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Neurology [TREMOR]

Parkinsons
1) Parkinsons
Essential
Parkinsons is caused by a Loss of Dopaminergic Neurons Tremor Huntingtons
within the substantia nigra. This essentially eliminates the go
Delirium Tremens
signal, preventing the initiation of movement. The classic
Cerebellar Dysfunction
symptoms of Parkinsons stems from bradykinesia (difficulty
initiating movement). This will manifest itself in slow-
movements in general and even cognitive slowing. Logo for the
classic cog-wheel rigidity, a resting pill-rolling tremor, and
gait disturbances / postural instability (the little muscles that
keep you straight up dont correct for position, so these patients
are high risk for falls). The patient will have difficulty with the
get-up-and-go test, and will walk with shuffling steps. A board
buzz word is a mask-like expressionless face.

The diagnosis is clinical. While brain imaging might be attempted


to rule out something else (CT for a bleed, MRI for stroke), said
imaging is not needed. The test might throw at you an MRI of the
substantia nigra showing degeneration, but that is NOT needed
for the diagnosis in life.

Treatment is about the go signal. The go signal is dopamine. The


stop signal is Acetylcholine. The focus of therapy is supplying the
go signal.

Dopamine Agonists agonists are the mainstay of therapy for


young, functional people (<70, maintained function).
Bromocriptine is an older, dirtier dopamine agonist, so the newer Parkinsons
ones should be used instead. Ropinirole = Pramipexole. <70 AND >70 OR Non-
functional Functional functional
Levodopa-Carbidopa is the mainstay of therapy for everyone
and Age
else (>70 or nonfunctioning). Levodopa CAN cross the blood
brain barrier, carbidopa cannot. Carbidopa prevents the
conversion of L-Dopa into dopamine. This means more levodopa Dopamine Carbidopa / Levodopa
gets into the brain, and more dopamine is created from more Agonists
levodopa. Deep Brain As problems arise
Stimulator add Selegiline,
But eventually, levodopa-carbidopa begins to wear off. The
(end game) Capone
COMT-inhibitors and the MAO-B-inhibitors are brought in as
levodopa-carbidopa begins to fail. Theres no way to determine
how to add them. Drug Mechanism Indications Side Effects
Amantadine Functional
Acetylcholine-R-antagonists like Benztropine could theoretically >60 years old
work, but the acetylcholine side effects are not worth it for the Carbidopa Dopamine Nonfunctional HoTN, Psychosis
elderly; the effect is also weak. Use this on young people who Levodopa Agonists
have a tremor only. Selegiline MAO-B Nonfunctional Delays Progression
Antagonist Exacerbate
Capones COMT Nonfunctional Delays Progression
While you DO want dopamine in the substantia nigra, the cost of
Antagonist Exacerbation
putting dopamine in the brain is overstimulation of other Bromocriptine Dopamine Functional -
dopamine tracts. In particular, it can induce psychosis with Agonist <60 years old
overstimulation of dopamine, causing schizophrenic symptoms
and hallucinations. Remember, you use anti-dopamine drugs
(antipsychotics) to treat schizophrenia. We havent figured out
how to target one tract over another just yet.


OnlineMedEd. http://www.onlinemeded.org
Neurology [TREMOR]

HYPERKINETIC DISORDERS Disease Rest Moving Other Tx
Parkinsons Improves Old (> 60) Complex
1) Essential Tremor Essential Worsens Middle ( >30) Propranolol
The essential tremor, also known as a familial tremor, is one Cerebellar Intention Cerebellar Lesion
Tremor
thats absent at rest but worsens with movement. Theres
Huntingtons Chore Anticipation
typically a family history of a tremor and its often a man. It Trinucleotide rpt
unfortunately doesnt have a treatment. Consider this when other Suicide
causes have been ruled out already. For control of symptoms try
beta blockers.

2) Intention Tremor = Cerebellar Dysfunction


A tremor thats absent at rest and gets worse the closer to the
target the finger gets. This is also called an intention tremor
because it arises as the patient attempts (intends) to do something.
Since theres a physical lesion (stroke, atrophy) of the cerebellum
theres no therapy.

3) Huntingtons
Huntingtons is an autosomal dominant genetic disease caused
by trinucleotide repeats. The more repeats a person has, the
earlier the disease sets in. Most people begin to exhibit symptoms
near middle age (30-60). It also exhibits anticipation: occurring
earlier and earlier in subsequent generations as the number of
trinucleotide repeats expands. Chorea is purposeless ballistic
movements. The prognosis is terrible as it leads to dementia,
psychosis, and often death by suicide. Theres no treatment.


OnlineMedEd. http://www.onlinemeded.org