Tremors 2017

TREMORS AND PARKINSON’S DISEASE

Dr Naomi WarrenConsultant NeurologistRVIMarch 2017

CONTENT Is it tremor? Tremor cases Parkinson’s Disease

MOVEMENT DISORDERSToo much or too little?

Too little

Bradykinesia

PD Other parkinsonisms

Too much

Tremor

Myoclonus

Dystonia

Chorea

Tics

video

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TREMOR Rhythmical oscillatory movement Ask about…

Duration of history Symmetry when occurs ADL FH Alcohol Drugs Associated features

HELPFUL CLUES - EXAMINATION Description

Rest, posture, action, intention Frequency & amplitude Which body part?

Gait Arm swing

Rigidity? Bradykinesia? Draw Archimedes spiral, writing

CASE 1 55 yr old man R handed Background psychotic depression many yrs Tremor hands R>L When holding cups, doing DIY Some difficulty with dexterity Sense smell normal Smoker Medication

Olanzapine 20mg many years, amlodipine O/E

symmetrical tremor Mild rigidity and bradykinesia

DIFFERENTIAL DIAGNOSIS Drugs

Da blocking drugs Antipsychotics Antiemetics

Inhalers – B agonists Ca channel blockers Li Valproate Digoxin

etc

PD

Thyrotoxicosis Check TFTs

Anxiety

ET

Dystonic

DIAGNOSIS Drug induced parkinsonism and tremor Can be immediate or delayed effect. Post synaptic blockade Da receptors

DaT scan normal (presynaptic receptors)

Clues Symmetry Smoker No non-motor features

CASE 2 85 yr old man R handed 5-6 years tremor R >L hand Carrying cups + holding paper Head tremor ? Started same time Sleeps well Gait – L TKR last year Alcohol no effect Mother – tremor Tried propranolol – initial effect, topiramate

and gbp – s/e, primidone – no effect

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DIFFERENTIAL DIAGNOSIS Essential tremor

Dystonic tremor

Parkinson’s disease

Investigations? Consider DaT

ESSENTIAL TREMOR Activity Bimodal age onset ½ alcohol benefit ½ FH Postural/action, symmetrical 4-12 Hz +/- head (late), jaw, voice Treatment

Propranolol LA 80mg – 240mg, Topiramate 25mg – 100mg

primidone, gbp. Rarely: deep brain stimulation

VIDEO

DYSTONIC TREMOR Asymmetric Can look like PD Neck/head (often in isolation), arm, hand Jerky Task/posture specific Sensory trick Tx Bo tox head, try propanolol

VIDEO

CASE 3 76 yr old man R handed 3 years tremor L hand (C4 decompression) More recent R hand temor Slowness L hand – no limitation ADL Occ feels stumbling Sleeps poorly, REM sleep behaviour disorder PMH HTN, on lisinopril Non-smoker No FH

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DIFFERENTIAL DIAGNOSIS

PD Dystonic Asymmetrical ET

Any Investigations? No need for Brain Scan unless atypical

features Consider DaT if unsure

DAT SCAN

DopaminereceptorsDopamineDOPA

The The DopaminergicDopaminergic Terminal Terminal

MAO-B COMT

Metabolites

Dopamine Transporter

[123I]FP-CIT SPECT (DAT SCAN)

Normal Abnormal

caudate

putamen

PARKINSON’S DISEASE Older age mostly Rest Non-motor features

Smell, RBD, depression Examination

Rest mostly, asymmetric, 4-6Hz +/- legs Jaw – not head Parkinsonism

NEWCASTLE PD SERVICE Movement disorder clinic (CRESTA, CAV)

Prof Nicola Pavese, Dr Naomi Warren + Dr Paul Goldsmith

Care of Elderly Dr Jane Noble (CAV) Dr Alison Yarnell (FRH)

3 x Parkinson’s disease nurses (RVI)

Referral form Fax See within 6 weeks

NEW DIAGNOSIS PD Explanation and information

PDUK website

PD nurse

DVLA + insurance

Consider Physiotherapy

Consider Research

TREATMENT Refer in untreated Treat if affects ADLs First line:

MAOB-I ( rasageline, selegiline) Da Agonist (ropinirole, pramipexole, rotigotine

patch) L Dopa (sinemet, madopar)

If elderly/severe symptoms – L dopa

CONTINUOUS DOPAMINERGIC THERAPY Aim for smooth drug delivery

Less long term comps Multiple drugs in low doses Long acting Da agonists Da agonist patch If wearing off – add entacapone (COMT-I)

Stalevo Later …. Dyskinesias……..Amantadine

PD TREATMENT – OTHER OPTIONS Apomorphine

Injections, infusion Duodopa

Into Jejenum Surgery

Deep brain stimulation Mostly STN Thalamus for tremor

NON-MOTOR SYMPTOMS Sleep problems

RBD Clonazepam

Restless legs PLMS

Bowel/bladder Drooling

Anticholinergics, bo tox Pain Depression/anxiety Dementia

ESTABLISHED PD - CHALLENGES Side effects medication

Impulse control disorders/psychosis (Da agonists) Avoid antiemetics (domperidone/ondansetron)

Infections/surgery Can worsen symptoms Keep meds same Physio

Dementia/depression/psychosis Common Avoid most antipsychotics (use clozapine/quetiepine) Cholinesterase inhibitors SSRI, SNRI, mirtazepine

REMINDER …..CAUSES Exaggerated physiological Metabolic/drugs Essential tremor Parkinson’s disease Dystonic tremor Rarer:

Cerebellar, rubral, functional….etc…..

WHO/WHEN TO REFER Uncertain diagnosis PD – untreated ET – unresponsive to propranolol +/-

topiramate Functional Cerebellar

CONCLUSIONS Common Challenging Think about the company they keep

Questions????