This document discusses tremors and Parkinson's disease. It provides information on different types of tremors, including essential tremor, drug-induced tremor, and tremors associated with Parkinson's disease. It also describes three patient cases presenting with tremors and the process of differential diagnosis. Treatment options for different tremors and Parkinson's disease are outlined. The document aims to help clinicians distinguish between tremor types and appropriately diagnose and manage patients.

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????