Essential Tremor diagnosis and treatment.ppt

7/28/2019 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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Essential Tremor diagnosis and treatment.ppt

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