Abnormal Movements in the In-patient Setting

Definitions

Initial approach to abnormal movements

Movement is rhythmic and oscillatory (tremor)

Movement is irregular (other hyperkinetic movement)

If rhythmic and oscillatory (tremor), it is present at:

Movement is suppressible, distractible, or entrainable (consider functional movement disorder)

Associated altered awareness is present (consider seizure)

Movement is: (focal structural lesion vs toxic/metabolic process)

Onset is: (Vascular, toxic/metabolic, degenerative, hereditary)

Recent medication changes, toxic exposures, or withdrawal states (drug-induced movement disorder, serotonin toxicity, withdrawal)

There are associated metabolic abnormalities, fever, infection, or organ dysfunction (toxic-metabolic encephalopathy)

Screen for pre-existing neurologic condition prior to hospitalization

Essential tremor: Moderate to high frequency (4-12 hertz), commonly involving bilateral upper extremities, absent at rest and occurring during voluntary movements and interfering with activities such as eating, drinking, writing, and tasks that require fine motor precision. Tremor may be worsened by caffeine and fatigue and improved with alcohol. Head tremor may also be observed while seated or standing (“yes-yes” or “no-no” appearance). Slowly progressive over years.

Parkinson’s Disease and Parkinsons Plus Syndromes (Dementia with Lewy Bodies, Multi-System Atrophy, Progressive Supranuclear palsy, Corticobasal Degeneration): Bradykinesia/slowness of movements, rigidity, postural instability, stooped shuffling gait, reduced voice volume, reduced facial expression, acting out dreams. PD tremor typically begins unilaterally or is worse on one side, occurs at rest involving distal upper extremity, 4-6 hertz, with a pill-rolling or supination-pronation (rotational) appearance.

Parkinson’s Disease-related dyskinesias: Encountered in patients with Parkinson’s Disease and other parkinsonian conditions on chronic dopaminergic therapies such as Levodopa. Often choreiform in appearance involving face, neck, torso, and extremities, occurring 30-60 minutes following oral dose

Drug-induced parkinsonism: Bilateral symmetric parkinsonism (bradykinesia and rigidity), stooped shuffling gait, tremor less common/prominent. Onset within weeks of initiation of dopamine blocking or depleting medication. May have concomitant akathisia or tardive dyskinesia.

Tardive dyskinesia: Orofacial (tongue, jaw) involuntary movements, history of long-standing use or recent withdrawal (within weeks) of dopamine blocking or depleting agents. May have concomitant drug-induced parkinsonism.

Wilson’s Disease: Symptom onset in 2nd-3rd decade, dysarthria, dystonia, parkinsonism, psychiatric symptoms, unexplained liver disease.

Acquired hepatocerebral degeneration: History of chronic liver disease, portosystemic shunting, neuropsychiatric symptoms, parkinsonism, ataxia. Lack of symptom improvement with ammonia lowering therapies.

Huntington’s Disease: Symptom onset in 4th to 5th decade, choreiform movements of face, limbs, trunk, parkinsonism (late finding), psychiatric symptoms, history of parent or siblings with similar symptoms.

Holmes tremor: History of CNS insult (stroke, head trauma, demyelination) involving cerebellum, red nucleus, thalamus. Slow (less than 4 hertz), high-amplitude unilateral (unless bilateral insult) tremor of upper and lower extremity, present at rest, worse with posture, and most severe with intention.

Medication-related tremor: most commonly symmetric tremor of upper extremities occurring with posture and action and absent at rest. Myoclonus may also occur independently or superimposed with action tremor, particularly in the setting of toxicity. Temporally related to initiation of or increase in medication. Non-progressive, improves or resolves with discontinuation or reduction. (corticosteroids, Lithium, Valproate, SSRI’s, SNRI’S, TCA’s, beta adrenoreceptor agonists, stimulants, calcineurin inhibitors, opioids, gabapentin, pregabalin, theophylline, cefepime, meropenem, fluoroquinolones)

Alcohol-related tremor: History of chronic alcohol use; tremor occurs with posture and worsens with intention. May have concomitant dysmetria with finger to nose or heel to shin testing and gait ataxia.

Consider seizure as cause for involuntary movements

Known history of epilepsy

Acute or remote cortically based brain insult (stroke, hemorrhage, tumor, CNS infection, TBI)

Recent cardiac arrest

Significant elevation in blood pressure (posterior reversible encephalopathy syndrome)

Movements are episodic and stereotyped (appear consistently similar from event to event)

Movements are restricted to one side of the body

Movements are clearly associated with alteration of awareness with return to baseline following cessation

Acute and Hospital-Acquired Causes of Abnormal Movements

Metabolic tremor: hyponatremia, hypocalcemia, hypomagnesemia, hypoglycemia, hyperthyroidism, pheochromocytoma.

Acute alcohol withdrawal: Generalized tremulousness, coarse irregular tremor of bilateral upper extremities seen with posture and action, seen within 6 to 48 hours of last drink.

Acute opioid withdrawal: Generalized tremulousness, nausea/vomiting, cramping, autonomic hyperactivity, restlessness, irritability beginning hours to days from opiate cessation.

Acute benzodiazepine withdrawal: Generalized tremulousness, restlessness, anxiety, autonomic hyperactivity, beginning 1 to 10 days from benzodiazepine cessation.

Medication-related tremor: see above list

Convulsive syncope: convulsive activity (most commonly multi-focal myoclonus) occurring simultaneously or within seconds of loss of consciousness from vasovagal/cardiac/orthostatic cause, typically less than 30 seconds in duration, rapid recovery to baseline.

Functional movement disorder: [NOTE: diagnosis of psychogenic tremor should be made by a practitioner with training in neurology and familiarity with movement disorders] abrupt onset, changing tremor characteristics, exacerbated by attention, reduced with distraction, and entrainable (movement changes frequency to match voluntary rhythmic movement in another body part).