Neuro - Tremor

Question 1

A 64yo man presents with a bilateral tremor in his hands. What is your differential diagnosis?

Answer 1

1. Postural tremor
   - essential tremor
   - exaggerated physiological tremor e.g. anxiety, thyrotoxicosis
   - alcohol abuse
   - peripheral neuropathies
2. Resting tremor
   - Parkinson’s disease
3. Intention tremor
   - cerebellar disease e.g. MS, stroke, tumours

Question 2

Which features suggest an essential tremor?

Answer 2

1. Bilateral postural tremor (5-10 Hz)
   - slowly progressive (intermittent then persistent)
   - worse with voluntary movement, stress, fatigue, caffeine
   - resolves at rest
   - improves with alcohol consumption
2. Bilateral distribution: teens and 60s
3. FHx in 50-70% (autosomal dominant inheritance)

Question 3

Discuss options for the management of an essential tremor.

Answer 3

• no Tx
• 1st line: PROPRANOLOL or PRIMIDONE (AED)
• 2nd line: other B-blockers or AEDs
• 3rd line: deep brain stimulation or thalamotomy

Question 4

What is the pathophysiology of Parkinson’s disease?

Answer 4

Build up of intraneuronal Lewy bodies… degeneration of dopaminergic neurones in substantia nigra… impaired motor function.

Question 5

Which clinical features suggest Parkinson’s disease?

Answer 5

1. resting ‘pill-rolling’ tremor (3-5 Hz): induced by concentration, improved by activity
2. bradykinesia e.g. reduced arm swing, hypomimia
3. lead-pipe/cogwheel rigidity
4. postural instability
5. altered gait e.g. forward-flexed shuffling, festination, ‘en-block’ turning
6. psych features e.g. depression, psychosis
7. fatigue and sleep disturbance

Question 6

What investigations would you perform in a case of suspected Parskinson’s?

Answer 6

clinical diagnosis

Question 7

What are the medical management options for a patient with Parkinson’s disease?

Answer 7

1st line:

• motor Sx affecting QoL: LEVODOPA + CARBIDOPA
• motor Sx not affecting QoL:
  
  • MAO-B inhibitor e.g. RASAGELINE, SELEGILINE
  • dopamine agonist e.g. ROPINIROLE

2nd line: LEVODOPA + MAO-B inhibitor OR dopamine agonist OR COMT inhibitor e.g. ENTACAPONE

Question 8

What are the pros + cons of levodopa comapred to other PD meds? What is its MOA?

Answer 8

MOA: dopamine precursor

Pros:

1. best effect on motor Sx + ADLs
2. fewer specified adverse effects

Cons:

1. more motor complications (esp. long term) e.g. on/off, dyskinesias, freezing
2. other s/e: hypotension, psychosis, tachycardia

Question 9

What are the specified adverse effects of dopamine agonists and MAO-B inhibitors?

Answer 9

• excessive sleepiness
• hallucinations
• impulse control disorders

Question 10

Describe the 3 parkinson’s plus syndromes.

Answer 10

1. Lewy body dementia: progressive neuronal degeneration (cholinergic + dopaminergic) due to accumulation of Lewy bodies
   - dementia with visual hallucinations
   - parkinsonism
   - ANS dysfunction
   - REM sleep disorder
   - fluctuating cognition/alertness/attention
2. progressive supranuclear palsy: progressive neuronal degeneration from accumulation of Tau proteins
   - supranuclear ophthalmoplegia (problems with downwards eye movements)
   - parkinsonism
   - ataxia
   - dementia
3. multiple system atrophy
   - orthostatic hypotension (L+S BP)
   - parkinsonism
   - poor response to dopamine meds