Tremors
3
www.npjournal.org The Journal for Nurse Practitioners - JNP 273 When patients come into your office with a chief complaint of tremor, usually they think they have Parkinson disease (PD). Although tremor is often a presenting sign of PD, tremor can often be some- thing other than PD, and PD sometimes does not present with tremor. So how do you decide what is the cause? No blood tests can tell you the defin- itive cause or any scans to give you a conclusive answer. Hence, the dilemma. Tremor is a diagnosis of history and physical examination as well as ruling out other possibili- ties. Tremor is a rhythmic oscillatory dyskinesia. Although there are many types of tremor, I find there are three main types: essential (action/ postural) extrapyramidal (resting), and cerebellar (intention). Essential Tremor Essential tremor (ET) is the most common form. It usually occurs in the hands but can also be seen in the head, trunk, voice, tongue, and legs. ET is usually bilateral and symmetric. Patients often state that it gets worse with stress or fatigue and temporarily improves with alcohol. Tremor is usually the only symptom. Frequently, there is a family history of tremor, but it is not essential to the diagnosis. Medications commonly used to treat ET include -blockers, such as propanolol and primi- done, and benzodiazepines, such as clon- azepam. These drugs are started at low doses and titrated to effect or side effect. If ET is refractory to medication, deep brain stimulation is a surgical alternative. This is referred to as Activa ® Tremor Control Therapy. Medtronic man- ufactures the device. Resting Tremor Resting tremor is usually due to dopamine depletion. It is typically the classic “pill rolling” tremor that is seen with PD. Sometimes, how- ever, it can be brought on by certain medications such as metoclopramide (Reglan) and phenoth- iazines. Patients on one or more of these med- ications should be taken off the medication to see whether the tremor improves or resolves. If no identifiable cause can be found, the patient should be assessed for other signs and symp- toms of PD (Table 1) or referred to a neurologist for further evaluation. It is safe to assume, if the patient is coming to your office complaining of tremor, it is affecting him or her enough to look for help. There is a plethora of medications on the market for PD. The most common are dopamine replacement (carbidopa/levodopa [Sinemet]), dopamine agonists (DAs) (both first and second generation), and COMT (catechol- O-methyltransferase) inhibitors ( Table 2). Soon several more will be available on the market. For the patient with more refractory PD, apo- morphine injection and Activa therapy are avail- able. I recommend that patients with more refractory PD be under the management of a neurology practice, if possible. Often, new onset and early management of PD is maintained in the primary care setting for many reasons. What are your treatment options? What do you do? Hence, the (second) dilemma. My experience has been that patients want quick relief of symptoms with the least side effects. The DAs, although a viable option as first-line therapy, have a complicated and Tremors DIAGNOSTIC TIPS Barbara Bishop
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www.npjournal.org The Journal for Nurse Practitioners - JNP 273
When patients come into your office with a chiefcomplaint of tremor, usually they think they haveParkinson disease (PD). Although tremor is often apresenting sign of PD, tremor can often be some-thing other than PD, and PD sometimes does notpresent with tremor. So how do you decide whatis the cause? No blood tests can tell you the defin-itive cause or any scans to give you a conclusiveanswer. Hence, the dilemma.
Tremor is a diagnosis of history and physicalexamination as well as ruling out other possibili-ties. Tremor is a rhythmic oscillatory dyskinesia.Although there are many types of tremor, I findthere are three main types: essential (action/postural) extrapyramidal (resting), and cerebellar(intention).
Essential TremorEssential tremor (ET) is the most common form.It usually occurs in the hands but can also beseen in the head, trunk, voice, tongue, and legs.ET is usually bilateral and symmetric. Patientsoften state that it gets worse with stress orfatigue and temporarily improves with alcohol.Tremor is usually the only symptom. Frequently,there is a family history of tremor, but it is notessential to the diagnosis.
Medications commonly used to treat ETinclude �-blockers, such as propanolol and primi-done, and benzodiazepines, such as clon-azepam. These drugs are started at low dosesand titrated to effect or side effect. If ET isrefractory to medication, deep brain stimulationis a surgical alternative. This is referred to asActiva® Tremor Control Therapy. Medtronic man-ufactures the device.
Resting TremorResting tremor is usually due to dopaminedepletion. It is typically the classic “pill rolling”tremor that is seen with PD. Sometimes, how-ever, it can be brought on by certain medications
such as metoclopramide (Reglan) and phenoth-iazines. Patients on one or more of these med-ications should be taken off the medication tosee whether the tremor improves or resolves. Ifno identifiable cause can be found, the patientshould be assessed for other signs and symp-toms of PD (Table 1) or referred to a neurologistfor further evaluation. It is safe to assume, if thepatient is coming to your office complaining oftremor, it is affecting him or her enough to lookfor help.
There is a plethora of medications on themarket for PD. The most common aredopamine replacement (carbidopa/levodopa[Sinemet]), dopamine agonists (DAs) (both firstand second generation), and COMT (catechol-O-methyltransferase) inhibitors (Table 2). Soonseveral more will be available on the market.For the patient with more refractory PD, apo-morphine injection and Activa therapy are avail-able. I recommend that patients with morerefractory PD be under the management of aneurology practice, if possible.
Often, new onset and early management ofPD is maintained in the primary care setting formany reasons. What are your treatmentoptions? What do you do? Hence, the (second)dilemma.
My experience has been that patients wantquick relief of symptoms with the least sideeffects. The DAs, although a viable option asfirst-line therapy, have a complicated and
Tremors
DIAGNOSTIC TIPS
Barbara Bishop
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April 2006274 The Journal for Nurse Practitioners - JNP
Table 2. Most Common PD Medications and Side Effect Profile
Classification Common Side Effects Serious Side Effects/contra-indications
Dopamine replacement Dyskinesias, N/V/D, Dyskinesias, orthostaticCarbidopa/levodopa hallucinations, hypotension, syncope,
confusion, dizziness, psychosis, suicidaldystonia, constipation, ideation, severeinsomnia, nightmares, hypertension (rare),anxiety/agitation, mood malignant melanoma,changes neuroleptic malignant
syndrome (rare)Dopamine Agonists
First generation N/V/D, lightheadedness, Hallucinations, psychosis,Bromocriptine constipation, orthostatic sudden sleep episodes,Pergolide hypotension, visual severe hypotension, HTN,
disturbances, elevated arrhythmias, MI; rare:
LFTs, dyspepsia, pleural effusion, pleuritis,anorexia pleural fibrosis,
pericarditis, pericardial effusion cardiac valvulopathy
Second generation Orthostatic hypotension, Sudden sleep episodes,Pramipexole dizziness, hallucinations, syncope, severeRopinirole confusion, peripheral hypotension, arrhythmias,
edema, insomnia, hallucinations malignantamnesia, weight loss, melanoma; rare: pleuralanorexia, N/V/D, fibrosis, interstitialconstipation pneumonitis, cardiac
valvulopathy, rhabdomyolysis
JNP
Table 1. Signs and Symptoms Commonly Seen in Parkinson Disease
Cardinal Features Secondary FeaturesBradykinesia/akinesia Masked faciesTremor Shuffling gait, decreased arm swing,Rigidity freezing phenomenonPostural instability Hypophonic/hypokinetic speechNote: Patient must have a minimum of 2 of 4 Micrographiacardinal features for a diagnosis of Parkinson Dystoniadisease. Sweating
Drooling/sialorrheaSexual/urinary dysfunctionSeborrheaSleep disturbancesDepressionCognitive dysfunctionPain/dysesthesias
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lengthy titration to reach target dosing. Patientstend to want immediate or close to immediateresults. Thus, it has been my preference to startthese patients on Sinemet or its generic equiva-lent. Keep in mind this is a combination drug (car-bidopa/levodopa). To be effective, the ratio of car-bidopa to levodopa must be 1:4. So 25/100 or50/200 dosing is adequate; 10/100 is not.
I continue to titrate Sinemet upward in frequen-cy and dose to effect or side effect. When thepatient starts to experience side effects, I reducethe dose and add a DA or COMT inhibitor. If sideeffects develop, I usually decrease thecarbidopa/levodopa, not the additive agent. Atthis point, you may want to enlist the help of neu-rology specialists because the management ofthese patients becomes more unpredictable.
Intention TremorThe last type of tremor is intention tremor. Thistype is most often associated with a cerebellardisorder. Therefore, other neurologic symptomsare usually seen. In a younger person, I wouldconsider multiple sclerosis as a leading cause ofintention tremor. In an older adult, cerebral vascu-lar disease would probably be more common.
Do not forget about substance abuse. Alcoholabuse often leads to signs and symptoms of acerebellar disorder. A history of alcohol abuseshould be assessed for, especially in the olderpopulation. Unfortunately, there is no effectivetreatment for intention tremor. Efforts are madeto manage the underlying disease process and tooffer supportive services.
ConclusionTremor, regardless of the cause, interferes with aperson’s ability to function. If we can correctly cate-gorize the type of tremor a patient has, we can bet-ter target the treatment and minimize its effect onour patients’ lives. Tremors can be complicated.They do not always present neatly into one of thesethree categories, but this is a basis on which to buildyour differential diagnosis.
1555-4155/06/$ see front matter© 2006 Elsevier Inc. All rights reserved.doi:10.1016/j.nurpra.2006.02.004
Barbara Bishop, MS, ANP-C, CNRN, MSCN, works atVirginia Beach Neurology in Virginia Beach, Va. She canbe reached at [email protected].
Suggested Resources
For more information about Activa® Therapyby Medtronic, go to www.medtronic.comand www.medronicconnect.com.
Apomorphine is produced by VernalisPharmaceuticals, Inc. More information isavailable at www.apokyn.com.
Watts RL, Koller WC. Movement disorders:neurologic principles and practice. NewYork: McGraw-Hill; 1997.
COMT Inhibitors Dyskinesias, N/V/D, urine Dyskinesias, orthostatic
Entacapone discoloration (orange), hypotension, syncope,
Stalevo® (combination dizziness, hallucinations, severe diarrhea; rare:
entacapone and constipation, flatulence, rhabdomyolysis, fibrotic
carbidopa/levodopa) somnolence, increased complications,
sweating, neuroleptic malignant
anxiety/agitation, mood syndrome
changes, confusionN/V/D, nausea, vomiting, diarrhea; LFTs, liver function tests; HTN, hypertension; MI, myocardial infarction.
Table 2. Most Common PD Medications and Side Effect Profile (Continued)
Classification Common Side Effects Serious Side Effects
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