Tremors for GP Event March 2015

1. TREMORS AND
PARKINSON’S DISEASE
Dr Naomi Warren
Consultant Neurologist
RVI
March 2015

2. CONTENT
 Is it tremor?
 Tremor cases
 Parkinson’s Disease

3. MOVEMENT DISORDERS
Too much or
too little?
Too
little
Bradykinesia
PD
Other
parkinsonisms
Too much
Tremor
Myoclonus
Dystonia
Chorea
Tics

4.  video

5.  video

6. TREMOR
 Rhythmical oscillatory movement
 Ask about…
 Duration of history
 Symmetry
 when occurs
 ADL
 FH
 Alcohol
 Drugs
 Associated features

7. HELPFUL CLUES - EXAMINATION
 Description
 Rest, posture, action, intention
 Frequency & amplitude
 Which body part?
 Gait
 Arm swing
 Rigidity?
 Bradykinesia?
 Draw Archimedes spiral, writing

8. 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

9. 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

10. 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

11. 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

12.  video

13. DIFFERENTIAL DIAGNOSIS
 Essential tremor
 Dystonic tremor
 Parkinson’s disease
 Investigations?
 Consider DaT

14. 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

15.  video

16. 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

17.  video

18. 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

19.  video

20. DIFFERENTIAL DIAGNOSIS
 PD
 Dystonic
 Asymmetrical ET
 Any Investigations?
 No need for Brain Scan unless atypical features
 Consider DaT if unsure

21. DAT SCAN
Dopamine
receptors
DopamineDOPA
TheThe DopaminergicDopaminergic TerminalTerminal
MAO-B COMT
Metabolites
Dopamine
Transporter

22. [123I]FP-CIT SPECT (DAT
SCAN)
Normal Abnormal
caudate
putamen

23. PARKINSON’S DISEASE
 Older age mostly
 Rest
 Non-motor features
 Smell, RBD, depression
 Examination
 Rest mostly, asymmetric, 4-6Hz
 +/- legs
 Jaw – not head
 Parkinsonian

24. NEWCASTLE PD SERVICE
 Movement disorder clinic (CRESTA, CAV)
 Prof David Burn, Dr Naomi Warren + Dr Paul
Goldsmith
 Care of Elderly
 Dr Jane Noble (CAV)
 Dr Alison Yarnell (FRH)
 4 x Parkinson’s disease nurses (RVI)
 Referral form
 Fax
 See within 6 weeks

25. NEW DIAGNOSIS PD
 Explanation and information
 PDUK website
 PD nurse
 DVLA + insurance
 Consider Physiotherapy
 Consider Research

26. 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

27. 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

28. PD TREATMENT – OTHER OPTIONS
 Apomorphine
 Injections, infusion
 Duodopa
 Into Jejenum
 Surgery
 Deep brain stimulation
 Mostly STN
 Thalamus for tremor

29. NON-MOTOR SYMPTOMS
 Sleep problems
 RBD
 Clonazepam
 Restless legs
 PLMS
 Bowel/bladder
 Drooling
 Anticholinergics, bo tox
 Pain
 Depression/anxiety
 Dementia

30. ESTABLISHED PD - CHALLENGES
 Side effects medication
 Impulse control disorders (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

31. video

33. REMINDER …..CAUSES
 Exaggerated physiological
 Metabolic/drugs
 Essential tremor
 Parkinson’s disease
 Dystonic tremor
 Rarer:
Cerebellar, functional….etc…..

34. WHO/WHEN TO REFER
 Uncertain diagnosis
 PD – untreated
 ET – unresponsive to propranolol +/- topiramate
 Functional
 Cerebellar

35. CONCLUSIONS
 Common
 Challenging
 Think about the company they keep
 Questions????