is the difference between major and minor neurocognitive disorders?
- Major: signficiant cognitive disorder in at least domain interfering with daily living
- Minor: modest cognitive disorder that does not interfere with daily living
When treating a patient suspected to have dementia, what should the history include?
- Timeline of symptom presentation
- Speed of progression
- Medication
- Recent hospitalizations
- Infection
What are some reversible causes of dementia?
- Hypothyroidism
- Vitamin deficiencies
- Intracranial tumors
- Normal pressure hydrocephalus
- Depression
- Hypoperfusion from heart failure
What are some screening tests for cognitive impairment?
- Mini-cog
- ASCERTAIN Dementia 8 Item Informant Questionnaire
- General Practioner Assessment of Cognition
Describe a Mini-Cog test.
- Patient asked to repeat three unrelated words
- Peform a clock drawing test
- Recall three words
Describe a ASCERTAIN Dementia 8 Item Informant Questionnaire.
- Screens for major and minor neurocognitive disorders
- If patient score is >2, cognitive impairment more than likely
If any of the screening tests are positive, what is the next step for dementia patients?
- Mini-Mental State Examination
- Montreal Cognitive Assesment
- SLU Mental Status Examination
Followed by:
- Geriatric Depression Scale
- Lab evaluation and neuroimaging
