Essential Tremor diagnosis and treatment.ppt
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Transcript of Essential Tremor diagnosis and treatment.ppt
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Essential Tremor, diagnosis and
treatment: Implications for the
elderly
Fenna Phibbs M.D.
Assistant Professor of Neurology
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Also known as..
Familial tremor
Benign essential tremor
Intention tremor
Hereditary tremor
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What is Essential Tremor?
A neurological disorder characterized by
rhythmic, involuntary shaking of a part or
parts of the body
Most commonly seen in the arms/hands
Can also be seen in the head, voice, legsand trunk
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What is Essential Tremor?
Action/Kinetic Tremor Occurs during voluntary action such as eating,
drinking, writing
Postural Tremor Occurs in positions against gravity such as holding
your arms out in front of your body
Internal sense of tremor
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What is affected
Body parts affected:
Hands 69%
Voice 40%
Head 17% (no-no 79%)
Leg 13%
Jaw 7% Others-face trunk and tongue
Can start at any age, which does not have bearing onthe rate of progression
Slowly progressive, defined as increased tremoramplitude and/or extension to previously unaffectedbody parts
Not associated increased mortality
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Genetics of ET
50% of patients have a family history Autosomal dominant pattern, most
common
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Prevalence Rate
4 to 5.6 percent of people aged 40 to 60
have ET
Age 60 and older is estimated at 6.3 to
9%
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(Benign) Essential tremor
Disability
Worse with anxiety, fatigue and illness
Socially withdraw
Physical disability related to age, tremoramplitude, ability to execute fine motor tasks such
as writing and eating.
Anxiety and depression
Gait changes, possible dementia
Medication side effects
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Normal
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Is it ET or PD?
Essential Tremor
Action tremor
More rapid frequency
Not associated with slowmovements, muscle
rigidity and postural
changes
Often affects both sides
Often familial
Parkinsons Disease
Resting tremor
Slower frequency
Associated with slowing,shuffling gait, rigidity,
stooped posture,
imbalance
Usually worse on one
side
Rarely familial
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Other Causes of Tremor
Enhanced physiologic tremor Occurs during stressful or fear-provoking times
Medication induced tremor Over the counter, herbal and prescription medications
Steroids, Depakote, Lithium, TCAs, Amiodarone,dopamine antagonists, Cyclosporin, stimulants, drugwithdrawal
Post traumatic tremor resulting from head
injury
Thyroid disease
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Other Causes of Tremor
Blood sugar fluctuations
Excessive use of caffeine or other
stimulants (supplements)
Presence of another neurological
disorder, most commonly ParkinsonsDisease
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Treatment
Treatment Goal Reduce the severity, not complete resolution
To improve daily functioning
Improve quality of life Medications can help mild to moderate tremor
the best
Aim for patient satisfaction
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Treatment
Beta-blockers Propranolol (Inderal)
Metoprolol (Lopressor)
Atenolol (Tenormin)
Sotalol (Betapace)
Concern for side effects, sedation, fatigue,exercise intolerance and coexistingdepression.
Often already on due to coexisting heartdisease, coordinate care!
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Treatment
Anticonvulsants Primidone (Mysoline)
Gabapentin (Neurontin)
Topiramate (Topamax)
Generally well tolerated
Primidone is generally first line, give at
bedtime to reduce problems with
sedation Topiramate can cause cognitive side
effects, less appealing for elderly
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Treatment
Botulinum toxin Blocks synaptic transmission to the muscle
Generally 3-6 month duration of response
Most useful for head or jaw tremor butsometimes used for hand and voice tremor
Postural tremor responds better
Smaller effect on intention tremor
Dependent on physicians expertise
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Treatment
Alcohol
Alcohol reduces tremor in some patients
Rebound tremor may occur after excessive alcohol
intake - tremor can be temporarily more severe the
next day
Often pre-treating prior to event helpful
Avoid excessive use of alcohol
Do not drink and drive
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Alternative Therapies
Benefit is unconfirmed when using alternative
therapies such as acupuncture, hypnosis, massage
therapy
For people whose tremor worsens with stress,biofeedback or behavioral therapy may be helpful
Occupational therapy has been found helpful
assistance with adaptive devices such as weighted
utensils, plate guards, etc.
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Alternative therapies
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Deep Brain Stimulation
Consider when: Medications have failed to provide adequate relief
Dose limiting side effects
Moderate to severe tremor
Most efficacious tremor treatment Tremor amplitude and frequency
80-95% reduction in extremity tremor
50-85% reduction in midline tremor (head, voice), oftenrequires bilateral stimulation
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Deep Brain Stimulation
Target the ventral intermediate nucleus of thethalamus (VIM)
Does not help
Balance Side effects
Paraesthesias
Contractions
Dysarthria
Gait?
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DBS background
1946 first stereotatic surgery 1952, improvement in symptoms following ligation
of the anterior choroidal artery.
1960s Thalamotomies for PD
1990s Pallidotomies
1993 first report of chronic high frequency
stimulation of the thalamus in essential tremor
1998 STN published as a target for Parkinsons
disease
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DBS background
1997 Essential tremor
2002 Parkinsons disease
2003 Dystonia
2009 Obsessive compulsive disorder
Future uses Epilepsy
Depression
Tourettes syndrome
Obesity Migraine
Bipolar disorder
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DBS Mechanism of action
Activation of inhibitory inputs
Exhaustion of neuronal signal
Jamming the abnormal signaling pathways
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Deep Brain Stimulation process
Neurologic evaluation
Pre-op screening
WHIGET tremor rating scale
Neuropsychiatric testing
DBS conference
Neurosurgical evaluation
Insurance approval
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Deep Brain Stimulation process
Surgery steps Step 1: Bone markers placed with CT and MRI
Step 2: electrode placement Done week after step 1
Done with patient awake
Overnight stay in the hospital
Step 3: Battery placement Done 1-3 weeks after step 2
Step 4: Initial programming Done 4 weeks after step 2
Programming maintenance Done every 1-6 months, will require fine tuning as the disease
progresses
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DBS for Essential tremor
No age cut off at Vanderbilt
Over 70 electrode placements are staged with at
least one week between sides
Can consider unilateral if higher surgical risk We have consider lesional surgery if there is
concern from infection risk, significant
cognitive changes
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Questions???