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Clin med exam 2 > Movement disorders > Flashcards

Movement disorders Flashcards

1
Q

Tremor

A

contraction of antagonistic muscles

most common movement disorder

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2
Q

Types of tremor

A

resting-
come and go depending on pt’s stress level
better during movement

action-

  • postural- body part held against gravity
  • kinetic- voluntary movement of limb
  • intention- worst with goal-directed movement
  • isometric- occur during muscle contraction against stationary objects
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3
Q

Action tremor types

A
  • postural- body part held against gravity
  • kinetic- voluntary movement of limb
  • intention- worst with goal-directed movement
  • isometric- occur during muscle contraction against stationary objects
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4
Q

Benign essential tremor (familial tremor)

A

increase with age

inherited- autosomal dominant disorder

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5
Q

Essential tremor is usually ____ tremor

A

postural- action tremor

with “essential” action (ex writing)

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6
Q

Essential tremor affect what limbs?

A

hands, forearms, head, voice- “essential” body parts

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7
Q

Essential tremor- exacerbating and relieving ?

A

stress exacerbates

alcohol relieves

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8
Q

Essential tremor workup

A

not needed- maybe TSH

clinical dx

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9
Q

Essential tremor tx- intermittent

A

propranol (BP med- a beta blocker)
s/e- hypotension, dizziness, light headedness
alcohol

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10
Q

Essential tremor tx- persistent

A 
1. propranol (BP med- a beta blocker)
s/e- hypotension, dizziness, light headedness 
2. primidone
3. second line choice: 
- gabapentin, topirimate, nimodipine
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11
Q

Essential tremor- prognosis

A

slow, gradual progression

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12
Q

Physiological tremor characteristics

A

occurs in all people- not neurological disease
in all voluntary muscle groups
not visible to eye

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13
Q

Physiological tremors are heightened by

A 
fear/anxiety
hypoglycemia
exhaustion 
hyperthyroidism 
caffeine 
alcohol 
benzodiazepine withdrawal 
stimulants 
fever
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14
Q

Parkinsonism tremor characteristics

A

rest tremor
pill-rolling
starts in 1 hand

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15
Q

Parkinsonism tremor is associated with

A

bradykinesia and rigidity

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16
Q

Cerebellar tremor characteristics

A

uni or bi
manifests as intention tremor
finger to nose test, heel to shin
worsens approaching target

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17
Q

Cerebellar tremor causes

A

MS
CVA
Brainstem tumor

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18
Q

Drug induced tremors

A 
long list- 
epinephrine
prozac 
caffeine 
thyroid hormone
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19
Q

Orthostatic tremors

A

legs and or trunk after standing
unsteadiness
not visible
responds to klonopin (sedative)

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20
Q

Psychogenic tremor (functional tremor)

A 
not neurological 
looks like others 
sudden onset and remission 
stops with distraction 
increases with stress
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21
Q

Primary writing tremor

A

action

limited to one hand

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22
Q

Restless leg syndrome (RLS) aka

Willis-ekbom disease (Wed)

A

uncomfortable urge to move legs when relaxed
“tingling”, creeping/crawling sensation, cramping, electric

relieved with movement

during sleep= PLMS (periodic limb movements of sleep)

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23
Q

Restless leg syndrome risk factors

A 
Diabetes
IDA
ESRD (end stage renal disease) 
RA
PD 
neuropathy 
myelopathy
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24
Q

RLS pathophysiology

A

iron deficiency anemia most common treatable cause (have decreased iron stores)

secondary to peripheral neuropathy, uremia, pregnancy

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25
Q

RLS tx

A
  • iron replacement

- avoid antidepressants, sedating antihistamines- makes you relax

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26
Q

RLS- intermittent symptoms tx

A
  • levodopa- “on demand”
    s/e: nausea, dizziness, somnolence
  • benzodiazepines (klonopin)
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27
Q

Dopamine agonists- RLS

A

mirapex
s/e: ortho hypotension, nausea, dizziness

requip
s/e: hypotension, drowsiness, dizziness, nausea, fatigue

neupro- patch
s/e: hypotension, edema, drowsiness, dizziness, dyskinesia

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28
Q

Alpha-2 delta calcium channel ligands- RLS

A

gabapentin
s/e: dizziness, drowsiness, fatigue

lyrica
s/e: somnolence, ataxia, edema

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29
Q

Huntington disease

A

inherited (autosomal dominant) and fatal progressive neurodegenerative disorder characterized by chorea, psychiatric disturbances and dementia

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30
Q

Huntington disease- clinical representation

A

chorea- “choreography= dance” rapid involuntary movements

  • can cause dysarthria, dysphagia, and involuntary vocalization
  • common cause of death= dysphagia and aspiration

weight loss/cachexia

dementia

psychiatric symptoms
- increased risk of suicide

abnormal eye movements

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31
Q

Huntington disease dx

A

clinical, family hx

genetic testing- confirm

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32
Q

Huntington disease tx

A

no cure, can’t halt

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33
Q

Huntington disease meds- help with chorea

A

xenazine
= dopamine-depleting agent
s/e: drowsiness, sedation, depression, etc.

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34
Q

Huntington disease meds- neuroleptics (depresses nerve functions- tranquilizer)

A 
- chorea and psych 
= antipsychotic 
zyprexa 
haldol 
clozapine

-psych
TCAs (tricyclic antidepressants) and SSRIs (selective serotonin reuptake inhibitor)

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35
Q

Parkinson disease

A

progressive neurodegenerative disorder characterized by bradykinesia, tremor, rigidity, & postural instability

36
Q

Parkinson disease- epidemiology

A

family hx- increased risk

genetic contribution

37
Q

Parkinson disease- pathophysiology

A

degeneration of dopaminergic neurons in the substantia nigra

imbalance of dopamine & acetylcholine
- dopamine decreased, excess acetylcholine relative to dopamine

note- acetylcholine activates skeletal muscles- tremors

38
Q

Parkinson disease classic triad

A

resting tremor

  • “pill rolling”
  • stress exacerbates

bradykinesia

  • slowness of voluntary movement- have trouble getting up from chair
  • slow shuffling gait (=festinating gait)
  • reduced blinking and masked facies (hypomimia)

rigidity

  • resistance to passive movement of a joint
  • decreased arm swing
  • stooped posture
39
Q

Parkinson disease- types of rigidity

A
  • cogwheel- able, rigid, able, rigid, etc.

- lead pipe- entire ROM

40
Q

Parkinson disease motor clinical features

A 
dysarthria 
dysphagia 
sialorrhea 
blurred vision 
micrographia 
freezing gait
41
Q

Parkinson disease non motor clinical features

A 
depression 
anxiety 
dementia 
constipation 
olfactory dysfunction
cognitive dysfunction
42
Q

Parkinson disease dx

A

clinical- must have bradykinesia and tremor or rigidity

beneficial response to dopaminergic therapy

43
Q

Parkinson disease tx

A

amantadine

  • antiviral med
  • mild, early disease
  • se: orthostatic hypotension, hallucinations

anticholinergic meds

  • tremor and drooling
  • cogentin- most common
  • se- dry mouth, confusion, hyperthermia, etc.

levodopa (a precursor of dopamine)

  • most reliable- drug of choice
  • for bradykinesia
  • combined w carbidopa to decrease se of nausea, light-headedness, and postural hypotension
  • carbidopa/levodopa (Sinemet)
  • patients >65

dopamine agonists

  • directly stimulate dopamine receptors
  • mirapex, nuepro, cycloset
  • cause dopamine behaviors “fun things”
  • patients <65-70

MAO B inhibitors

COMT inhibitors

  • extender for sinemet, not alone
  • tasmar (needs LFT monitoring), comtan
44
Q

Tardive dyskinesia (TD)

A

hyperkinetic movement disorder with a delayed onset that appears after prolonged use of dopamine receptor blocking agents (antipsychotics (neuroleptics) and antiemetics (anti-nausea))

45
Q

Antipsychotics first gen

A

haldol

chlorpromazine

46
Q

Antipsychotics second gen

A

clozapine
zyprexa
seroquel
risperdal

47
Q

Antiemetics

A

reglan (metoclopramide)

compazine

48
Q

Tardive dyskinesia clinical features

A

insidious onset

after a dose reduction, discontinuation or switch to a less potent antipsychotic

49
Q

Tardive dyskinesia- orofacial manifestations

A 
protruding, twisting tongue 
smacking lips 
retraction of corners of mouth 
puffing cheeks 
chewing movements 
puckering lips
50
Q

Tardive dyskinesia- limb movements

A 
twisting finger 
piano playing 
finger spreading 
tapping foot 
extending toes
51
Q

Tardive dyskinesia- neck and trunk

A 
retrocollis 
shoulder shrugging 
rocking or swaying 
rotating hip movements 
thrusting hip
52
Q

Tardive dyskinesia- respiratory

A

tachypnea
irregular breathing rhythms
grunting noises

53
Q

Tardive dyskinesia- dx

A

clinical
must have:
1. dyskinetic or dystonic involuntary movements
2. 1 month use of drug tx
3. excluded other causes of abnormal movements

54
Q

Tardive dyskinesia- tx

A

discontinue meds if possible

switch from typical to atypical antipsychotic (second gen- clozapine, seroquel)

55
Q

Tardive dyskinesia- prognosis

A

can achieve remission if early detection

56
Q

Amyotrophic lateral sclerosis (ALS)

A

Also known as Lou Gehrig’s disease or Motor Neuron Disease (MND)

progressive neurodegenerative disorder of motor neurons that cause muscle weakness, disability, and death

57
Q

Amyotrophic lateral sclerosis (ALS)- epidemiology

A

sporadic

smoking likely a risk factor

58
Q

Amyotrophic lateral sclerosis (ALS)- pathophysiology

A

degeneration of MOTOR neurons at ALL level of the CNS

onset- only UMN involvement or LMN but progressive loss of both

59
Q

Amyotrophic lateral sclerosis (ALS)- clinical features- LMN

A 
weakness
atrophy
fasiculations 
difficulty rising from chair 
foot drop 
cramps
difficulty writing
60
Q

Amyotrophic lateral sclerosis (ALS)- clinical features- UMN

A 
hyperreflexia
spasticity 
slowed rapid alternating movements
spastic gait 
poor balance/falling 
incoordination of movement 
stiffness/slowness
61
Q

Amyotrophic lateral sclerosis (ALS)- clinical features- bulbar

A

head, face, neck areas

Jaw spasticity
Slow tongue movement
Facial diparesis
Dysphagia
Dysarthria
Laryngospasm
Pseudobulbar affect
Sialorrhea
Poor lip closure/seal
Difficulty managing pharyngeal secretions
Muscle atrophy and fasiculations
Hoarseness
Increased facial reflexes
62
Q

Amyotrophic lateral sclerosis (ALS)- clinical features- axial

A 
absent abdominal reflexes 
difficulty holding up head 
difficulty maintaining an erect body posture 
lumbar lordosis 
cramps
63
Q

Amyotrophic lateral sclerosis (ALS)- clinical features- respiratory

A 
Tachypnea 
Reduced vocal volume 
Shorter sentences & frequent pauses for breath
Use of accessory respiratory muscles
Dyspnea
Weak cough
Sleep disordered breathing
Confusion
64
Q

Amyotrophic lateral sclerosis (ALS)- dx summary

A

LMN degeneration by clinical, electrophysiological, or neuropathological examination

UMN degeneration by clinical examination

Progressive spread of s/sx to other regions

65
Q

Amyotrophic lateral sclerosis (ALS)- tx

A

Riluzole (rilutek)- extend tracheostomy-free survival by 2-3 months
- se: nausea, weakness, hepatic impairment, neutropenia, dizziness

nutrition

respiratory management

  • pulmonary function tests
  • ventilation

pseudobulbar affect- (ex- laughing then crying)
- neudexta, elavil

spasicity
- baclofen, zanaflex

sialorrhea
- atropine, hyoscyamine, glycopyrrolate

66
Q

Amyotrophic lateral sclerosis (ALS)- prognosis

A

3-5y survival

67
Q

Myasthenia gravis

A

autoimmune disorder characterized by dysfunction at the neuromuscular junction, causing weakness and fatigability of skeletal muscles

68
Q

Myasthenia gravis- pathophysiology

A

autoantibodies against acetylcholine receptor in postsynaptic neurotransmitter junction –> weakness & fatigue of muscles

have thymic abnormalities

69
Q

Myasthenia gravis- clinical features

A

symptoms fluctuate throughout day

improve after rest

ocular symptoms
- ptosis, diplopia

bulbar symptoms

  • dysarthria (speaking)
  • dysphagia (swallowing)
  • fatigable chewing

expressionless- “she lost her smile”

dropped head syndrome

respiratory insufficiency and failure “myasthenic crisis”

limb weakness

no reflex changes

70
Q

Myasthenia gravis- dx

A

ice pack test- improves

edrophonium test- improves

serum AChR antibiodies- (+)
- (-) then (+) for MuSK (muscle specific receptor tyrosine kinase)

single-fiber electromyography=most sensitive test for MG

repetitive nerve stimulation

71
Q

Myasthenia gravis- tx

A

1st line: acetylcholinesterase inhibitors (mestinon)

immunotherapy added to above

  • corticosteroids
  • azathioprine
  • mycophenolate mofetil
  • cyclosporine

exacerbation?
- Plasmapheresis and IVIG

72
Q

Tourette syndrome

A

neurological disorder manifested by multiple motor and phonic tics

73
Q

Tourette syndrome- epidemiology

A

kids, teens

74
Q

Tourette syndrome- pathophysiology

A

bilineal transmission (innervated by both social & environmental factors and genetic abnormalities)

disinhibition of motor and limbic system

75
Q

Tourette syndrome- types of tics

A

tics- sudden, brief movements or utterances
involuntary but can be suppressed

motor
phonic

76
Q

Tourette syndrome motor tics

A

motor tics:
simple- blinking, head thrusting
complex- gesturing

involve face, neck, shoulders

Echopraxia= imitation of movement of others

self-mutilating- hair pulling, biting nails, lips, tongue

77
Q

Tourette syndrome phonic tics

A

grunts, hisses, coughing, utterances, barks

Coprolalia- involuntary obscene speech

echolalia- repetition of others’ speech

palilalia- rep. of words of phrases

78
Q

Tourette syndrome- comorbidities

A

ADHA
OCD
Learning disorders
Conduct disorders

79
Q

Tourette syndrome- dx

A

multiple motor ticks and >1 phonic tic present
occur many times during day or intermittently for 1 year
tics grow and change location overtime

80
Q

Tourette syndrome- tx general

A

Cognitive behavior therapy- Habit reversal training

81
Q

Tourette syndrome- antidopaminergic meds

A

haldol (1st gen antipsychotic)

pimozide

fluphenazine

etc.

82
Q

Tourette syndrome tx for those with ADHD

A

alpha adrenergic agonists

clonidine (catapres)- BP med
guanfacine (intuniv)

83
Q

Tourette syndrome- tx for focal tics

A

botulinum toxin

84
Q

Tourette syndrome tx for disabling tics

A

deep brain stimulation of globus pallidus, thalamus, or other subcortical targets

85
Q

Tourette syndrome tx for those with OCD

A

behavior therapy + SSRI
prozac
if no response, 2nd gen antipsychotic

Clin med exam 2 (12 decks)

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