Joel S. Hurwitz, MB, FRCPC, FRCP (London), Associate Professor, Department of Medicine (Division of Geriatric Medicine), University of Western Ontario, London, ON.

This article will assist the clinician in defining and categorizing tremor, also suggesting key questions and physical examination techniques to facilitate a probable diagnosis in an older adult. The role of many drugs in the causation and exacerbation of tremor is discussed and the treatment of several specific tremor disorders is reviewed.
Key words: essential tremor, postural tremor, kinetic tremor, enhanced physiological tremor, parkinsonism.

David J Burn, MD, MA, FRCP, Consultant & Senior Lecturer in Neurology, Regional Neurosciences Centre, Newcastle General Hospital, Westgate Road Newcastle upon Tyne, UK.

Ian G McKeith, MD, FRCPsych, Professor of Old Age Psychiatry, Department of Old Age Psychiatry, Institute for Ageing and Health Wolfson Research Centre, Newcastle General Hospital, Newcastle upon Tyne, UK.

Introduction
Parkinsonism is a common problem, particularly in the elderly. One percent of the population over the age of 65 has Parkinson's Disease (PD), rising to 2% over the age of 80. Parkinsonism is also a core feature of dementia with Lewy bodies (DLB), the second most common cause of neurodegenerative dementia, after Alzheimer disease (AD). To differentiate patients with PD who develop cognitive impairment from DLB, Consensus Criteria stipulate that parkinsonism must be present for 12 months or less for a patient with dementia to qualify for a diagnosis of DLB.¹ If the extrapyramidal features are present for longer than this before the dementia develops, the diagnosis is referred to as PD with dementia.

Although parkinsonism occurs in numerous other neurodegenerative diseases, including multiple system atrophy, progressive supranuclear palsy and corticobasal degeneration, as well as AD, hallucinations are less common.

Editors: Jolyon Meara and William C. Koller
Cambridge University Press, 2000
ISBN 0 521 62884 9

Reviewed by Barry Goldlist, MD, FRCPC, FACP

This text is a collaboration between chapter authors and editors from the United Kingdom and the United States.

Of late, there has been an explosion of knowledge and literature in the broad field of movement disorders, so to stand out from this field, the text would have to be well written and truly focus on the elderly. Many texts simply state "condition X" is common in the elderly, and then present a discussion that could have been lifted from any general textbook.

This book is certainly well written. The first chapter gives a glossary of terms that is helpful, particularly for a non-neurologist. The second chapter, on the diagnosis of parkinsonism in the elderly by Professor Rodnitzky, is extremely well written. The chapter is organized in a way that follows normal clinical reasoning, and although concise, contains more than enough information for a generalist physician. Reading this chapter made me feel I was in the company of a master clinician. The third chapter is also very good. Although the neuropathological basis of PD is not age-specific, the chapter discusses specific geriatric issues such as comorbidity, clinical heterogeneity, age-related pattern of disease presentation and the nature of a comprehensive geriatric assessment as it relates to patients with PD. Specific problems related to the elderly are also stressed. There are individual chapters on essential tremor, gait apraxia and epidemiology, and there has been a concerted effort to focus on the elderly. The relatively minimal amount of repetition in the chapters is further evidence of high quality editing.

The numerous chapters on the role of rehabilitation professionals in the care of elderly PD patients really distinguishes this book from a more general text, and might make this text suitable for general neurologists who want specific details about handling older PD patients. It is certainly of value for generalists and geriatricians who manage elderly patients with PD. It is also probably of interest and value to rehabilitation professionals who work with PD patients.

Drugs, Toxins and Pugilism May All Lead to PD-Like Symptoms

D'Arcy L. Little, MD, CCFP
Director of Medical Education
York Community Services,
Toronto, ON

Introduction
Diagnosing a patient with Parkinson's disease might, at first, seem to be straightforward. In some cases, a medical student can make the diagnosis from across a room. However, fully one quarter of the diagnoses of idiopathic Parkinson's, which were made clinically by specialists, were found upon pathological examination to be some other disease.^1,2,3 This figure is even higher in situations where the diagnosis was made in the early stages of the disease, by a non-specialist.³ Given that the list of conditions in the differential diagnosis of Parkinson's is vast, and the diagnosis is essentially a clinical one made by the process of elimination or exclusion, the clinician needs a solid approach when considering a diagnosis of this illness. The purpose of this review is to itemize an approach to the exclusion of cases of secondary parkinsonism, in the diagnosis of idiopathic Parkinson's disease (See Figure 1: Approach to Diagnosis of Parkinsonism). Table 1 lists clues that suggest a diagnosis of secondary parkinsonism.