Antipsychotic-Induced Movement Disorders: Evaluation and Treatment
Using these scans, your doctor can potentially rule out defects in your brain that may be causing tremors. Cutting down on morning coffees and working fewer hours may improve symptoms for many people. Liver failure can cause asterixis—a flapping negative myoclonus (brief loss of muscle tone) due to toxin buildup that affects brain function. It refers to the invisible tremor everyone experiences as a consequence of being alive and having a nervous system.
- A list of clinical features that help differentiate between essential tremor and Parkinson disease is available.
- Important clues about an underlying neurologic disorder in patients presenting with a tremor can be found during the examination of the cranial nerves, speech, gait, balance, and muscle tone.
- Treatment involves stopping the drug, lowering the dose, or switching to another drug.
- Short- and long-acting propranolol reduces tremor by 50% to 70% in 50% of patients at daily doses varying from 60 mg/d to 200 mg/d.55 Dizziness, fatigue, erectile dysfunction, and sedation are common side effects.
Neuroleptic malignant syndrome
As most articles included only a few participants, classifying treatment effects based on the number of patients tested instead would have resulted in similar results, with oxprenolol as the only notable exception, as mentioned previously. Treatment of refractory medication‐induced tremor is challenging, and (international) guidelines are not available. We report the successful long‐term effect of thalamus DBS (Vim) in a patient with a severe treatment‐resistant medication‐induced tremor, which had been reported only in another case previously (Vop).
Interview and Clinical Examination of Patients with Tremor
- Intention tremor is a subheading of kinetic tremor that is a terminal kinetic tremor (as can be seen when nearing the target on finger-to-nose testing).
- Results from systematic review of the literature on surgical treatments for drug-induced tremor.
- The patient returned to his administrative office job and began normal socialization, including eating in restaurants, 2 weeks following the procedure, which was not possible prior to the procedure.
- Although sometimes daunting, the patient with tremor offers the clinician the opportunity to demonstrate clinical expertise.
Bronchodilators, which are commonly used in the treatment of conditions such as asthma, can also cause tremors. Drug-induced tremors can occur when you move your body a certain way or are in certain positions. Medications that cause the tremors include certain antipsychotics, anticonvulsants, and antidepressants. Certain medications can both cause tremors and worsen any tremors you already have from Parkinson’s disease or another similar disorder. Surgical treatment for ET is reserved for those selected patients who have severe drug-induced tremor: symptoms, diagnosis treatments tremor not adequately controlled by medical therapy.
Table 2 – Illicit drugs and associated movement disorders
Obtaining an accurate diagnosis for medication-induced tremors involves a comprehensive evaluation by a healthcare professional. The process typically includes a detailed medical history review, physical examination, and potentially additional tests to rule out other causes of tremors. It’s important to note that the severity and frequency of medication-induced tremors can vary from person to person. Some individuals may experience mild, occasional tremors, while others may have more persistent and disruptive symptoms. If any of these symptoms occur, it’s crucial to consult a healthcare provider for proper diagnosis and treatment options. The primary cause of medication-induced tremors is the effect of certain drugs on the central nervous system, particularly those that alter neurotransmitter levels or affect muscle function.
The studies involving humans were approved by West Virginia University, School of Medicine, Department of Neurosurgery. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.
Despite these limitations, he decided to undergo MRgFUS right VIM thalamotomy for his left-hand tremor (Figure 2) since it is a minimally invasive procedure and requires fewer follow-up clinic visits. Given the uncertainty of the diagnosis and poor understanding of the underlying pathology, surgical options for drug-induced tremor have been hesitantly tried. There are very few reports of deep brain stimulation (DBS) successfully attempted in these patients (Table 1) (8–11). However, DBS may be contraindicated in active or poorly controlled neuropsychiatric conditions, and certain DBS targets can aggravate mood and psychiatric symptoms when stimulated (12–14).
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A common mistake in examining patients with tremor is to rush the examination. Remember that some forms of tremor take 30 seconds or more to emerge—patience is a virtue! Examine all patients in the true rest position, with hands pronated and resting on their lap. Ask the patient to reposition her or his hands with pinkies down and thumbs up, as both parkinsonian and Holmes tremors are often triggered by this posture.
In psychiatric conditions such as bipolar disorder, this is often not recommended given the disease severity and dearth of suitable alternatives. If the tremor persists or the offending drug cannot be altered, symptomatic treatment with tremor-reducing medications is initiated. Amerika et al. conducted a systematic review of the literature to identify and analyze treatments for drug-induced tremor (8). Their review found that β-blockers, most notably propranolol, have shown the most effectiveness. Unfortunately, there are several downsides to using drugs to control drug-induced tremor (8).
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In this position, the oscillatory movement increases in amplitude and tends to involve the proximal wrist or elbow joints (these joints become the distal pendulum). In the wing-beating posture, tremors in both arms sometimes oscillate out of phase, which could be leveraged for functional benefits. For example, a patient holding a cup with both hands can counterbalance the dropping movement of one hand with the other (VIDEO 5-1). The kinetic component is examined by asking patients to perform standard tasks such as pouring water from a cup, writing a sentence, or drawing spirals on a paper following standardized instructions.
Further differential diagnoses described in this review include drug- or toxin-induced tremor, neuropathic tremor, psychogenic tremor, orthostatic tremor, palatal tremor, tremor in Wilson’s disease, and tremor secondary to cerebral lesions, such as Holmes’ tremor (midbrain tremor). An individualized approach to treatment of tremor patients is important, taking into account the degree of disability, including social embarrassment, which the tremor causes in the patient’s life. Although postural and kinetic components are the main elements of essential tremor, the presence of a resting tremor seen in a small proportion of patients with advanced essential tremor can potentially lead to an erroneous diagnosis of Parkinson disease.
The diagnosis of tremor is based on clinical information obtained from the history and physical examination. The most common tremors in patients presenting to primary care physicians are enhanced physiologic tremor, essential tremor, and parkinsonian tremor. All persons have low-amplitude, high-frequency physiologic tremors at rest and during action that are not reported as symptomatic, but can be enhanced by anxiety, medication use, caffeine intake, or fatigue.
