April 1, 2025

Volume 2, Issue 2

SILVER LINING
GERIATRIC MEDICINE NEWSLETTER

WORLD
Tremors in Older Adults

PARKINSONS Motor Fluctuations in Advanced

DAY APRIL 11 Parkinsons

“A COMMUNITY FINDING THEIR LIGHT”

Read more
 From Editors desk
~ Dr. Monika Pathania

CONTENTS

TREMORS IN OLDER
When nature shakes the humans to pause …
ADULTS
On World Parkinson’s Day , 11 April , the newsletter highlights
clinical ,diagnostic and management perspectives of the
Parkinsons Disease (PD). Prevalence rates of PD vary from 15- MOTOR
45 per 100000 population with India showing a trend towards FLUCTUATIONS IN
early onset motor symptoms at an early age that’s a decade ADVANCED PD
younger than the global average of disease onset. The disease
is more than just tremors and stiffness, it encompasses
disruption of daily activities, stress, anxiety of patient as well as
caregivers burden, malnutrition and other related
CASE SCENARIO AND
complications. Though the awareness about the disease is CLINICAL IMAGES
increasing yet the disease is underdiagnosed. The disease
being multifaceted, needs a comprehensive multidisciplinary
care. Advancements in research and treatment options are ANSWER TO
critical, there is need to look into the best from all the systems, PREVIOUS ISSUE
conventional drugs like levodopa, carbidopa are well QUESTIONS
researched. Along with newer pharmacotherapeutic strategies,
there is upcoming evidence and research on phytochemicals
like Withania somnifera(ashwagandha) and Bacopa Linn
FUN FACTS
(Brahmi). The newsletter reflects on clinical perspectives, newer
therapies and a will to prioritise managing symptoms and
improve the quality of life of patients living with PD. Lets show
solidarity to the patients with Parkinsons Disease that not only PHOTO GALLERY
shakes the lives of patients but also their caregivers . AND STATISTICS

1
 Tremors in older adults:
A clinical perspective

~Dr. Parul Bhutani

Aging brings a myriad of changes, and among tremors arise from peripheral nerve
them, tremors are one of the most common dysfunction. Furthermore, clinicians must
yet often misunderstood movement disorders remain vigilant for drug-induced tremors,
seen in older adults. Whether subtle or commonly triggered by medications such as
pronounced, these involuntary, rhythmic lithium, valproate, or certain neuroleptics.
movements can significantly impact daily
activities, diminishing quality of life. While Diagnosing tremors requires a keen eye and
tremors may be dismissed as a benign sign of a structured approach. Observing tremor
aging, they often serve as an early clue to patterns at rest, during posture holding, and
underlying neurological conditions such as with voluntary movements can provide
Parkinson’s disease, essential tremor (ET), or significant diagnostic clues. Electromyography
even metabolic disturbances. As clinicians, (EMG) and accelerometry offer objective
recognizing and classifying these tremors confirmation, while neuroimaging, particularly
accurately is crucial for guiding appropriate MRI, helps rule out structural causes. In familial
management and improving patient cases, genetic testing may reveal hereditary
outcomes. links, particularly in conditions like
spinocerebellar ataxias or Fragile-X Tremor
Essential tremor (ET), one of the most Ataxia Syndrome (FXTAS). Beyond the
frequently encountered movement disorders neurological sphere, metabolic conditions such
in the elderly, presents as a progressive action as hyperthyroidism can also manifest with
tremor affecting the hands, head, or voice. The tremors, necessitating a broad differential
recently introduced category of ET Plus has diagnosis.
sparked debate in the medical community,
encompassing patients with additional Treatment options for tremors vary
neurological signs such as mild dystonia, depending on the underlying cause. Essential
impaired gait, or cognitive decline. tremor often responds well to beta-blockers
Distinguishing ET from Parkinsonian tremors like propranolol or anticonvulsants such as
is vital, as the latter predominantly occurs at primidone, while Parkinsonian tremors
rest and is often asymmetric, with associated improve with dopaminergic therapy. For
bradykinesia and rigidity. Another distinct patients with disabling focal tremors,
form, Holmes tremor, characterized by slow, botulinum toxin injections can provide
high-amplitude movements, often points to targeted relief, especially in head or voice
structural brain lesions, while neuropathic tremors.
2
Deep brain stimulation (DBS) remains a
game-changer for refractory cases, offering
long-term control when medications fail.
Complementary strategies, including physical
therapy, occupational therapy, and lifestyle
modifications, play an essential role in
maintaining independence and function.

As the global population ages, tremors will

become an increasingly prevalent concern in
clinical practice. Understanding their
classification, causes, and treatment options
allows for timely interventions and improved
patient care. While much progress has been
made, the evolving classification of tremor
disorders, particularly the debate surrounding
ET Plus, highlights the need for further
research into pathophysiology and
biomarkers. With continued advancements,
the goal remains clear: to offer patients a
steadying hand amid the uncertainties of age-
related tremors.

References:

Lenka A, Jankovic J. Tremor Syndromes: An

Updated Review. Front Neurol. 2021;12:684835.
doi: 10.3389/fneur.2021.684835.
Crawford P, Zimmerman EE. Tremor: Sorting
Through the Differential Diagnosis. Am Fam
Physician. 2018 Feb 1;97(3):180-186. PMID:
29431985.

insulation on
Myelin, the fatty
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signals travel slo
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good news? You
experience and
compensate with
clever shortcuts!

3
 Motor fluctuations in Advanced
Parkinson’s Disease: new horizons in
therapeutic strategies

~ Dr. Kritartha Kashyap

Introduction
Parkinson’s disease (PD) is a progressive In recent times, there have been various trials
neurodegenerative disorder characterized by on lesioning therapies, newer drug delivery
motor symptoms such as bradykinesia, modalities to mitigate the effects of motor
rigidity, tremor, and postural instability. The fluctuations in Advanced PD. Some of them
mainstay of treatment for PD is levodopa, are summarised below.
often combined with carbidopa, which helps
mitigate motor symptoms by replenishing Device assisted treatments are becoming
dopamine levels in the brain. However, as the more popular in the treatment of Advanced
disease advances, many patients experience PD. Deep Brain Stimulation (DBS) is a
motor fluctuations, where the efficacy of surgical treatment for Parkinson’s disease
levodopa becomes inconsistent, leading to that involves implanting electrodes in specific
periods of "On" time (when symptoms are brain regions, such as the subthalamic
well-controlled) and "Off" time (when nucleus (STN) or globus pallidus interna (GPi).
symptoms return). These motor fluctuations These electrodes deliver electrical impulses to
in PD arise due to the progressive loss of modulate abnormal neural activity that
dopaminergic neurons and the contributes to motor symptoms. By doing so,
pharmacokinetic limitations of oral levodopa. DBS helps smooth out motor fluctuations,
These fluctuations include wearing-off reducing tremors, rigidity, and bradykinesia.
phenomena, where levodopa’s effect DBS is particularly effective in patients with
diminishes before the next scheduled dose, advanced PD who experience significant
and dyskinesias, involuntary movements that “Off” periods and dyskinesias despite
often accompany prolonged levodopa optimal medication, and in those without
therapy. Advanced PD patients require more cognitive impairment or history of psychiatric
frequent dosing, which increases the risk of disorders. Although it carries certain risks
unpredictable "Off" periods and worsens their such as infection, bleeding, or hardware
quality of life. Managing these fluctuations complications, DBS remains one of the most
has been a significant challenge in PD effective long-term interventions for
therapy, necessitating the development of managing motor complications in PD.
newer treatment modalities, including and
other device-assisted therapies.

4
LCIG (Levodopa-Carbidopa Intestinal Gel) is symptom control with less "Off" time and
a therapy for Parkinson’s disease where a dyskinesia. LDp/CDp consists of prodrugs of
continuous infusion of levodopa-carbidopa is levodopa and carbidopa, which are
delivered directly into the small intestine converted into their active forms via
through a surgically placed tube. This method enzymatic reactions. The continuous 24-hour
bypasses erratic gastric absorption, providing subcutaneous infusion bypasses the
steady drug levels and reducing motor gastrointestinal tract, eliminating variability in
fluctuations. However, surgical risks, daily drug absorption. A pharmacokinetic study
maintenance, and tube-related complications comparing LDp/CDp infusion with levodopa-
(such as infections or blockages) are carbidopa intestinal gel (LCIG) showed that
potential drawbacks. Despite these LDp/CDp maintains equivalent levodopa
challenges, LCIG is highly effective in exposure with less fluctuation and provides
managing advanced PD symptoms when oral sustained symptom relief, particularly during
medications become insufficient. nighttime hours.

One of the recently US-FDA approved MRI-guided Focused Ultrasound (FUS) is an

therapeutic modality is Continuous innovative, non-invasive procedure used to
Subcutaneous Apomorphine Infusion (CSAI), treat motor symptoms in Parkinson’s disease
which is a dopamine agonist therapy used in (PD). Unlike traditional surgical methods, FUS
advanced Parkinson’s disease (PD) to uses high-frequency ultrasound waves to
manage motor fluctuations when oral create precise, targeted brain lesions in areas
medications become ineffective. It involves responsible for motor dysfunction, such as
delivering a steady dose of apomorphine via the globus pallidus interna (GPi) or
a portable infusion pump, which helps subthalamic nucleus (STN). Studies have
smooth out "On" and "Off" periods by shown that FUS pallidotomy is particularly
maintaining consistent dopamine receptor effective in reducing dyskinesia and motor
stimulation. It acts directly on dopamine impairment in patients with advanced PD.
receptors without requiring conversion in the This technique helps alleviate symptoms by
brain. This makes it useful for rapid symptom interrupting abnormal neuronal circuits
relief, especially for unpredictable "Off" involved in PD, leading to improved motor
episodes. However, CSAI has drawbacks,
including infusion-site reactions, skin nodules,
and potential nausea, which often require
pre-treatment with antiemetics. Despite these
challenges, CSAI offers a non-surgical
alternative to deep brain stimulation (DBS)
and levodopa infusions for patients with
severe motor fluctuations.

Foslevodopa/foscarbidopa (LDp/CDp) is a
novel continuous subcutaneous infusion
therapy that provides stable levodopa levels,
reducing motor fluctuations in advanced
Parkinson’s disease. Compared to oral
levodopa, it ensures more consistent
Figure: Deep-Brain Stimulation Surgery (courtesy: NEJM.org)

5
control. The technique is generally used for References:
1. Ahlskog JE, Muenter MD. Frequency of levodopa-related
patients with unilateral motor symptoms, dyskinesias and motor fluctuations as estimated from the
as bilateral lesioning may lead to side effects cumulative literature. Mov Disord 2001; 16:448.
2. Williams DR, Evans AH, Fung VSC, et al. Practical approaches to
like speech or cognitive impairments. commencing device-assisted therapies for Parkinson disease in
Australia. Intern Med J 2017; 47:1107.
Because of its minimally invasive nature, it
3. Weaver FM, Follett K, Stern M, et al. Bilateral deep brain
significantly reduces risks associated with stimulation vs best medical therapy for patients with advanced
Parkinson disease: a randomized controlled trial. JAMA 2009; 301:63.
open surgery, such as infections or
4. Vitek JL, Jain R, Chen L, et al. Subthalamic nucleus deep brain
complications from anesthesia. Additionally, stimulation with a multiple independent constant current-controlled
device in Parkinson's disease (INTREPID): a multicentre, double-blind,
the procedure is performed in real-time under randomised, sham-controlled study. Lancet Neurol 2020; 19:491.
MRI guidance, allowing precise targeting of 5. Olanow CW, Kieburtz K, Odin P, et al. Continuous intrajejunal
infusion of levodopa-carbidopa intestinal gel for patients with
brain structures with minimal damage to advanced Parkinson's disease: a randomised, controlled, double-
surrounding tissues. blind, double-dummy study. Lancet Neurol 2014; 13:141.
6. Deuschl G, Antonini A, Costa J, et al. European Academy of
Neurology/Movement Disorder Society-European Section Guideline
Other surgical approaches include on the Treatment of Parkinson's Disease: I. Invasive Therapies. Mov
Disord 2022; 37:1360.
Conventional Thalamotomy and 7. Hallett M, Litvan I. Evaluation of surgery for Parkinson's disease:
Pallidotomy, Subthalamotomy for a report of the Therapeutics and Technology Assessment
Subcommittee of the American Academy of Neurology. The Task
Asymmetrical PD. Force on Surgery for Parkinson's Disease. Neurology 1999; 53:1910.
8. Rosebraugh M, Stodtmann S, Liu W, Facheris MF.
Foslevodopa/foscarbidopa subcutaneous infusion maintains
Conclusion equivalent levodopa exposure to levodopa-carbidopa intestinal gel
Motor fluctuations remain a major challenge delivered to the jejunum. Parkinsonism Relat Disord. 2022 Apr;97:68-
72. doi: 10.1016/j.parkreldis.2022.03.012.
in managing advanced Parkinson’s disease. 9. Fung VSC, Aldred J, Arroyo MP, Bergquist F, Boon AJW, Bouchard
Newer therapies like M, Bray S, Dhanani S, Facheris MF, Fisseha N, Freire-Alvarez E,
Hauser RA, Jeong A, Jia J, Kukreja P, Soileau MJ, Spiegel AM,
foslevodopa/foscarbidopa subcutaneous Talapala S, Tarakad A, Urrea-Mendoza E, Zamudio J, Pahwa R.
infusion offer continuous dopaminergic Continuous subcutaneous foslevodopa/foscarbidopa infusion for the
treatment of motor fluctuations in Parkinson's disease:
stimulation, reducing fluctuations and Considerations for initiation and maintenance. Clin Park Relat Disord.
2024 Feb 10;10:100239. doi: 10.1016/j.prdoa.2024.100239.
improving patient quality of life. Compared to
LCIG and DBS, LDp/CDp provides a non-
surgical, convenient alternative with similar
efficacy. Lesioning procedures, particularly
MRI-guided focused ultrasound, offer
additional options for select patients. As
research continues, further refinements in
therapy delivery and individualized
approaches will enhance outcomes for PD Also k
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6
 Clinical case vignette
~ Dr. Pankhuri Saxena
Mr. X, a 72-years-old gentleman, retired accountant presented to the cognitive clinic with a two-years
history of progressive decline in his memory. Initially, he experienced mild forgetfulness and difficulty in
multitasking, which gradually worsened, associated with episodes of confusion, especially in the
evenings. His family reported he had also started seeing “things” around the house which were not really
there, and it had become more frequent recently. Although according to his wife, there were periods of
lucidity in between these episodes. She further added that there were nights, when she woke up from
sleep to find her husband loudly screaming or fidgeting around in his sleep. Over the past year, he
became slow in his daily activities and started experiencing frequent episodes of falls.
On examination, he was alert but restless. He scored a total 50 scores in ACE-III, with predominant
memory and visuospatial impairment. Cranial nerve examination was unremarkable. Motor examination
revealed bradykinesia, rigidity (more pronounced on the right side), and a stooped posture. His gait was
slow and shuffling. Deep tendon reflexes were normal, and the plantar response was flexor.

1. What is his most likely clinical diagnosis?

2. Define the core diagnostic criteria for this condition?

Clinical images
~ Dr. SurjitKumar Singh

1 2

A) What is the finding ? A) What is the finding ?

B) What is the treatment of the condition? B) Which type of proteinopathy is this ?

7
 Answers for last Issue
~ Compiled by Dr. Nikhil Choudhary
Dr. Arun Shankar

The clinical presentation suggests Infective Endocarditis (IE) in a patient with a history of
rheumatic heart disease (which predisposes him to valvular pathology). The presence of low-
grade fever, fatigue, weight loss, progressive dyspnea, bilateral lower limb swelling, and embolic
phenomena (splinter hemorrhages, petechiae) along with a loud diastolic murmur (suggesting
aortic regurgitation) and positive blood cultures for Streptococcus viridans strongly supports
this diagnosis.

Answer was given by

Dr. P. Aravind Babu, MD Geriatrics
Assistant Professor
Department of Geriatrics
Virudhunagar, Tamil Nadu

8
Source: Harrisons Principle of Internal Medicine, 21st Edition

Clinical Images answers

1.
A) Cardiac tamponade

just
B) Becks triad - Hypotension, Elevated JVP, Muffled heart sounds
OT
It’s N ents
em
2. mov
A) Fish mouth appearance of Mitral valve
B) Rheumatic heart disease - Mitral Stenosis

Parkinsons is MORE THAN JUST typical motor

symptoms.
The non-motor symptoms can help in early
detection of this condition.

Your NOSE knows…..Anosmia !!

GUT FEELINGS ?? Trust it!…..Constipation
DREAMS can really get scary!…REM sleep
behavioural disorder
BRAIN FOGGING is real!…Bradyphrenia or
slowed processing
The TINY HANDWRITING mystery
!!….Micrographia
MOOD SWINGS are true!….Depression and
Anxiety
The ICE EFFECT ?? Yes…..Hypomimia
GETTING DIZZY !!!…..Orthostatic Hypotension

9
 CREATIVE CORTEX
Pandemonium
~ Dr. Kritartha Kashyap
“How have you been?”
A question that people have been asking since the last two years.
My lips part and a familiar line comes out,
almost immediately,
“It’s getting better, Thanks.”;
followed by a nod and a hint of a smile.
Almost automated, rehearsed.
My eyes dart back to the table,
A puddle of freshly prepared tea
Clear enough to see my own reflection there,
grey, wrinkled, with eyes I don’t recognise myself.
I stare at its pupil, dark, hollow
and it slowly shape shifts into a saucer,
another me trying to pick it up.
”Don’t!!!…..” I make almost a muffled cry.
Too late! I watch as a 8.2 richter quake jolts my body.
The saucer shattering into pieces;
sharp enough to cut through the silence of the room.
Tearing through the open door,
that’s been waiting forever for the return of a memory.
I look through it, another me,
Trying to get on my coat. For what ?
Probably the funeral of my memories!
The world suddenly slows down;
And I get pulled back,
Like a million hands tugging at my back.
Why is there no one to help me?
The world spins and wham!!!
“Papa!!!” I suddenly wake up to the familiar face, concerned.
“He asked you how you’ve been?”
And I hear the crisp scribbling of a pen go….
“Let us try increasing the dose.”
Another voice goes.
Maybe he’s right! Because in reality,
I haven’t really been well.

10
 FLASHLIGHT

~Contributed by
Dr. Dipesh Jha

AC
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Got a knack for photography ?

Then hurry up and send in your sition
ing third po
submissions to in rece
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S S a i S ach u iz h eld by D
[email protected] D r. V D ay Q
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in Wor ulm onary M
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11
 DEPARTMENT STATISTICS
January - March

Gender wise distribution Age category wise distribution

Co-morbidities distribution Distribution of Malignancies

MDR organisms isolated Patients discharged succesfully

12
 PHOTO GALLERY

Snippets from 2nd Annual

anniversary celebration of the
Department!!
“Still miles to go….”

“Yaadein sath reh jaati hain…” We bid adieu to few, with a promise to meet again

Mrs. Anita Gaira, Ms. Pragati Negi, Nursing

Dr. Sudeep Mathew George, Senior Resident Dr. Tabassum Firdaus, Junior Resident Officers

13
SEND IN YOUR SUBMISSIONS Chief Patron:
Prof. Meenu Singh,
Director, AIIMS Rishikesh
If you know the answers to the above asked
questions, kindly mail us your answers with your
name and department. Correct answers win a Patron:
SHOUT-OUT on subsequent issues of the Prof. Jaya Chaturvedi,
newsletter. Dean, AIIMS Rishikesh

If you don’t know the answers, well wait for it in the

President:
next issue. Do you have a talent for writing,
Prof. Minakshi Dhar,
whether it’s in scientific or creative fields ? Show
Professor and Head,
off your skills in our newsletter! We’re accepting
Geriatric Medicine
submissions for Creative sections. Send us your
essays, stories, memoirs, poetry, prose or artwork
at [email protected]
Editor-in-chief:
Dr. Monika Pathania,
We hope you’ve enjoyed this edition of “SILVER
Additional Professor,
LINING”. We value your feedback and would love to
Geriatric Medicine
hear about your experience. Contact us for any
queries or feedback at
Editorial Board:
[email protected]
Senior Residents:
Dr. Kritartha Kashyap
Dr. Parul Bhutani
Our next issue is going to be released on July 1st. Contributors:
That’s right!! On “Doctor’s Day”. We heartily Senior Resident:
welcome any kind of creative or scientific entries, Dr. Dipesh Jha
personal experiences on this occasion. So hurry up Junior Residents:
and send in your submissions on or before June 1st.
Dr. Pankhuri Saxena
Show your talent through our newsletter.
Dr. Nikhil Chaudhary
Happy Reading !!
Dr. Surjit Kumar Singh
Dr. Arun Shankar
 APRIL 2025 ISSUE

SILVER LINING
DEPARTMENT OF GERIATRIC MEDICINE
ALL INDIA INSTITUTE OF MEDICAL SCIENCES
RISHIKESH, UTTARAKHAND
249203

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