Tremor, Rigidity, Tics and Dystonia: The 4 Most Common Movement Disorders
|
|
- Jason Rice
- 6 years ago
- Views:
Transcription
1 Tremor, Rigidity, Tics and Dystonia: The 4 Most Common Movement Disorders
2 VIGNETTE 1: HAND SHAKING 62 YOF tremor of both hands for 6 years FHx: Shaking in mother & maternal cousin PMH: Depression, HTN, obesity, asthma Meds: Verapamil, MVI, Paxil, theophylline Exam: Tremors of R>L hand with arms outstretched, with writing, not at rest; mild cogwheeling on PROM Patient is worried she has Parkinson s disease
3 VIGNETTE #1 Is this Parkinson s disease? What is it? What work-up would you do? Would you treat? What would you use? What about the cogwheeling?
4 What Are Tremors? Description: rhythmic, stereotyped, distal>proximal, positional dependent movements. Arm>leg>head Resting tremor - prominent at rest, often slow, pill roll & pronation/supination common Postural tremor - prominent with limbs extended Kinetic tremor - prominent with goal directed movement (writing)
5 TREMOR EXAM Arms completely at rest Outstretched paper on back of hands Finger-nose-finger Write name Archimedes spiral ROM for UE tone
6 TYPE FREQ OCCURS ASSOCIATION Postural 5-9 HZ Rest 3-6 HZ Arms outstretch Rest, Walk Physiologic, ET, ETOH w/d, toxic-metabolic, Parkinson's Dis, rare meds Action 3-10 HZ Movement ET, cerebellar lesions, MS, ETOH
7 ESSENTIAL TREMOR 3-20X as common as PD 50-70% positive family history Postural & kinetic tremor Rapid and distal>proximal Increases with anxiety Clinical examination otherwise normal Less often involvement of head, voice or legs
8 DRUG INDUCED TREMOR Beta adrenergic agonist Theophylline Lithium Steroids Lamotrigine Tricyclic antidepressants SSRIs Depakote Dopa blockers (antipsychotics, anti-emetics, anti-vertigo) Thyroid hormone Cardiac anti-arrhythmics (amiodarone, procainamide) Calcium channel blockers Mercury, lead, arsenic toxic Pseudoephedrine & Caffeine Amphetamines/Ritalin
9 WORK-UP OF POSTURAL TREMOR Family history TSH Medication levels Electrolytes Rarely: MRI and serum Ceruloplasm (for Wilson s disease)
10 Avoid meds causing tremor, caffeine; Relaxation/biofeedback, Wrist weights,?etoh Primidone Beta Blocker Topamax, Benzodiazepines, Neurontin Botulinum Toxin Thalamic ablation/dbs
11 MEDICATION DOSAGES Propranolol (Inderal) max dose 240 mg If contraindication or failure: Primidone (Mysoline) start 25 mg, max 100 mg Consider supplementing with: Gabapentin (Neurontin) 100 mg tid up to 800 mg tid Topiramate (Topamax) mg/d Klonopin & Alprazolam risk of tachyphylaxis & abuse
12 VOICE & HEAD TREMOR Start with beta blocker &/or primidone Try botulinum toxin if not effective
13 VIGNETTE 2: A STIFF OFFICER 59 YOM police officer with stiffness in walking, rolling over in bed, teased for staring, some muscle aching Exam: reduced blinking, doesn t shift or gesture, voice quiet, stiffness noted on PROM of arms, no tremor Walks with short steps, decrease arm swing L>R
14 QUESTIONS What other questions would you ask? What could this be? What do you think of the absent tremor? What work-up if any?
15 BRADYKINETIC-RIGID SYNDROME History Exposure to neuroleptics or anti-nausea med? New medications? Repeated head trauma? Family history of PD? Falls? Cognitive decline? Autonomic sx: postural dizziness, bowel/bladder dysfunction, impotence Sleep disturbances
16 BRADYKINETIC RIGID SYNDROME EXAMINATION Postural BP check Observe spontaneous movements, blinks Check EOMs Tremor: arms out, at rest, F-N-F, walking PROM of arms & head Froment s sign Handwriting: small Gait: initiation, step length, turns, arm swing, Pull test Consider MMSE
17 PD: DIAGNOSIS A Clinical Diagnosis R/O neuroleptic exposure When to test: 1. Rapid or early onset 2. Atypical features 3. Poor response to Tx Test: MRI, slit lamp & serum ceruloplasm (r/o Wilson s disease)
18 RED FLAGS Early onset (<50) Poor response to L-Dopa No tremor Early orthostatic hypotension Early dementia/confusion Early gait impairment Rapid progression Symmetrical from onset Abnormal EOMs
19 PD LOOK- A -LIKES 20% patients misdiagnosed Neuroleptic induced PD Progressive supranuclear palsy (PSP): Decrease up/down gaze, neck very stiff & extended, no rest tremor, early postural instability Diffuse Lewy Body Disease: Dementia then bradykinesia, visual hallucinations, fluctuate Multisystem Atrophy: No tremor, poor response to Tx, cerebellar dysfunction, autonomic problems
20 CARDINAL FEATURES OF PD Resting Tremor Bradykinesia Rigidity Postural Instability
21 PD REST TREMOR Unilateral tremor in hand Worse with rest or walking, better with use of the hand Slow & often pill-rolling or pronation supination in type
22 SYMPTOMATIC THERAPY Anticholinergics Trihexyphenidyl Amantadine MAO inhibitors Selegiline Rasagiline Carbidopa/L-dopa Sinemet Dopamine agonists Pramipexole Ropinirole COMT inhibitors Entacapone
23 LEVODOPA THERAPY: STILL THE MOST EFFECTIVE Sinemet is carbidopa and levodopa. Carbidopa prevents peripheral conversion to dopamine Sinemet 10/100, 25/100, 25/250 Start 25/100 bid or tid Avg patient needs ~ mg L-dopa/day Take on empty stomach Sinemet CR 25/100, 50/200 Reduces dose frequency by 1/3 Take with food Supplementary carbidopa (Lodosyn) 25 mg or Domperidone mg prior to Sinemet if N/V occurs
24 DOPAMINERGIC MEDICATIONS DON T IMPROVE: Motor freezing Autonomic dysfunction Dementia Postural instability modest benefit
25 OTHER EARLY SYMPTOMS Poor dexterity Micrographia Reduced voice volume Difficulty getting out of car, chair Drooling Fatigue
26 DOPAMINE AGONISTS Direct Dopaminergic effect Clinical uses: 1. Early use to delay problem SE of Levodopa 2. Later use to smooth out motor response Side effects: BP, N/V, headache, hallucinations, confusion, dyskinesias
27 THE AGONISTS Mirapex (Pramipexole): mg tid to 1.5 mg tid Requip (Ropinirole): 0.25 mg tid to 8 mg tid Rotigotine patch (Neurpo): apply once a day
28 WHICH DOPA AGONIST SHOULD I USE? Bromocriptine not as effective & more expensive The other 3 are similar in reducing off time and improving the motor score Rotigotine offers potential advantages but no good comparisons with po med
29 MAO INHIBITORS Rasagiline: Mono or adjunctive tx Selegiline: Adjunctive tx only May improve motor fluctuations May be neuroprotective Caution with SSRIs & TCAs
30 COMT INHIBITORS Adjunctive Tx Only Tolcapone (Tasmar): mg tid & Entacapone (Comtan): 200 mg with Sinemet Effects: Increase on time, decrease off Reduce levodopa dosage Slightly more effective than dopa agonists Tasmar requires monitoring
31 ADVERSE EFFECTS Dyskinesias Nausea Diarrhea Tolcapone - 3/60,000 fatal hepatotoxicity, requires LFT monitoring
32 WHEN SHOULD TREATMENT BE STARTED? When the patient is clinically impaired vs early use of rasagiline Younger patients should be treated less aggressively early on in their disease For younger patients direct treatment to their particular symptom
33 IMPORTANT TREATMENT CONSIDERATIONS Dopa agonists: Higher risk of cognitive problems Dopa agonists: Longer to titrate dosage Anticholinergics: Help mild rest tremor, may worsen confusion Dopa agonists: may delay dyskinesias & wearing off symptoms (c/w levodopa)
34 SO WHAT SHOULD YOU DO? Start with low dose Sinemet (1/2 tab 25/100 tid) in older patients Increase q week till symptomatic response or until 2 1/2 tab tid Most patients: satisfactory, sustained response Failures: Most are not true PD, other meds won t help In some younger patients start with anticholinergic (tremor) or dopa agonist
35 AGE OLD CONSIDERATIONS Younger <60-65 More benign course Better cognition Will be treated for many more years Therefore: Start more conservatively, use anticholinergics for tremor or dopa agonist Older>60-65 More rapid course Dementia/confusion more likely Shorter lifespan Therefore: Start earlier with levodopa, watch for confusion
36 PD in the Elderly Carbidopa/levodopa is the most effective medication for PD; optimize dose before adding other drugs in the elderly. Anticholinergics and amantadine have little role in treating elderly PD patients. COMT inhibitors are very expensive for modest gain. Dopamine agonist more likely to cause delusions/hallucinations.
37 PD: COURSE OF THE ILLNESS Initially, many years of well-controlled symptoms After 3-5 years of Sinemet: Wearing off & dyskinesias
38 DYSKINESAS Usually dyskinesia refers to chorea that occurs at the time when Sinemet is at a maximum Treatment: Reduce individual dose (same daily dose more frequently) then reduce daily dose & add amantadine or dopa agonist
39 EVOLVING DOPANINERGIC RESPONSE Response Threshold Dyskinesia Threshold Early PD Moderate PD Late PD When the DA activity is between the blues lines the patient has normal ambulation ( on ) when the activity is above blue lines the patient has dyskinesias & below blue line impaired gait ( off )
40 WEARING OFF Response to Sinemet fades and disappears prior to the next scheduled Sinemet dose Patient can tell you when it will occur Treatment: Increase frequency of dosing, use extended release (Sinemet CR), add rasagiline, selegiline, dopa agonist, amantadine, anticholinergic
41 TREATING OTHER MOTOR FLUCTUATIONS Unpredictable wearing off: Add dopa agonist, rasagiline or entacapone (or combinations)
42 MOTOR FREEZING May be off period or on period Occurs when initiating, turning, crossing doorways Treat: reduce off periods, step to a target (cane, laser pointer), rocking movements, clap hands, trained dog
43 PSYCHOSIS & HALLUCINATIONS Infection, meds may trigger Visual hallucination & paranoia common First try medication reduction - 1 st : Anti-cholinergics - 2 nd : Amantidine - 3 rd : COMT antagonist - 4 th : Dopa agonists Consider neuroleptic next
44 USE OF NEUROLEPTICS IN PD Traditional neuroleptic worsen symtoms Clozapine: reduces hallucinations, no increase PD symptoms, rare agranulocytosis *Quetiapine: slightly less effective, safer 25 mg bid Other atypical neuroleptics not as effective
45 DEMENTIA & DEPRESSION 18-70% develop dementia - often drug related - Reduce meds as in psychosis - Consider cholinesterase inhibitor 40-60% develop depression: Treat with usual antidepressants, avoid anticholinergics - +/- avoid SSRIs with MAO-I - Avoid TCA in elderly or demented patient
46 DEEP BRAIN STIMULATION Subthalamic nucleus> globus pallidus Benefits - Reduction in off-time - Reduces dyskinesia Complications - Neuropsychiatric disturbances - Bleeding
47 TICS Definition: stereotyped, repetitive, nonrhythmic jerks Can be simple of complex Are suppressible --- but then increase May be vocal Rare complex vocal tics: repeat words or obscenities
48 GILLES DE LA TOURETTE S SYNDROME Onset <21 yrs Motor & verbal tics, >1 year Tics change over time Coprolalia (cursing) rare No other medical illness explains the tics +/- Attention deficit disorder +/- Obsessive compulsive disorder
49 TICS IN NON-TOURETTE S PATIENTS Sporadic tics Secondary - Post viral encephalitis - PANDAS - HIV - Lyme - Amphetamines - Ritalin - Sinemet - Cocaine -AEDs - CO - MR - Chromosomal disorders - Stroke - AD - antidepressants Other inherited disorders - Huntington s - Primary dystonia - Tuberous sclerosis - Wilsons
50 TREATMENT OF TICS Neuroleptics: typical and atypical (e.g. resperidone, Haldol, pimozide) Clonidine (Catapres) Tetrabenazine Clonazepam Botulinum toxin Low dose dopamine agonist Guanfacine (Tenex)
51 FOCAL DYSTONIAS
52 FOCAL DYSTONIAS Dystonia: Muscle spasms & limb twisting Focal dystonias - Most common dystonias: 1/ Usually middle age onset - Relatively benign
53 IDIOPATHIC CERVICAL DYSTONIA Most common dystonia - about 30/100,000 63% Women, mean age 41 Mean Age of onset: 41 Head deviation, decrease ROM, neck pain, neck tremor all common
54 Anterocollis Retrocollis Torticollis Lateralcollis
55 BLEPHAROSPASM Onset usually 6-7th decade, F>M Sore & photophobia increased blink spasms Worsens: Lights, wind, read, anxiety DDx: Dry eyes, blepharitis, tics (younger pt)
56 SPASMODIC DYSPHONIA Adductor type: most common, thyroarytenoid muscle involved, voice is strained/strangled, often tremulous Abductor type: Posterior crycoarytenoid muscle, voice is breathy Refer pt to ENT specialist for laryngoscopy & injection with botulinum toxin
57 BOTULINUM TOXIN TREATMENT OF FOCAL DYSTONIA 70-90% improvement Duration 2 ½ - 4 mos Side effects are infrequent, transient, mild & site specific: - Neck: Weak neck, mild dysphagia - Eye: Ptosis, eye closure weakness - Vocal cords: Breathy voice
58 BOTULINUM TOXIN FOR CERVICAL DYSTONIA Botulinum toxin A (Botox) & B (Myobloc) FDA approved Botox!! Oil Can!
59 SUMMARY Essential tremor is tremor alone, best treated with beta blocker or Mysoline PD treatment in elderly is Sinemet, in young is usually a dopa agonist Tics usually improve as child matures, may be treated in severe cases Focal dystonia is best treated with botulinum toxin
60 SNAP QUIZ What type of FOCAL DYSTONIA is demonstrated by the heroines?
61
62
63
64
65
66
67
68
69
70
Movement Disorders. Eric Kraus, MD! Neurology!
Movement Disorders Eric Kraus, MD! Neurology! Classify Bradykinesia! Tic! Myoclonus! Tremor! Dystonia! Athetosis! Chorea! Ballismus! Case 1 This 64 year-old female has had progression of a tremor over
More informationParkinson s Disease. Sirilak yimcharoen
Parkinson s Disease Sirilak yimcharoen EPIDEMIOLOGY ~1% of people over 55 years Age range 35 85 years peak age of onset is in the early 60s ~5% of cases characterized by an earlier age of onset (typically
More informationProfessor Tim Anderson
Professor Tim Anderson Neurologist University of Otago Christchurch 11:00-11:55 WS #91: Shakes Jerks and Spasms - Recognition and Differential Diagnosis 12:05-13:00 WS #102: Shakes Jerks and Spasms - Recognition
More informationParkinson s Disease WHERE HAVE WE BEEN, WHERE ARE WE HEADING? CHARLECE HUGHES D.O.
Parkinson s Disease WHERE HAVE WE BEEN, WHERE ARE WE HEADING? CHARLECE HUGHES D.O. Parkinson s Epidemiology AFFECTS 1% OF POPULATION OVER 65 MEAN AGE OF ONSET 65 MEN:WOMEN 1.5:1 IDIOPATHIC:HEREDITARY 90:10
More informationEvaluation and Management of Parkinson s Disease in the Older Patient
Evaluation and Management of Parkinson s Disease in the Older Patient David A. Hinkle, MD, PhD Comprehensive Movement Disorders Clinic Pittsburgh Institute for Neurodegenerative Diseases University of
More informationProfessor Tim Anderson
Professor Tim Anderson Neurologist University of Otago Christchurch 11:00-11:55 WS #91: Shakes Jerks and Spasms - Recognition and Differential Diagnosis 12:05-13:00 WS #102: Shakes Jerks and Spasms - Recognition
More informationScott J Sherman MD, PhD The University of Arizona PARKINSON DISEASE
Scott J Sherman MD, PhD The University of Arizona PARKINSON DISEASE LEARNING OBJECTIVES The Course Participant will: 1. Be familiar with the pathogenesis of Parkinson s Disease (PD) 2. Understand clinical
More informationPARKINSON S DISEASE. Nigrostriatal Dopaminergic Neurons 5/11/16 CARDINAL FEATURES OF PARKINSON S DISEASE. Parkinson s disease
5/11/16 PARKINSON S DISEASE Parkinson s disease Prevalence increases with age (starts 40s60s) Seen in all ethnic groups, M:F about 1.5:1 Second most common neurodegenerative disease Genetics role greater
More informationOptimizing Clinical Communication in Parkinson s Disease:
Optimizing Clinical Communication in Parkinson s Disease:,Strategies for improving communication between you and your neurologist PFNCA Symposium March 25, 2017 Pritha Ghosh, MD Assistant Professor of
More informationParkinson s Disease Update. Presented by Joanna O Leary, MD Movement disorder neurologist Providence St. Vincent s
Parkinson s Disease Update Presented by Joanna O Leary, MD Movement disorder neurologist Providence St. Vincent s What is a movement disorder? Neurological disorders that affect ability to move by causing
More informationPharmacologic Treatment of Parkinson s Disease. Nicholas J. Silvestri, M.D. Assistant Professor of Neurology
+ Pharmacologic Treatment of Parkinson s Disease Nicholas J. Silvestri, M.D. Assistant Professor of Neurology + Overview n Brief review of Parkinson s disease (PD) n Clinical manifestations n Pathophysiology
More information10th Medicine Review Course st July Prakash Kumar
10th Medicine Review Course 2018 21 st July 2018 Drug Therapy for Parkinson's disease Prakash Kumar National Neuroscience Institute Singapore General Hospital Sengkang General Hospital Singhealth Duke-NUS
More informationPharmacologic Treatment of Parkinson s Disease. Nicholas J. Silvestri, M.D. Associate Professor of Neurology
+ Pharmacologic Treatment of Parkinson s Disease Nicholas J. Silvestri, M.D. Associate Professor of Neurology + Disclosures n NO SIGNIFICANT FINANCIAL, GENERAL, OR OBLIGATION INTERESTS TO REPORT + Learning
More informationCardinal Features of Parkinson s. Management of Parkinson s Disease. Drug Induced Parkinson s. Other Parkinson s Symptoms.
Cardinal Features of Parkinson s Management of Parkinson s Disease Kristin S. Meyer, PharmD, CGP, FASHP Assistant Professor of Pharmacy Practice Drake University & Iowa Veterans Home Spring 2009 Tremor
More informationParkinson s Disease: initial diagnosis, initial treatment & non-motor features. J. Timothy Greenamyre, MD, PhD
Parkinson s Disease: initial diagnosis, initial treatment & non-motor features J. Timothy Greenamyre, MD, PhD Involuntary tremulous motion, with lessened muscular power, in parts not in action and even
More informationMedications used to treat Parkinson s disease
Medications used to treat Parkinson s disease Edwin B. George, M.D., Ph.D. Director of Wayne State University Movement Disorder Clinic University Health Center Neurology Clinic University Health The John
More informationPD: Key Treatment Considerations
PD: Key Treatment Considerations 2018 Management of Neurologic and Neurosurgical Disorders in Daily Practice Elise Anderson MD Medical Co-Director, PBSI Movement Disorders 11/27/2018 1 Outline Treatment
More informationParkinson s disease Therapeutic strategies. Surat Tanprawate, MD Division of Neurology University of Chiang Mai
Parkinson s disease Therapeutic strategies Surat Tanprawate, MD Division of Neurology University of Chiang Mai 1 Scope Modality of treatment Pathophysiology of PD and dopamine metabolism Drugs Are there
More informationTreatment of Parkinson s Disease: Present and Future
Treatment of Parkinson s Disease: Present and Future Karen Blindauer, MD Professor of Neurology Director of Movement Disorders Program Medical College of Wisconsin Neuropathology: Loss of Dopamine- Producing
More informationParkinson s Disease Current Treatment Options
Parkinson s Disease Current Treatment Options Daniel Kassicieh, D.O., FAAN Sarasota Neurology, P.A. PD: A Chronic Neurodegenerative Ds. 1 Million in USA Epidemiology 50,000 New Cases per Year Majority
More informationSTEADY YOUR APPROACH TO TREMOR (OVERVIEW OF DIFFERENTIAL DIAGNOSIS)
STEADY YOUR APPROACH TO TREMOR (OVERVIEW OF DIFFERENTIAL DIAGNOSIS) Karen M. Thomas D.O. Diplomate, ABPN Director of Movement Disorders Program Director of Comprehensive Parkinson s Disease Program Sentara
More informationHyperkinetic movement disorders are. Hyperkinetic Movement Disorders. Cases in Movement Disorders. James case. About Tom
Hyperkinetic Movement Disorders Sarah Furtado, MD, PhD, FRCPC James case A mother brings her son James, 10, to your office because of repetitive sniffing sounds and repetitive eye blinking. This sniffing
More informationParkinson s Disease. Prevalence. Mark S. Baron, M.D. Cardinal Features. Clinical Characteristics. Not Just a Movement Disorder
Prevalence Parkinson s Disease Mark S. Baron, M.D. Associate Professor of Neurology Movement Disorders Section VCU School of Medicine Common disorder Approaching 1% by 65 yrs of age, 2% by 80 yrs of age
More informationEnhanced Primary Care Pathway: Parkinson s Disease
Enhanced Primary Care Pathway: Parkinson s Disease 1. Focused summary of PD relevant to primary care Parkinson s Disease (PD) and Essential tremor (ET) are two of the most common movement disorders encountered
More informationParkinson s Disease Initial Clinical and Diagnostic Evaluation. J. Timothy Greenamyre, MD, PhD
Parkinson s Disease Initial Clinical and Diagnostic Evaluation J. Timothy Greenamyre, MD, PhD Involuntary tremulous motion, with lessened muscular power, in parts not in action and even when supported
More informationTremor 101. Objectives 9/30/2015. Importance of tremors
Tremor 101 Umer Akbar, MD Assistant Professor, Brown University Movement Disorders Program, Rhode Island Hospital & Butler Hospital Objectives Recognize and describe the qualities of common types of tremor
More informationOverview. Overview. Parkinson s disease. Secondary Parkinsonism. Parkinsonism: Motor symptoms associated with impairment in basal ganglia circuits
Overview Overview Parkinsonism: Motor symptoms associated with impairment in basal ganglia circuits The differential diagnosis of Parkinson s disease Primary vs. Secondary Parkinsonism Proteinopathies:
More informationPARKINSON S PRIMER. Dr. Kathryn Giles MD, MSc, FRCPC Cambridge, Ontario, Canada
PARKINSON S PRIMER Dr. Kathryn Giles MD, MSc, FRCPC Cambridge, Ontario, Canada COPYRIGHT 2017 BY SEA COURSES INC. All rights reserved. No part of this document may be reproduced, copied, stored, or transmitted
More informationParkinson s Disease Update
Parkinson s Disease Update Elise Anderson MD Providence Center for Parkinson s Disease October 26, 2017 11/6/2017 1 Disclosures GE Speaker, DaTSCAN 11/6/2017 2 Outline PD diagnosis Motor and nonmotor symptoms
More informationDr Barry Snow. Neurologist Auckland District Health Board
Dr Barry Snow Neurologist Auckland District Health Board Dystonia and Parkinson s disease Barry Snow Gowers 1888: Tetanoid chorea Dystonia a movement disorder characterized by sustained or intermittent
More informationEvaluation of Parkinson s Patients and Primary Care Providers
Evaluation of Parkinson s Patients and Primary Care Providers 2018 Movement Disorders Half Day Symposium Elise Anderson MD Medical Co-Director, PBSI Movement Disorders 6/28/2018 1 Disclosures GE Speaker,
More informationParkinson Disease. Lorraine Kalia, MD, PhD, FRCPC. Presented by: Ontario s Geriatric Steering Committee
Parkinson Disease Lorraine Kalia, MD, PhD, FRCPC Key Learnings Parkinson Disease (L. Kalia) Key Learnings Parkinson disease is the most common but not the only cause of parkinsonism Parkinson disease is
More informationClinical Features and Treatment of Parkinson s Disease
Clinical Features and Treatment of Parkinson s Disease Richard Camicioli, MD, FRCPC Cognitive and Movement Disorders Department of Medicine University of Alberta 1 Objectives To review the diagnosis and
More informationDisorders of Movement M A R T I N H A R L E Y N E U R O L O G Y
Disorders of Movement M A R T I N H A R L E Y N E U R O L O G Y Educational Objectives Improved history taking in patients with movement disorders. Develop a systematic approach to observing and describing
More informationparts of the gastrointenstinal tract. At the end of April 2008, it was temporarily withdrawn from the US Market because of problems related to
parts of the gastrointenstinal tract. At the end of April 2008, it was temporarily withdrawn from the US Market because of problems related to crystallization of the drug, which caused unreliable drug
More informationFaculty. Joseph Friedman, MD
Faculty Claire Henchcliffe, MD, DPhil Associate Professor of Neurology Weill Cornell Medical College Associate Attending Neurologist New York-Presbyterian Hospital Director of the Parkinson s Institute
More informationMOVEMENT DISORDERS UPDATE H. MURRAY TODD, M.D., F.A.A.N.
MOVEMENT DISORDERS UPDATE H. MURRAY TODD, M.D., F.A.A.N. Movement Disorders Hypokinesia : decreased voluntary and automatic movements Hyperkinesia : excessive movements HYPOKINESIAS Parkinson s disease
More informationClassification of Tremors. Tremor& Ac,on& Tremor& Isometric& Tremor& Rest&tremor& Parkinson s* disease* Kine,c& tremor& Task5specific& tremor&
Common Movement Disorders in the Elderly David F. Tang-Wai MDCM FRCPC Assistant Professor (Neurology and Geriatric Medicine), University of Toronto 2013 UHN-MSH Geriatrics Update -- Friday November 1,
More informationParkinson s Disease Medications: Professionals Edition
Parkinson s Disease Clinic and Research Center University of California, San Francisco 505 Parnassus Ave., Rm. 795-M, Box 0114 San Francisco, CA 94143-0114 (415) 476-9276 http://pdcenter.neurology.ucsf.edu
More informationThe symptoms of the Parkinson s disease may vary from person to person. The symptoms might include the following:
1 PARKINSON S DISEASE Parkinson's disease is a long term disease related to the central nervous system that mainly affects the motor system, resulting in the loss of dopamine, which helps in producing
More informationAlison Charleston 1 st September 2016
Alison Charleston 1 st September 2016 Clinical features of Parkinson s disease Differential diagnosis Management of the motor features Non-motor and neuropsychiatric aspects 100-200 per 100,000 prevalence
More information2/20/18. History of Parkinson s. What is happening in the brain? DOPAMINE! Epidemiology. Parkinson s Disease. It s much more than tremor
Parkinson s Disease History of Parkinson s It s much more than tremor Laura Dixon, DNP, MPA, APRN, FNP-BC University of Louisville Department of Neurology Movement Disorders Division Parkinson s Disease
More informationKey Concepts and Issues in Parkinson s Disease in 2016
Key Concepts and Issues in Parkinson s Disease in 2016 Michael Rezak, M.D., Ph.D. Section Chief, Neurosciences Institute Director, Movement Disorders and Neurodegenerative Diseases Center Northwestern
More information8/28/2017. Behind the Scenes of Parkinson s Disease
BEHIND THE SCENCES IN Parkinson s Disease Behind the Scenes of Parkinson s Disease Anna Marie Wellins DNP, ANP C Objectives Describe prevalence of Parkinson's disease (PD) Describe the hallmark pathologic
More informationProgram Highlights. Michael Pourfar, MD Co-Director, Center for Neuromodulation New York University Langone Medical Center New York, New York
Program Highlights David Swope, MD Associate Professor of Neurology Mount Sinai Health System New York, New York Michael Pourfar, MD Co-Director, Center for Neuromodulation New York University Langone
More informationDate of Referral: Enhanced Primary Care Pathway: Parkinson s Disease
Specialist LINK Linking Physicians CALGARY AND AREA Patient Name: Date of Birth: Calgary RHRN: PHN / ULI: Date of Referral: Referring MD: Fax: Today s Date: CONFIRMATION: TRIAGE CATEGORY: REFERRAL STATUS:
More informationWhat s new for diagnosing and treating Parkinson s Disease?
What s new for diagnosing and treating Parkinson s Disease? Erika Driver-Dunckley, MD Associate Professor of Neurology Program Director Movement Disorders Fellowship Assistant Program Director Neurology
More informationTreatment of Parkinson s Disease and of Spasticity. Satpal Singh Pharmacology and Toxicology 3223 JSMBS
Treatment of Parkinson s Disease and of Spasticity Satpal Singh Pharmacology and Toxicology 3223 JSMBS singhs@buffalo.edu 716-829-2453 1 Disclosures NO SIGNIFICANT FINANCIAL, GENERAL, OR OBLIGATION INTERESTS
More informationIssues for Patient Discussion
onmotor complications radykinesia Screening Tools asked PD micrographia eurodegeneration Designed for Use by Family Practitioners remor on-off opamine agonists tiffness depression ostural instability wearing
More informationPresented by Joanna O Leary, MD Providence St. Vincent Medical Center Movement Disorder Department
Presented by Joanna O Leary, MD Providence St. Vincent Medical Center Movement Disorder Department Hyperkinetic movement disorders Increase in muscle movements causing involuntary motion Tremor Dystonia
More informationMovement Disorders- Parkinson s Disease. Fahed Saada, MD March 8 th, th Family Medicine Refresher Course St.
Movement Disorders- Parkinson s Disease Fahed Saada, MD March 8 th, 2019 48 th Family Medicine Refresher Course St. Joseph s Health Disclosure ACADIA Pharmaceuticals Objectives Review the classification
More informationBest Medical Treatments for Parkinson s disease
Best Medical Treatments for Parkinson s disease Bernadette Schöneburg, M.D. June 20 th, 2015 What is Parkinson s Disease (PD)? Progressive neurologic disorder that results from the loss of specific cells
More informationASHI691: Why We Fall Apart: The Neuroscience and Neurophysiology of Aging. Dr. Olav E. Krigolson Lecture 5: PARKINSONS DISEASE
ASHI691: Why We Fall Apart: The Neuroscience and Neurophysiology of Aging Dr. Olav E. Krigolson krigolson@uvic.ca Lecture 5: PARKINSONS DISEASE The Basal Ganglia Primary motor cortex Execution of movement
More informationIII./3.1. Movement disorders with akinetic rigid symptoms
III./3.1. Movement disorders with akinetic rigid symptoms III./3.1.1. Parkinson s disease Parkinson s disease (PD) is the second most common neurodegenerative disorder worldwide after Alzheimer s disease.
More informationSemivoluntary movement (=unvoluntary)
EXTRAPYRAMIDAL DISORDERS = Movement disorders = Degenerative disease 1 4 types of movements: Voluntary movement Semivoluntary movement (=unvoluntary) Involuntary movement Automatic movement 2 3 Movement
More informationPARKINS ON CENTER. Parkinson s Disease: Diagnosis and Management. Learning Objectives: Recognition of PD OHSU. Disclosure Information
OHSU PARKINS ON CENTER Parkinson s Disease: Diagnosis and Management for Every MD Disclosure Information Grants/Research Support: National Parkinson Foundation, NIH, Michael J. Fox Foundation Consultant:
More informationMovement Disorders: A Brief Overview
Movement Disorders: A Brief Overview Albert Hung, MD, PhD Massachusetts General Hospital Harvard Medical School August 17, 2006 Cardinal Features of Parkinsonism Tremor Rigidity Bradykinesia Postural imbalance
More informationObjectives. Emerging Treatments in Parkinson s s Disease. Pathology. As Parkinson s progresses it eventually affects large portions of the brain.
Objectives Emerging Treatments in Parkinson s s Disease 1) Describe recent developments in the therapies for Parkinson s Disease Jeff Kraakevik MD Assistant Professor OHSU/Portland VAMC Parkinson s Center
More informationMotor Fluctuations Stephen Grill, MD, PHD Parkinson s and Movement Disorders Center of Maryland and Johns Hopkins University
Motor Fluctuations Stephen Grill, MD, PHD Parkinson s and Movement Disorders Center of Maryland and Johns Hopkins University I have no financial interest with any entity producing marketing, re-selling,
More informationParkinsons Disease update. Sindhu R Srivatsal MD MPH Virginia Mason Medical Center
Parkinsons Disease update Sindhu R Srivatsal MD MPH Virginia Mason Medical Center PARKINSONISM Vs PARKINSON S Parkinsonism Bradykinesia: slowness of movements (essential feature) PLUS one of Tremor: resting
More information475 GERIATRIC PSYCHOPHARMACOLOGY (p.1)
475 GERIATRIC PSYCHOPHARMACOLOGY (p.1) I. General Information? Use lower doses? Start low and go slow? Expect prolonged elimination ½ lives? Expect sedative-hypnotics to be dementing, to impair cognitive
More informationMartin A. Samuels, M.D. MOVEMENT DISORDERS
Martin A. Samuels, M.D. MOVEMENT DISORDERS I. Nomenclature of Movement Disorders A. Too Little Movement 1. Paralysis (paresis) 2. Rigidity a. spasticity (pyramidal) b. "lead pipe" (extra pyramidal) c.
More informationParkinson s Disease. Gillian Sare
Parkinson s Disease Gillian Sare Outline Reminder about PD Parkinson s disease in the inpatient Surgical patients with PD Patients who cannot swallow End of life care Parkinson s disease PD is the second
More informationParkinson s Disease Update. Colleen Peach, RN, MSN, FNP Movement Disorders Clinic Emory University School of Medicine March 7, 2015
Parkinson s Disease Update Colleen Peach, RN, MSN, FNP Movement Disorders Clinic Emory University School of Medicine March 7, 2015 Parkinson s Disease Progressive, chronic, neurodegenerative disease Slow,
More informationUnderstanding Parkinson s Disease Important information for you and your loved ones
Patient Education Understanding Parkinson s Disease Important information for you and your loved ones This handout explains the signs, symptoms, and possible treatments of Parkinson s disease. Parkinson
More informationPD ExpertBriefings: Parkinson s Medications: Today and Tomorrow Led By: Cynthia L. Comella, M.D., F.A.A.N.
PD ExpertBriefings: Parkinson s Medications: Today and Tomorrow Led By: Cynthia L. Comella, M.D., F.A.A.N. To hear the session live on: Tuesday, April 17, 2012 at 1:00 PM ET. DIAL: 1 (888) 272-8710 and
More informationMovement Disorders Will Garrett, M.D Assistant Professor of Neurology
Movement Disorders Will Garrett, M.D Assistant Professor of Neurology I. The Basal Ganglia The basal ganglia are composed of several structures including the caudate and putamen (collectively called the
More informationPrior Authorization with Quantity Limit Program Summary
Gocovri (amantadine) Prior Authorization with Quantity Limit Program Summary This prior authorization applies to Commercial, NetResults A series, SourceRx and Health Insurance Marketplace formularies.
More informationMedication Management & Strategies When the levodopa honeymoon is over
Medication Management & Strategies When the levodopa honeymoon is over Eric J Pappert, MD Parkinson s Disease & Movement Disorders Center Neurology Associates Medication Options in Parkinson s Carbidopa/Levodopa
More informationDIFFERENTIAL DIAGNOSIS SARAH MARRINAN
Parkinson s Academy Registrar Masterclass Sheffield DIFFERENTIAL DIAGNOSIS SARAH MARRINAN 17 th September 2014 Objectives Importance of age in diagnosis Diagnostic challenges Brain Bank criteria Differential
More informationDrugs used in Parkinsonism
Drugs used in Parkinsonism قادة فريق علم األدوية : لي التميمي & عبدالرحمن ذكري الشكر موصول ألعضاء الفريق املتميزين : جومانة القحطاني ندى الصومالي روان سعد القحطاني pharma436@outlook.com @pharma436 Your
More informationWHAT DEFINES YOPD? HANDLING UNIQUE CONCERNS REBECCA GILBERT, MD, PHD VICE PRESIDENT, CHIEF SCIENTIFIC OFFICER, APDA MARCH 14, 2019
WHAT DEFINES YOPD? HANDLING UNIQUE CONCERNS REBECCA GILBERT, MD, PHD VICE PRESIDENT, CHIEF SCIENTIFIC OFFICER, APDA MARCH 14, 2019 YOUNG ONSET PARKINSON S DISEASE Definition: Parkinson s disease diagnosed
More informationAssessing a Tremor. Tremor diagnosis and Treatment. Outline. Chorea. Assessing a Tremor. Tics 4/10/2012
Assessing a Tremor Tremor diagnosis and Treatment Amie Peterson, MD Portland VA/ OHSU Parkinson s Center of Oregon Can sometimes be a combination of disorders Other disorders can sometimes look similar
More informationUpdate on the Treatment of Parkinson s Disease. Neurotherapeutics for Rehab Professionals November 6 th, 2015
Brent Bluett, DO Dr. Brent Bluett completed medical school at Touro Unviersity Nevada College of Osteopathic Medicine, neurology residency at the University of Texas Southwestern at Austin, and a Movement
More informationDEMENTIA and BPSD in PARKINSON'S DISEASE. DR. T. JOHNSON. NOVEMBER 2017.
DEMENTIA and BPSD in PARKINSON'S DISEASE. DR. T. JOHNSON. NOVEMBER 2017. Introduction. Parkinson's disease (PD) has been considered largely as a motor disorder. It has been increasingly recognized that
More information10/13/2017. Disclosures. Deep Brain Stimulation in the Treatment of Movement Disorders. Deep Brain Stimulation: Objectives.
Deep Brain Stimulation in the Treatment of Movement Disorders Disclosures None Eleanor K Orehek, M.D. Movement Disorders Specialist Noran Neurological Clinic 1 2 Objectives To provide an overview of deep
More informationHistory Parkinson`s disease. Parkinson's disease was first formally described in 1817 by a London physician named James Parkinson
Parkinsonismm History Parkinson`s disease Parkinson's disease was first formally described in 1817 by a London physician named James Parkinson Definition : Parkinsonism: Parkinsonism is a progressive neurological
More informationCONTRIBUTORS The American Academy of Neurology Institute.
Several of these multiple-choice questions were originally published in Continuum: Lifelong Learning in Neurology Movement Disorders, Volume 22, Issue 4, August 2016 based on the content in the issue developed
More informationof common terms Amplitude Resting Position Essential Tremor (ET) Glossary
Essential Tremor (ET) Glossary of common terms Because knowledge is essential to making informed choices, we ve developed this glossary to help ET patients, their loved ones, and caregivers better understand
More informationMoving fast or moving slow: an overview of Movement Disorders
Moving fast or moving slow: an overview of Movement Disorders Mini Medical School October 25, 2018 Heather Rigby, MD, FRCPC 2014 MFMER slide-1 2014 MFMER slide-2 Basal Ganglia Dysfunction - Movement Disorders
More informationApproach to Tremor in Older Adults
Neurology Primer Approach to Tremor in Older Adults Joel S. Hurwitz, MB, FRCPC, FRCP (London), Associate Professor, Department of Medicine (Division of Geriatric Medicine), University of Western Ontario,
More informationWith Time, The Pathology of PD Spreads Throughout the Brain
With Time, The Pathology of PD Spreads Throughout the Brain Braak s staging of Parkinson s disease pathology dm co sn mc hc fc 1 Hubert H. Fernandez, MD, FAAN Professor of Medicine (Neurology) Cleveland
More information9/26/18. Objectives. Disclosures. Parkinson s Disease Update Clinical and Operational Considerations
Parkinson s Disease Update Clinical and Operational Considerations Dana Saffel, PharmD, BCGP, CPh, FASCP President, CEO PharmaCare Strategies, Inc. September 2018 Objectives Describe epidemiology and pathophysiology
More informationPARKINSON S MEDICATION
PARKINSON S MEDICATION History 1940 50 s Neurosurgeons operated on basal ganglia. Improved symptoms. 12% mortality 1960 s: Researchers identified low levels of dopamine caused Parkinson s leading to development
More informationDrug Therapy of Parkinsonism. Assistant Prof. Dr. Najlaa Saadi PhD Pharmacology Faculty of Pharmacy University of Philadelphia
Drug Therapy of Parkinsonism Assistant Prof. Dr. Najlaa Saadi PhD Pharmacology Faculty of Pharmacy University of Philadelphia Parkinsonism is a progressive neurological disorder of muscle movement, usually
More informationUnderstanding Tremor Diagnosis, Cause, Treatment. Monique Giroux, MD Englewood and Fort Collins, CO
Understanding Tremor Diagnosis, Cause, Treatment Monique Giroux, MD Englewood and Fort Collins, CO What is Tremor? Involuntary Rhythmic and Oscillatory Produced by contraction of alternating muscles Types
More informationObjectives. Distinguishing Parkinson s disease from other parkinsonian and tremor syndromes. Characteristics. Basal Ganglia Structures
12:45 1:30 pm PD or not PD? Distinguishing Parkinson s Disease From Other Parkinsonian and Tremor Syndromes SPEAKER Jennifer G. Goldman, MD, MS Presenter Disclosure Information The following relationships
More informationDifferential Diagnosis of Hypokinetic Movement Disorders
Differential Diagnosis of Hypokinetic Movement Disorders Dr Donald Grosset Consultant Neurologist - Honorary Professor Institute of Neurological Sciences - Glasgow University Hypokinetic Parkinson's Disease
More informationThe art of treating Parkinson disease in the older patient
CLINICAL PRACTICE: Therapeutic review The art of treating Parkinson disease in the older patient Daniel Kam Yin Chan, MD, MHA, MBBS, FRACP, FHKCP, AFCHSE, is Associate Professor, University of New South
More informationParts of the motor circuits
MOVEMENT DISORDERS Parts of the motor circuits cortical centers: there are centers in all the cortical lobes subcortical centers: caudate nucleus putamen pallidum subthalamical nucleus (Luys) nucleus ruber
More informationCommunicating About OFF Episodes With Your Doctor
Communicating About OFF Episodes With Your Doctor Early in Parkinson s disease (PD), treatment with levodopa and other anti-pd drugs provides continuous benefit. As the disease progresses, however, symptom
More information2-The age at onset of PD is variable, usually between 50 and 80 years, with a mean onset of 55 years (1).
Parkinson Disease 1-Parkinson disease (PD) is a chronic, progressive movement disorder resulting from loss of dopamine from the nigrostriatal tracts in the brain, and is characterized by rigidity, bradykinesia,
More informationParkinson s Disease. Patients will ask you. 8/14/2015. Objectives
Parkinson s Disease Jean Van Kingsley MS, FNP-BC Objectives Describe the pathophysiolgy of PD. Review clinical charachteristics of PD. Identify management strategies, to maximize functional status. Recognize
More informationPharmacy Coverage Guidelines are subject to change as new information becomes available.
ZELAPAR (selegiline hydrochloride) orally disintegrating tablet Coverage for services, procedures, medical devices and drugs are dependent upon benefit eligibility as outlined in the member's specific
More informationParkinson's Disease and how you can make a difference with medication
Parkinson's Disease and how you can make a difference with medication Alyson Franks Parkinson's and Movement Disorder Nurse Specialist Royal Hallamshire Hospital No treatment all Complementary Therapy
More informationThe Role of Pharmacists in Treating & Managing Parkinson s Disease Author: Mary Jo Carden, RPh, JD Principal, Carden Associates
The Role of Pharmacists in Treating & Managing Parkinson s Disease Author: Mary Jo Carden, RPh, JD Principal, Carden Associates Editor: Marsha K. Millonig, MBA, RPh President/CEO Catalyst Enterprises,
More informationUpdate on Parkinson s disease and other Movement Disorders October 2018
Update on Parkinson s disease and other Movement Disorders October 2018 DR. JONATHAN EVANS CONSULTANT IN NEUROLOGY QUEEN S MEDICAL CENTRE NOTTINGHAM Disclosures: Honoraria UCB, Britannia, Allergan, AbbVie
More informationYour reference guide for the most common movement disorder
Essential Tremor (ET) Your reference guide for the most common movement disorder What is essential tremor? Essential tremor (ET) is one of the most common neurological conditions and the most common cause
More informationThe Shaking Palsy of 1817
The Shaking Palsy of 1817 A Treatment Update on Parkinson s Disease Dr Eitzaz Sadiq Neurologist CH Baragwanath Acadamic Hospital Parkinson s Disease O Premature death of dopaminergic neurons O Symptoms
More informationPL CE LIVE July 2015 Forum
July 2015 PL CE LIVE Rachel Maynard, PharmD Associate Editor Pharmacist s Letter/Pharmacy Technician s Letter CE Information Pharmacist's Letter / Therapeutic Research Center is accredited by the Accreditation
More information