Management of hand tremor in Primary care setting. Specialist in Family Medicine

Transcription

1 Management of hand tremor in Primary care setting Dr. Ko Wai Kit, Welchie Specialist in Family Medicine

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4 Types of hand tremor Causes of hand tremor How to approach a hand tremor patient Management of common causes of hand tremor When to refer?

5 Definition of Tremor Any abnormal repetitive shaking movement of the body

6 Types of hand tremor Causes of hand tremor How to approach a hand tremor patient Management of common causes of hand tremor When to refer?

7 Types of Tremor Resting Tremor Postural Tremor Intention Tremor Flapping Tremor

8 Resting tremor Tremor present at rest Most marked with the arms supported on the lap and during walking Decrease in finger-nose nose test Character: pill-rolling movement of the fingers at the metacarpophalangeal joints is combined with movement of thumb

9 Postural tremor Fine tremor Tremor noted with the arms outstretched and finger apart More obvious if a sheet of paper is placed over the dorsum of hands

10 Intention tremor Coarse oscillating tremor Exacerbated by action and increase as the target is approached Absent at rest Test: finger-nose nose touching

11 Flapping tremor Observed when the arms are extended with hyperextension of wrists Character: slow, coarse and jerky movement of flexion and extension at the wrist

12 Types of hand tremor Causes of hand tremor How to approach a hand tremor patient Management of common causes of hand tremor When to refer?

13 Causes of tremor Resting tremor Parkinsonism Postural tremor Physiological Anxiety / emotional Alcohol Hyperthyroidism Essential tremor Drugs Phaeochromocytoma

14 Intention tremor Cerebellar lesion Flapping tremor Wilson s s disease Hepatic encephalopathy Uraemia Respiratory failure Lesion of the red nucleus of the midbrain

15 Parkinsonism Most common cause: Parkinson s disease (PD) A neurodegenerative disease of unknown cause. Cause progressive disability and increases the mortality rate by 3 to 5 times

16 Epidemiology Common among older people (usu. After age of 50 years) ~ 1% adult >65 years Male to Female ratio: 3:2

17 Pathophysiology Loss of pigmented dopaminergic neurons (>2/3 before symptoms appear) and presence of Lewy bodies in the substantia nigra pars compacta Reduce dopamine content => =>overactive of subthalamic nucleous-globus pallidus-sn pars reticulata complex => =>inhibits the projection to motor cortex through thalamus

18 Dopaminergic pathways of the human brain in normal condition (left) and Parkinson's disease (right). Red Arrows indicate suppression of the target, blue arrows indicate stimulation of target structure.

19 Etiology Multifactorial Genetic; environmental toxin and aging 2-33 fold higher risk in first-degree relatives of PD (esp. for young onset <50 years)

20 Clinical features Insidious onset, involve one side initially but the other side also involve as the disease progress. Triad of classical symptoms: Resting tremor pill rolling Bradykinesia (may complaint as difficult in walking or leg weakness) Rigidity cogwheel rigidity

21 Other features: Mask face Stoop posture Gait: Shuffling, festinant,, poor arm swinging Monotonous and soft speech Micrographia Retropulsion (fall backward easily when pushed) Freezing (late feature, sudden transient inability to move when initiating walking and turning) Frequent fall Glabellar tap +ve+

22 DDx of Parkinson s s disease Secondary Vascular Drug induced e.g. neuroleptics Toxin e.g. MPTP, Manganese, cyanide Trauma e.g. Boxer s s injury Infection e.g. posttyphoid fever, AIDS Parkinson-plus syndrome Multiple system atrophy e.g. Shy-Drager syndrome Heredodegenerative Wilson s s disease

23 Hyperthyroidism Most common causes: Graves disease Toxic multinodular goiter Other less common causes: Subacute thyroiditis Thyroid caricinoma

24 Graves disease Autoimmune disorder present of stimulating immunoglobulin G antiboidies to the TSH receptor of thyroid follicular cell (TRAb( TRAb) Familial predisposition Male:Female ration 1:9 Onset 20 to 40 (in Asia)

25 Toxic nodular Goiter Unknown etiology Usu. In older patients May related to Iodine deficiency

26 Clinical features Can affect any organs Most common presentation: Hand tremor Weight loss Fatigue Heat intolerance Sweating Palpitation Nervous Diarrhoea

27 Common Signs Tachycardia / Atrial Fibrillation Postural hand tremor Goiter +/- bruit Lid retraction, Lid lag Exophthalmos

28 Investigations TSH FT4 FT3 Anti-TG TG Thyroid Thyroid globulin antibody Anti-TM TM--thyroid microsomal antibody

29 Essential tremor Autosomal dominant disorder (variable penetrance) Onset peaks bimodally in the teens and 50s Insidious onset with slow progression Start in one hand then spread to other with time Interferes with writing and handling Worse while arms held out Exacerbated by anxiety May affect other parts of body included head, chin, tongue, legs and speech Relieved by alcohol

30 Triad of features Positive family History Tremor with little disability Normal gait

31 Common medication causing hand tremor Caffeine Beta-adrenergic adrenergic agonist e.g. ventolin Hypoglycaemic agent Pseudoephedine Theophylline Thyroxine Antidepression: : TCA, Prozac Tegretal Haldol Lithium Alcohol withdraw or chronic alcoholism

32 Types of hand tremor Causes of hand tremor How to approach a hand tremor patient Management of common causes of hand tremor When to refer?

33 How to approach a hand tremor History taking: patient Description of the tremor Nature Involved body parts Onset Course and progression Precipitating factor / relieving factor How the symptom affecting the patient s s life

34 Other related symptoms Included systemic review Idea / Concern / Expectation (ICE) Past Medical history (included current medications) Family History Psychosocial History Drug allergy

35 Physical examinations: Check for the hand tremor Check other signs according to the provisional diagnosis

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37 Types of hand tremor Causes of hand tremor How to approach a hand tremor patient Management of common causes of hand tremor When to refer?

38 Management of Common causes of hand tremor Parkinson s s disease Essential tremor Hyperthyroidism

39 Management for Parkinsonism Treatment principle: Treatment should be individualized according to patient s s functional impairment, age, stages of disease and response Current medications are effective in control symptoms but not neuroprotective Medication only start when symptoms are disabling

40 Non-pharmacological treatment Provide appropriate explanation and education Support group 香 港 柏 金 遜 症 會 Tel: Physiotherapy Physical Aids e.g. walking stick

41 Pharmacological treatment Levodopa Dopamine agonist Selegiline Catechol-O-Methyltransferase (COMT) inhibitors Anticholinergic drugs Amantadine

42 Levodopa Immediate precursor of dopamine to correct striatal dopamine deficiency Add peripheral decarboxylase inhibitor e.g. Benserazide and carbidopa)=>prevent peripheral dopaminergic side effect such as nausea and hypotension Common drug use: Sinemet (levodopa/carbidop) Madopar (Levodopa/Benserazide)

43 Side Effect & Precaution Side effect while prolong use: Wearing off : : gradual shortening of drug effect Peak dose Dyskinesia: : chorea after each dose of levodopa Toxic to dopaminergic neuron Precaution: Delay levodopa therapy as possible esp. for younger patient

44 Dopamine agonist Direct stimulate striatal dopamine receptors Lower risk of motor complications Advice for young patient with mild symptom Use as initial monotherapy or adjunctive to Levodopa during wearing off SE: nausea, hypotension, hallucination and sleep attacks Cautious use for elderly patient Common drug use: Bromocriptine; Pergolide; Pramipexole

45 Selegiline Monoamine oxidase B inhibitor=>prevent dopamine metabolism by MAO Can prolong half-life life of levodopa Use as initial therapy or adjunctive Common drug use: Deprenyl

46 COMT inhibitor Prevent metabolize of levodopa=>prolong half-life life As adjunct in severe wearing-off complication Common drug use: Comtan

47 Anticholinergic drug Antagonizing uninhibited striatal cholinergic neurons Only for treating resting tremor SE: Dry mouth, blurred vision, urinary retention, constipation and confusion in elderly Not recommend for older patient >60 Common drug use: Artane

48 Amantadine With anticholinergic, dopaminergic and antiglutaminergic effects Use as initial treatment or adjunctive Reduce levodopa-induced dyskinesia in high dose

49 Surgical treatment Only for severe disabling symptoms refractory to medical treatment Destroy or inhibit abnormally discharging nuclei

50 Management for Essential Tremor Appropriate explanation is sufficient in most cases Alcohol before activity may help Maintenance vs intermittent therapy Medication therapy ~ 75% response: Propranolol Primidone

51 Propanolol Prefer for younger patient (increase risk of serious SE in elderly) Starting dose 20mg daily, max 320 mg/d

52 Primidone Anticonvulsant agent Prefer for older patient Initial dose 12.5/25mg at bedtime, max 1000mg/d Common SE (usu. in first dose): sedation, ataxia, vertigo, dizziness, nausea, vomiting, diplopia,, and nystagmus

53 Management of hyperthyroidism Antithyroid drugs Carbimazole Propylthiouracil (PTU) Radioactive Iodine (I 131 Subtotal thyroidectomy 131 )

54 Antithyroid drug Carbimazole and Propylthiouracil Mechanism: reduce thyroid hormone synthesis by inhibiting Iodine organification and iodotyrosyl coupling 40% relapse within 2 years after stopping therapy

55 Carbimazole Starting dose: 20-40mg/d Maintenance dose: 5-15mg/d5 SE: Hypersensitivity reaction (rash, pruritus and fever) Agranulocytosis (onset (onset within 3 mths,, recover within 2 weeks after stopped medication) Avoid in pregnancy

56 Propylthiouracil (PTU) Starting dose: mg/d Maintenance dose: mg/d SE: Hepatic necrosis (rare) Preferred during pregnancy and lactation (lesser cross placenta and secrete into breast milk)

57 Radioactive Iodine (I 131 ) Indication: 1. Recurrence after antithyroid drug 2. Poor drug compliance 3. Not tolerate SE of medication 50-70% resolve after single dose % develop hypothyroidism in 1 year, increase 2-4% 2 per subsequent years Contraindication: Pregnancy Confirm not pregnant before treatment and at least 4 months afterward

58 Indication: Thyroidectomy Large goiter with pressure symptoms Complications (<1%) Haemorrhage Recurrent laryngeal nerve palsy Hypoparathyroidism Rate of Hypothyroidism: 1% per year

59 Types of hand tremor Causes of hand tremor How to approach a hand tremor patient Management of common causes of hand tremor When to refer?

60 When to refer Not feel comfortable for further management Diagnosis is unclear at the initial presentation Treatment failure Develop complications

61 Take Home Message 1. Hand tremor Parkinsonism 2. Tailor make management plan for each patient 3. Treat your patient while feel comfortable, otherwise refer

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