Neuro Cases 2

Question 1

What is a tremor?

Answer 1

Involuntary, rhythmic, oscillatory movement of a body part and is the most common movement disorder seen in primary care

Question 2

What are the different classifications of tremors?

Answer 2

Resting, action, enhanced physiological tremor, essential, parkinsonism, cerebellar, psychogenic, dystonic, Wilson disease

Question 3

What is a resting tremor?

Answer 3

Occurs in a body part that is relaxed and completely supported against gravity; enhanced by stress or movement of another body part; diminished by voluntary movement of that body part

Question 4

What is a postural tremor?

Answer 4

Maintaining a position against gravity (arm elevation)

Question 5

What is a isometric tremor?

Answer 5

Muscle contraction against a rigid stationary object (making fist)

Question 6

What is an action tremor?

Answer 6

Kinetic tremor associated with voluntary movement and includes intention tremor, which is produced with target-directed movement (reaching for a pen)

Question 7

What is an enhanced physiologic tremor?

Answer 7

Everybody has an asymptomatic physiologic tremor; low amplitude, high frequency at rest and during activity; enhanced by anxiety, stress, certain medications and metabolic conditions; if patients have tremors that come and go with anxiety, med use, caffeine intake or fatigue, they don’t need further testing

Question 8

What is an essential tremor?

Answer 8

Most common pathological tremor; most common in hands and wrists, but can also affect head, LEs, and voice; usually bilateral, present with different tasks, and interferes with activities; can be inherited, tends to progress with age; caffeine and fatigue exacerbate these tremors, alcohol can help symptoms

Question 9

T/F: 95% of patients have primarily kinetic rather than postural tremors

Answer 9

True

Question 10

What percent of those affected by essential tremors retire early or modify their career path?

Answer 10

25%

Question 11

What is a parkinsonism tremor?

Answer 11

Classic tremor that starts as pill-rolling motion of the fingers; bradykinesia incldues difficulty rising from a seated position, reduced arm swing while walking, and micrographia; 70% of patients with Parkinson’s Disease have a resting tremor as their presenting feature, can get better with action

Question 12

What is a cerebellar tremor?

Answer 12

Classic tremor; low-frequency, slow-intension or postural tremor, and is typically caused by multiple sclerosis with cerebellar plaques, stroke, or brainstem tumors

Question 13

What is a psychogenic tremor?

Answer 13

Can be difficult to differentiate from organic tremor; some features that are inconsistent include abrupt onset, spontaneous remission, changing tremor characteristics (including location and frequency), increase with attention and extinction with distraction; more frequently seen in patients employed in allied health professions, those involved in litigation

Question 14

What is dementia?

Answer 14

Loss of cognitive functioning - thinking, remembering, and reasoning - and behavioral abilities to such an extent that it interferes with a person’s daily life and activities; these functions include memory, language skills, visual perception, problem solving, self-management, and the ability to focus and pay attention

Question 15

What is a major neurocognitive disorder?

Answer 15

Significant cognitive decline in at least one domain interfering with activities of daily living

Question 16

What is a minor neurocognitive disorder?

Answer 16

Modest cognitive decline that does not interfere in daily living

Question 17

What is a mini-cog test? What is the sensitivity and specificity?

Answer 17

Patient is asked to repeat three unrelated words, perform a clock drawing test, then recall the three words; sensitivity of 76-100%, specificity of 54-85% for detecting cognitive impairment; demonstrates better performance in patients with dementia than mild cognitive impairment

Question 18

How do you score the mini-cog?

Answer 18

One point for each word remembered; 2 points for good clock (numbers correct, clock hands with arrows, length of arms doesn’t matter); score of 3, 4, or 5 indicates lower likelihood of dementia but doesn’t exclude some element of cognitive impairment

Question 19

What does the ASCERTAIN 8-item informant questionnaire screen for? What is the specificity and sensitivity? How do you score it?

Answer 19

Screens for major and minor neurocognitive disorders; sensitivity of 85%, specificity of 86%; count the “yes” answers; 0-1 is normal, 2 or more means cognitive impairment likely to be present

Question 20

If a screening is positive, what is your next step?

Answer 20

Next screen for DEGREE

Question 21

What is a mini-mental state examination (MMSE)? What is the sensitivity and specificity?

Answer 21

Most commonly used DEGREE screening; sensitivity is 81% and specificity is 81% for detecting dementia; nomograms for normal versus impaired are based on age

Question 22

What is the montreal cognitive assessment (MOCA)?

Answer 22

Designed for persons scoring 24 or higher on MMSE; accurate in patient’s with Parkinson’s Disease; another type of DEGREE screening

Question 23

What are the 3 DEGREE screenings?

Answer 23

Mini-mental state examination (MMSE), Montreal Cognitive Assessment (MOCA), and St. Louis Mental Status Examination

Question 24

What are the next steps after DEGREE screenings?

Answer 24

Geriatric Depression Scale to rule out pseudodementia; lab evaluation and neuroimaging for reversible causes of dementia