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Tremors for GP Event March 2015 - NW

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Tremors for GP Event March 2015

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Tremors for GP Event March 2015 - NW

  1. 1. TREMORS AND PARKINSON’S DISEASE Dr Naomi Warren Consultant Neurologist RVI March 2015
  2. 2. CONTENT  Is it tremor?  Tremor cases  Parkinson’s Disease
  3. 3. MOVEMENT DISORDERS Too much or too little? Too little Bradykinesia PD Other parkinsonisms Too much Tremor Myoclonus Dystonia Chorea Tics
  4. 4.  video
  5. 5.  video
  6. 6. TREMOR  Rhythmical oscillatory movement  Ask about…  Duration of history  Symmetry  when occurs  ADL  FH  Alcohol  Drugs  Associated features
  7. 7. HELPFUL CLUES - EXAMINATION  Description  Rest, posture, action, intention  Frequency & amplitude  Which body part?  Gait  Arm swing  Rigidity?  Bradykinesia?  Draw Archimedes spiral, writing
  8. 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. 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. 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. 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. 12.  video
  13. 13. DIFFERENTIAL DIAGNOSIS  Essential tremor  Dystonic tremor  Parkinson’s disease  Investigations?  Consider DaT
  14. 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. 15.  video
  16. 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. 17.  video
  18. 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. 19.  video
  20. 20. DIFFERENTIAL DIAGNOSIS  PD  Dystonic  Asymmetrical ET  Any Investigations?  No need for Brain Scan unless atypical features  Consider DaT if unsure
  21. 21. DAT SCAN Dopamine receptors DopamineDOPA TheThe DopaminergicDopaminergic TerminalTerminal MAO-B COMT Metabolites Dopamine Transporter
  22. 22. [123I]FP-CIT SPECT (DAT SCAN) Normal Abnormal caudate putamen
  23. 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. 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. 25. NEW DIAGNOSIS PD  Explanation and information  PDUK website  PD nurse  DVLA + insurance  Consider Physiotherapy  Consider Research
  26. 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. 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. 28. PD TREATMENT – OTHER OPTIONS  Apomorphine  Injections, infusion  Duodopa  Into Jejenum  Surgery  Deep brain stimulation  Mostly STN  Thalamus for tremor
  29. 29. NON-MOTOR SYMPTOMS  Sleep problems  RBD  Clonazepam  Restless legs  PLMS  Bowel/bladder  Drooling  Anticholinergics, bo tox  Pain  Depression/anxiety  Dementia
  30. 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. 31. video
  32. 32. REMINDER …..CAUSES  Exaggerated physiological  Metabolic/drugs  Essential tremor  Parkinson’s disease  Dystonic tremor  Rarer: Cerebellar, functional….etc…..
  33. 33. WHO/WHEN TO REFER  Uncertain diagnosis  PD – untreated  ET – unresponsive to propranolol +/- topiramate  Functional  Cerebellar
  34. 34. CONCLUSIONS  Common  Challenging  Think about the company they keep  Questions????

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