PREFERRED PRACTICE PATTERN
A 40-year-old man presents to the psychiatry emergency room for inappropriate behavior and confusion. He works as a janitor and has had reasonably good work attendance. His coworkers say that he has appeared “fidgety” for several years. They specifically mention jerky movements that seem to affect his entire body more recently. His mother is alive and well, although his father died at age 28 in an auto accident. On examination, he is alert but easily distracted. His speech is fluent but is noted to be tangential. He has trouble with spelling the word “world” backwards and counting in serial sevens, but recalls three objects at 3 minutes. When he walks, there is a lot of distal hand movement, and his balance is precarious, although he can stand with both feet together for several seconds. His deep tendon reflexes are increased bilaterally, and there is bilateral ankle clonus. A urine drug screen is negative.2
Genetic dysfunction on fourth chromosome
Autosomal dominant inheritance
Characterized by choreoathetosis and dementia
Schematic representation of the sequence of neurons involved in Huntington disease. A. Dopaminergic neurons (red) originating in the substantia nigra normally inhibit the GABAergic output from the striatum (caudate and putamen), whereas cholinergic neurons (green) exert an excitatory effect. B. In Huntington disease, GABAergic neurons (black) are preferentially lost, resulting in reduced inhibitory output from the striatum. (From Aminoff MJ. Pharmacologic management of parkinsonism and other movement disorders. In: Katzung BG, Masters SB, Trevor AJ, eds. Basic and Clinical Pharmacology. 12th ed. New York, NY: McGraw-Hill; 2012.)
Adult onset generally in fourth or fifth decade of life
Early onset, not common but may occur in adolescence
Most common in people who are Caucasian of European ancestry
SIGNS AND SYMPTOMS
Slight but evident alteration in character initially, followed by issues of self-control, eventually leading to failure of all cognitive functions
Difficulty with attention and concentration, poor mental flexibility
Movement abnormalities begin in the hands and face, initial slowing of movement and loss of coordination, progressing ...
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