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Abnormal involuntary movements

Medicine > Medicine of older adult

Differential Diagnosis Schema 🧠

Hyperkinetic Disorders

  • Tremor: Regular rhythmic oscillations, often seen in Parkinson’s disease (resting tremor), essential tremor (action tremor), or hyperthyroidism (fine tremor).
  • Chorea: Rapid, involuntary, non-rhythmic movements, often associated with Huntington’s disease, Sydenham’s chorea, or drug-induced causes (e.g., levodopa, antipsychotics).
  • Myoclonus: Sudden, brief, jerky movements, seen in conditions like juvenile myoclonic epilepsy, metabolic disorders (e.g., hepatic encephalopathy), or post-anoxic brain injury.
  • Tics: Stereotyped, sudden, and repetitive movements or vocalizations, commonly associated with Tourette’s syndrome or as side effects of stimulant medications.
  • Dystonia: Sustained or intermittent muscle contractions causing twisting and repetitive movements or abnormal postures, seen in conditions like cervical dystonia, writer’s cramp, or dystonia secondary to cerebral palsy.

Hypokinetic Disorders

  • Parkinsonism: Bradykinesia, rigidity, and resting tremor, with primary causes including idiopathic Parkinson’s disease, drug-induced parkinsonism (e.g., antipsychotics), and vascular parkinsonism.
  • Akinetic mutism: Severe reduction in motor activity, seen in conditions like advanced Parkinson’s disease, catatonia, or frontal lobe lesions.
  • Stiff-Person Syndrome: Progressive muscle rigidity and spasms, often triggered by sudden movement or emotional stress, associated with autoimmune conditions or paraneoplastic syndromes.

Other Movement Disorders

  • Ataxia: Uncoordinated movement often resulting from cerebellar lesions, with causes including multiple sclerosis, alcohol misuse, and genetic conditions like Friedreich’s ataxia.
  • Restless Legs Syndrome (RLS): Uncomfortable sensations in the legs with an urge to move, often worse at night, associated with iron deficiency, pregnancy, or chronic kidney disease.
  • Wilson’s Disease: Copper accumulation leading to hepatic, neurological, and psychiatric symptoms, including a wing-beating tremor and dystonia.
  • Hemiballismus: Large, flinging movements usually affecting one side of the body, typically resulting from a lesion in the subthalamic nucleus.

Key Points in History 🥼

Onset and Duration

  • Sudden onset: Suggestive of stroke, trauma, or drug-induced causes.
  • Gradual onset: More indicative of degenerative conditions such as Parkinson’s disease or Huntington’s disease.
  • Fluctuating course: Consider metabolic or autoimmune causes (e.g., Wilson’s disease, paraneoplastic syndromes).

Character of Movements

  • Tremor: Assess whether it is resting, postural, or intention, to differentiate between Parkinson’s, essential tremor, and cerebellar disorders.
  • Chorea: Look for irregular, non-repetitive movements, which are often seen in Huntington’s disease or Sydenham’s chorea.
  • Dystonia: Inquire about sustained or repetitive contractions that may indicate primary dystonia or secondary causes like medication side effects.

Background

  • Past Medical History: Consider relevant neurological, autoimmune, or metabolic conditions such as stroke, multiple sclerosis, or Wilson’s disease.
  • Drug History: Assess for use of neuroleptics, antiemetics, or other drugs that may cause movement disorders as a side effect (e.g., tardive dyskinesia).
  • Family History: Look for hereditary conditions like Huntington’s disease or essential tremor.
  • Social History: Include alcohol use (linked with cerebellar degeneration), and occupational history (exposure to toxins like manganese).

Possible Investigations 🌡️

Blood Tests

  • Full Blood Count: To rule out anemia or infection.
  • Liver Function Tests and Ceruloplasmin: Essential for diagnosing Wilson’s disease.
  • Thyroid Function Tests: Hyperthyroidism can cause tremor.
  • Autoimmune Screen: To assess for conditions like lupus or paraneoplastic syndromes.

Imaging

  • MRI Brain: To identify structural lesions, white matter changes, or atrophy patterns seen in conditions like multiple system atrophy or Huntington’s disease.
  • DaTscan: Useful in differentiating Parkinsonian syndromes from essential tremor.
  • CT Brain: May be indicated in acute settings to rule out hemorrhage or stroke.
  • PET Scan: Occasionally used in research or complex cases to assess metabolic activity in specific brain regions.

Special Tests

  • Electromyography (EMG): To evaluate muscle activity patterns in suspected myoclonus or dystonia.
  • Genetic Testing: Indicated in hereditary conditions like Huntington’s disease, Wilson’s disease, or dystonia.
  • Lumbar Puncture: Occasionally performed to rule out CNS infection or paraneoplastic syndromes.

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Medicine of older adult