Tremor and PD Flashcards
Types of Tremors
Anxiety/Hyperthyroid - find, rapid, reduced with rest
Parkinsonism - fine, regular, at rest, with movement
Cerebellar - Variable rate with movement
Essential - symmetrical with movement
Metabolic - flapping
Essential Tremor
Common,
Increases with age
Symmetrical action tremor – hands & arms
Isolated head tremor – “no-no”
No established testing or criteria
Alcohol – 50% of persons see improvement after drinking alcohol
Normal neuro and MS exam
Family history - often
Tx: Propranolol 120-320 mg/day;
Primidone 25 -300 mg/ daPD Hx
Unilateral tremor in hand At rest Handwriting changes (micrographia) Slowness of movement Slowed – bradykinesia Decreased – hypokinesia Difficult to initiate – akinesia Speech change Voice lowered - hypophonia Gait and balance change Early subtle changes in gait – foot drag Shuffle Rarely impaired balance early Functional status Slowness, awkwardness Difficulty turning in bed or getting up Difficulty with fine motor tasks
Targeted exam for tremor
Face to face: diminished blinking, hypophonia
Tremor – with hands supported
Shoulder shrug- affected side slight lag
Limp arms, wrists – check for rigidity
Tapping with index finger and RAM – slow and awkward movements
Up and go – will required 1 or more attempt or arms
Righting reflex – more than 1 or 2 steps backward
Walking – leaning forward, asymmetric shoulder height, reduced arm swing, flexed elbow
Meds that cause PD-like symptoms
Dopamine antagonists:
Metoclopramide (Reglan)
Typical and Atypical antipsychotics
Procholperazine (Compazine)
Can take up to 1 yr for symptoms to resolve
Primary Parkinsonism DD
Primary Parkinsonism Idiopathic Parkinson’s disease Multiple systems atrophy Progressive supranuclear palsy Dementia with Lewy bodies Frontotemporal dementia with parkinsonism Corticobasal degeneration
Secondary Parkinsonism DD
Secondary Parkinsonian Disorders Infection- induced parkinsonism Vascular parkinsonism due to stroke Drug-induced parkinsonism Toxin-induced parkinsonism
How to Discuss Dx
Discuss observations
Share suspicions: probable Parkinson’s disease
Broad range of symptom severity
Progressive disease: long periods of clinical stability
Many symptoms are treatable
Symptoms don’t worsen abruptly
Medications, or infection might worsen symptoms
Is not genetically transmitted
PD Plan of Care
Start medical tx early - as soon a dx is confirmed
Referral to neurology or movement disorder clinic
Physical, Occupational, Speech therapy
Medication management:
Dopamine agonist
Levodopa
Dopamine Agonists
Stimulates dopamine receptors in the brain
Used as monotherapy or with levodopa
Started at low dose and titrated
Side effects: nausea, hypotension, leg edema, vivid dreams, hallucinations, somnolence, sudden sleep attack; compulsive disorders possible
Caution with driving when starting therapy
Common Rx: Pramipexole (Mirapex); Ropinirole (Requip); Selegiline (Eldepryl); Entacapone (Comtan)
Levodopa
Most motor symptoms are related to dopamine deficiency: provides dopamine
Given with carbidopa to inhibit conversion to dopa-carboxylase – blocks sx of nausea & vomiting
Motor fluctuations – wearing off common as disease progresses.
Frequent dosing to counter on-off phenomena
SE: n,v, anorexia, confusion, drowsiness, psychosis, postural hypotension, dyskinesias
Common Rx: Sinemet
Levodopa Considerations
Protein in meal can interfere with transport to brain
Take immediate release 30-60 min before meal
If problem with nausea can take with fruit or non protein
Can take controlled release (CR) tabs with meal
Dyskinesias occur when levodopa reaches peak effect
Freezing associated with duration of PD and duration of time on levodopa therapy
Non-motor PD Symptoms
Neurospychiatric symptoms Antonomic disorders Sleep disorders Sensory disorders Depression - SSRI 1st line
Neuropsychiatric PD Symptoms
Psychosis: hallucinations or delusions Common as the disease progresses Look for secondary cause, meds, dementia Visual hallucinations More common in the evening Can be caused by meds Treat if threatening or frightening Serequel 12.5 – 25mg and titrate to lowest effective dose Discuss risks: Atypical antipsychotics may increase the risk of cardiovascular or cerebral vascular events including the risk of death (2 in 100).
Dementia r/t PD
Early stages: slowed thinking, memory retrieval, poor concentration
Disease progression – development of dementia
Lewy bodies contribute to dementia process
Progressive loss of executive function
Short term memory loss
Aphasia, apraxia, agnosia not common
MMSE or clock drawing test (CDT)
PDD vs. Dementia of Lewy Body – motor symptoms precede neuropsychiatric symptoms
