[] Vol.2 No.1 Taiwan Geriatr Gerontol 4% (Parkinson s disease)(parkinsonism) 2006 2(1) 53-62 (essential tremor) (disorder) 4% [1] ( hereditary tremor) ( familial tremor) E-mail: kaominchen@yahoo.com.tw 53
2 1 [2] 1. (rest tremor) (parkinsonism) 2. (postural tremor) physiological tremor 3. (kinetic tremor) (intention tremors) 4. (essential tremor) harmaline harmaline ( inferior olive) harmaline γ-aminobutyric acid A (GABA A )diazepam Barbiturateharmaline [3-5] (locus coeruleus) Lewy bodies Lewy bodies disease [6] 1. 54
Vol.2 No.1 Taiwan Geriatr Gerontol ( 95% ) ( 34% ) ( 12% ) ( 5% ) ( 20% ) 75% 2. (bradykinesia) (ataxia) 3. ( ) 4 12HZ 2 8HZ 4. ( ) 6.1% 6.9% (dystonia)[7] re-emergent rest tremor Lewy bodies disease (electromyography, EMG) ( Archimedes spiral) 1992Koller 678 55
2 1 (progressive supranuclear palsy) (dopamine transporter scan) (dopamine transporter )(ligands) (single photon emission computed tomography, SPECT) [8] (multiple system atrophy ) 1 1. [2] 2. (dystonic tremor) (jerk) 1 50 20 60 4-6 Hz 4-12 Hz ( ) (rigidity) (bradykinesia) (Dopamine Transporter Scan) Propranolol, Primidone 2 56
Vol.2 No.1 Taiwan Geriatr Gerontol 3. (intention tremor) 4. (mid brain tremor ) (midbrain tegmentum) (red nucleus) (superior cerebellar peduncles)[9] (red nucleus) (cerebellothalamic, cerebelloolivary and nigrostriatal fiber tracts) [10] (3-5 HZ) 5. (physiological tremor) ß metoprolol, atenolol, propranolol propranolol propranolol 40-50% 40 mg 320 mg Primidone 25 mg 50-250 mg 57
2 1 Alcohol Benzodiazepines Alprazolam 50% [11] BZD (benzodiazepines)γ- (GABAergic transmission) Clozapine (extrapyramidal side effects)12.5 clozapine 1513 [12] Clozapine (agranulocytosis) Botulinum toxin-a (BTX-A) Botulinum toxin-a 75% Botulinum toxin-a Botulinum toxin-a [15] Carbonic anhydrase inhibitors (CAIs) zonisamide (ZNS) CAI (antiepileptic activity) ZNS arotinolol ( ) zonisamide [16] Gabapentine gabapentine GABAergic Gabapentine [13,14] 1968 Blacker 58
Vol.2 No.1 Taiwan Geriatr Gerontol (ventralis intermedius nucleus)[17] thalamotomy 1997 Koller high- frequency unilateral thalamic stimulation thalamotomy (ventralis intermedius nucleus) (stimulation therapy) [18] 1. Louis ED, Marder K, Cote L, et al: Differences in the prevalence of essential tremor among elderly African Americans, whites, and Hispanics in northern Manhattan, NY. Arch Neurol 1995; 52: 1201-5. 2. Bhomraj Thanvi, Nelson Lo and Tom Robinson : Essential tremor the most common movement disorder in older people. Age Ageing 2006; 35: 344-9. 3. Wilms H, Sievers J, Deuschl G: Animal models of tremor. Mov Disord 1999; 14: 557-71. 4. Montigny C de, Lamarre Y: Rhythmic activity induced by harmaline in the olivo-cerebello-bulbar system of the cat. Brain Res 1973; 53: 81-95. 5. Stratton SE, Lorden JF: Effect of harmaline on cells of the inferior olive in the absence of tremor: differential response of genetically dystonic and harmaline-tolerant rats. Neuroscience 1991; 41: 543-9. 6. Louis ED, Honig LS, Vonsattel JP, Maraganore DM, Borden S, Moskowitz CB: Essential tremor associated with focal nonnigral Lewy bodies: a clinicopathologic study. Arch Neurol 2005; 62: 1004-7. 7. Koller WC, Busenbark K, Gray C, Hassanein RS, Dubinsky R: Classification of essential tremor. Clin 59
2 1 Neuropharmacol 1992; 15: 81-7. 8. Marshall V, Grosset D: Role of dopamine transporter imaging in routine clinical practice. Mov Disord 2003; 18: 1415-23. 9. Findley L J: Classification of tremors. J. Clin Neurophysio 1996; 13: 122-32. 10. Elble RJ Central mechanisms of tremor. Neurophysiol1996; 13: 133-44. 11. Huber SJ, Paulson GW: Efficacy of alprazolam for essential tremor. Neurology 1988; 38: 241-3. 12. Ceravolo R, Salvetti S, Piccini P, et al.: Acute and chronic effects of clozapine in essential tremor. Mov Disord 1999; 14: 468-72. 13. Pahwa R, Lyons K, Hubble JP, et al: Double-blind controlled trial of gabapentin in essential tremor. Mov Disord 1998; 13: 465-67. 14. Gironell A, Kulisevsky J, Barbanoj M, et al: A randomized placebo-controlled comparative trial of gabapentin and propranolol in essential tremor. Arch Neurol 1999; 56: 475-80. 15. Jankovic J, Schwartz K, Clemence W, Aswad A, Mordaunt J: A randomized, double-blind, placebo controlled study to evaluate botulinum toxin type A in essential tremor. Mov Disord 1996; 11: 250-6. 16. Morita S, Miwa H, Kondo T: Effect of zonisamide on essential tremor: a pilot crossover study in comparison with arotinolol. Parkinsonism Relat Disord 2005; 11: 101-3. 17. Blacker HM, Bertrand C, Martinez N, Hardy J, Molina-Negro P: Hypotonia accompanying the neurosurgical relief of essential tremor. J Nerv Ment Dis 1968; 147: 49-55. 18. Koller W, Pahwa R, Busenbark K, et al: High-frequency unilateral thalamic stimulation in the treatment of essential and parkinsonism tremor. Ann Neurol 1997; 42: 292-9. 60
[Special Report] Essential Tremor in the Elderly Min-Chen Kao, Chi-hua Yen Abstract Essential tremor is a benign condition of unknown etiology but associated with substantial disability in older people. Essential tremor that is often misdiagnosed as Parkinson s disease affects about 4% of the population above 65 years of age, and tremor amplitude increases with age. The pathogenesis of essential tremor is not fully understood, and there are still large gaps in our knowledge despite significant progress in our understanding of this condition in recent years. Essential tremor can cause considerable personal and social handicap. Current therapy for essential tremor has significant limitations in the older population. We hope there is a better understanding of the pathophysiology of essential tremor in the future, eventually leading to development of more effective therapy. (Taiwan Geriatr Gerontol 2006;2(1):53-62) Key words: essential tremor, parkinsonism, differential diagnosis Division of Geriatric Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan Address: Division of Geriatric Medicine, Chung Shan Medical University Hospital, No. 110, Sec. 1, Chien-Kuo N. Road, Taichung, 402, Taiwan. Correspondence: Min-Chen Kao E-mail: kaominchen@yahoo.com.tw 61