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7/19/2018 1 Falls and Movement Disorders 7/19/2018 Falls and Movement Disorders Victor Sung, MD AL Medical Directors Association Annual Conference July 28, 2018 Falls and Movement Disorders • Gait Disorders and Falls • Movement Disorders Primer • Hypokinetic Movement Disorders • Hyperkinetic Movement Disorders • Other Neurologic Contributors to Falls • Non‐Neurologic Contributors to Falls • Pearls/Pitfalls Physiology/Epidemiology of Gait Disorders • 3 Key Subsystems for Maintaining Balance • Visual • Vestibular • Somatosensory / Proprioception • Gait disorders are common • 15% of people age 65 • 25% of people age 85 • Increases risk of falls by 2.5‐3 X • >80% of gait disorders in patients >65 are multifactorial • Most common are orthopedic and neurologic factors 1 7/19/2018 Epidemiology of Gait Disorders Frequency of Etiologies for Patients Referred to Neurology for Gait D/O Etiology Percent Sensory deficits 18.3% Myelopathy 16.7% Multiple infarcts 15.0% Unknown 14.2% Parkinsonism 11.7% Cerebellar degeneration / ataxia 6.7% Hydrocephalus 6.7% Psychogenic 3.3% Other* 7.5% *Other = metabolic encephalopathy, sedative drugs, toxic disorders, brain tumor, subdural hematoma Evaluation of Gait Disorders • Start with history • Do they have falls? If so, what type/setting? • In general, what setting does the gait disorder occur? • What other medical problems may be contributing? • Exam • Abnormalities on motor/sensory/cerebellar exam • What does the gait look like? Anatomy of the Motor System Overview • Localize the Lesion!! • Motor Cortex • Subcortical Corticospinal tract • Modulators (*Extrapyramidal*) • Basal Ganglia • Cerebellum • Spinal Cord • Ant. Horn cell • Peripheral nerve • NMJ • Muscle 2 7/19/2018 Movement Disorders • The entire motor system is extensive • BUT the field of movement disorders is really focused on diseases of the basal ganglia and cerebellum (extrapyramidal) • Neuromuscular division handles all LMN area problems Movement Disorders and Falls • Hypokinetic – not enough movement • Parkinsonism • NPH • Hyperkinetic –too much movement • Dystonia • Chorea • Cerebellar Ataxia Hypokinetic Movement Disorders 3 7/19/2018 Parkinsonism • Parkinsonism – classic tetrad of symptoms • Rigidity (velocity Independent –differentiate this from spasticity) • Rest Tremor • Bradykinesia • Postural instability • Diseases • Idiopathic Parkinson Disease (PD) • Parkinson‐Plus Syndromes • Diffuse Lewy Body Disease (DLB) • Multiple Systems Atrophy (MSA) • Progressive Supranuclear Palsy (PSP) • Cortical basal ganglionic degeneration (CBD) Idiopathic PD and Gait Disorders/Falls • Gait Disorder Features • In addition to postural instability, classically described as “festinating gait” or shuffling gait • Stooped posture, en bloc turns • Decreased arm swing is first sign • Gait disorders/falls are usually late feature (avg. 5‐10 years duration of disease) • Highly unusual for PD to present with a gait disorder • Freezing of Gait • Difficulty initiating first step, foot feels frozen to the ground PD and Gait Disorder/Falls • What about worsening gait/falls in a KNOWN Parkinson’s patient? • Don’t forget autonomic dysfunction and orthostatic hypotension • If from the PD itself, should correlate to exam of bradykinesia/rigidity of limbs • Of 4 cardinal symptoms, gait/balance is LEAST responsive to medication adjustments 4 7/19/2018 PD and Gait Disorders • U‐Step Walker • Specially designed for PD • Weight in base prevents tipping with festination or retropulsion • Brake stays engaged • Laser to overcome freezing • Metronome auditory cue to help with stride cadence U‐Step Walker Parkinson Plus Syndromes • All have poor prognosis, poor levodopa response • Progressive Supranuclear Palsy • Parkinsonism with limited vertical eye movements • Early/frequent falls (within first year of disease) • Multiple Systems Atrophy • Parkinsonism + dysautonomia (most commonly orthostatic hypotension) • OH and gait – commonly missed contributor • Treat by reducing anti‐hypertensives (triple digit SBP rule) • And/or fludrocortisone/midodrine/droxidopa if necessary 5 7/19/2018 Other Forms of Parkinsonism • Drug‐induced parkinsonism • Will have symmetric parkinsonism • Reglan/anti‐emetics a common culprit • Anti‐psychotics (atypicals just as likely as typicals except for Seroquel/Clozaril) • Treat by withdrawing offending agent • Vascular parkinsonism • Stroke to BG, usually pure unilateral, non‐progressive symptoms Case • 82yo WM presents to the ER after a fall at home. X‐ rays reveal a fractured left hip that will require surgical fixation. • CT head radiology report: • “No apparent tumor, stroke, or hemorrhage. Diffuse cerebral atrophy but also ventriculomegaly mildly disproportionate for age. Normal pressure hydrocephalus vs. age‐related atrophy, clinical correlation recommended.” Question • What do you do next? A. MRI brain B. Consult neurology for NPH evaluation C. Consult neurosurgery for consideration of VP shunt D. Fix the hip first and refer to neurology as an outpatient E. Fix the hip only, as this is not likely to represent NPH 6 7/19/2018 Normal Pressure Hydrocephalus (NPH) • Clinical • Triad: magnetic gait, urinary incontinence, cognitive impairment/dementia • Differentiate magnetic gait from parkinsonian shuffling • Gait disorder precedes dementia • MUST have the imaging showing hydrocephalus plus the clinical • Either gait plus incontinence or gait plus cognitive impairment or all three • Diagnosis • Must show clinical improvement after high volume removal of CSF • “30/ 30 / 30” tap or lumbar CSF drain • If no gait disorder, no way to make the diagnosis! Normal Pressure Hydrocephalus (NPH) Normal Pressure Hydrocephalus (NPH) • Treatment • VP shunt is still preferred treatment • Good short term outcomes (80‐90% improvement) • Long term is poorer (30‐90% with sustained benefit depending on study) • Cognition generally does NOT improve with shunting • Predictors of good outcome • Early diagnosis • Gait disturbance as primary clinical feature • Good initial response to high volume tap 7 7/19/2018 Hyperkinetic Movement Disorders Dystonia and Gait • Defined as involuntary, sustained contraction of muscles around a joint • Often results in (often painful) twisting postures and/or repetitive movements • Most common forms: • Focal: cervical dystonia (torticollis, latero/antero/retrocollis, etc), blepharospasm • If involves lower extremities, can affect gait • Treatment focused on botulinum toxin injections Chorea and Gait • Chorea – derived from the Greek word for dance • Jerky, irregular, non‐rhythmic movements • Interferes with voluntary movements such as gait • Truncal chorea affects balance • LE chorea leads to stumbling/tripping • In adults, most common causes are: • Huntington’s Disease • Tardive Dyskinesia 8 7/19/2018 Huntington’s Disease and Gait Disorder • AD‐inherited neurodegenerative disorder • Triad: Motor (Chorea), Cognitive (dementia), and Behavioral (depression, perseveration, delusional) • Clinical suspicion (Chorea +/‐ FHx) confirmed by gene test • Treatment • FDA‐approved tetrabenazine and deutetrabenazine to treat chorea • Typicals like haloperidol and heavily dopamine‐blocking atypicals like risperidone can treat chorea AND psychosis, though more cognitive adverse effects • Prognosis • Average age of onset 45 but fastest growing group is patients over 65 • Life expectancy usually 15‐25 years from onset of physical symptoms Tardive Dyskinesia • Usually seen after chronic exposure to anti‐ dopaminergic agents (antipsychotics, anti‐emetics) • Classic is repetitive lip‐smacking/ tongue protruding movements but can be chorea in any part of body • Therefore can affect gait if in trunk/legs • Treatment: • Slow withdrawal of causative agent helpful in some • FDA‐approved valbenazine and deutetrabenazine • Some use off‐label tetrabenazine or amantadine • Once TD develops, benztropine can make chorea worse Cerebellar Ataxia and Gait • In addition to wide‐based ataxic gait, should have ataxia in limbs (finger‐to‐nose, heel‐to‐shin) and in speech (scanning dysarthria) • Neurologists prefer reservation of term ataxia for cerebellar syndromes • NOT just any patient with a gait problem • Imaging should confirm cerebellar atrophy 9 7/19/2018 Cerebellar Ataxia and Gait • History to tell you acquired or hereditary • Causes: • SCA’s • Alcoholic or other toxic/metabolic • Structural (stroke/tumor) • OPCA • Paraneoplastic – look for cancer risk factors, usu. Anti‐Yo Ab • Treatment • Remove offending agent (EtOH, etc) or treat underlying malignancy / paraneoplastic syndrome • Otherwise largely supportive with PT, supportive appliances/devices Other Neurologic Contributors to Gait Disorders Cerebrovascular Disease and Falls • Corticospinal tract damage from old strokes • Residual weakness / spasticity • If extensive frontal lobe microangiopathy, can cause an apraxic gait with freezing • Very difficult to distinguish from parkinsonism 10 7/19/2018 Cervical Spondylosis/Myelopathy and Falls • DJD in C‐spine • Can present with NO arm findings… • Can be any other UMN lesion to corticospinal tract • MS /demyelinating disease • PML – other infectious white matter disease • TM / other spinal cord /myelopathic process Neuromuscular Disease and Gait Disorders • Neuropathy • Predominantly sensory neuropathies can give profound sensory ataxia –correlates best to vibration/proprioception loss on exam • High‐stepping gait as they slap feet down to increase sensation • **Autonomic neuropathies causing orthostatic hypotension • Autoimmune like CIDP cause gait disturbance by combo of motor/sensory • ALS • Most
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