Tremor Predominant Parkinson’s Disease

The patient who is a stocky wide- shouldered, healthy looking man, says he’s never slept through an entire night in his life. While making an extraordinary statement his face remains unexpressive, placid. His eyebrows and mouth convey no indication of emotion. The physician behind the desk shakes his head and comments the need for sleep varies considerably between people. Though few people respond to Seroquel so strangely. The first time the patient took the drug he slept for twenty-four hours straight. He describes trembling with cold for several hours on one occasion, on a separate night he blames the prescription for extreme tension, which made him pace through the house for hours. Clearly, he responds aberrantly to the medication.
The wife comments he thrashes during the night, sometimes calling out or shouting in his sleep; she reports this occurs three to four times a month. The doctor comments no one with PD has a normal sleep pattern and he describes how rapid eye movement sleep shifts to become out of phase with other sleep architecture- or wave patterns, allowing the person with PD to be able to move while dreaming. Essentially, the person is able to enact dream content, which is not possible in someone else whose sleep architecture is unaffected by illness.
The wife states they have been married forty- seven years. Her spouse leans towards her and comments they have been fighting for forty- six. An amiable banter flows between them. The wife offhandedly states her husband is an artist and describes the fine work he has been involved in, commenting he never has tremor when he’s working, it’s only later on when he’s resting. The physician responds,
“… that’s why it’s called a resting tremor…”
The patient asks whether he can increase the Mirapex he takes while experiencing stressful events, for example he is due to undergo eye surgery to for glaucoma- to release pressure on the orbits of his eyes. It requires the ophthalmologist create holes in the membrane at the back of the eye. The doctor with a head full of wavy and graying hair nods,
“Certainly, there is no contraindication to the drug.”
On physical examination, the doctor finds some rigidity on the man’s left side, and in the neck. When asked to raise his shoulders, he barely shrugs. His walk has little arm swing on either side, and when they retake their seats, the doctor asks how long ago was it when you first came in?
The wife thinks it was 2008, and the records on the computer confirm her guess. In 2008 the patient stated he had experienced symptoms of illness for five years prior to visiting a neurologist. He still gets sufficient symptomatic relief from Mirapex (pramipexole) a dopamine agonist, to avoid Sinemet. The doctor comments that most people require Sinemet after a year or two of treatment with an agonist, and he is an unusually fortunate case.

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