Vascular & Infectious & Neoplastic
Gradual onset symptoms are less typical but could indicate chronic microvascular changes affecting motor coordination.
Stroke (subtle lacunar infarct)
Classic features include bradykinesia, tremor, and postural instability; soft voice (hypophonia) and masked facies.
Parkinson’s disease
Chronic demyelination can result in cerebellar dysfunction and gait abnormalities.
Multiple sclerosis
Slowed reflexes, bradykinesia, and mental fog could mimic Parkinsonism; screen with TSH.
Hypothyroidism
Dopamine-blocking drugs can cause Parkinsonism; even prior use may have residual effects.
Medication side effect (antipsychotics, anti-emetics)
Could contribute to progressive motor slowing and gait instability in older adults.
Chronic small vessel ischemia
Tremor typically improves with movement, unlike Parkinson’s rest tremor.
Essential tremor
Typically presents earlier in life, but late-onset cases are possible; family history might help guide diagnosis.
Spinocerebellar ataxias (SCA)
Deficiency states can lead to ataxia, paresthesia, and weakness; often reversible with supplementation.
Vitamin deficiencies (B12, E)
Polypharmacy in the elderly may lead to motor slowing or tremor.
Cumulative effect of multiple medications
Rare but characterized by progressive ataxia and sensory deficits; requires consideration in cases with coordination issues.
Tabes dorsalis (tertiary syphilis)
Progressive motor neuron disease affecting both upper and lower motor neurons; usually involves weakness and atrophy early.
Amyotrophic lateral sclerosis (ALS)
Rare but may cause progressive cerebellar dysfunction; can be triggered by infections or paraneoplastic processes.
Autoimmune cerebellitis
Rare but may cause tremor and coordination issues; check for Kayser-Fleischer rings and ceruloplasmin levels.
Wilson’s disease
Tumors affecting the cerebellum can impair motor coordination and balance over time.
Cerebellar tumor
Features overlap with Parkinson’s disease but with autonomic dysfunction and more rapid progression.
Multisystem atrophy (MSA)
History of heavy drinking, even remote, can lead to cerebellar degeneration; "split a bottle" hints at the possibility.
Chronic alcohol use
Remote effects of cancer can manifest with cerebellar or motor dysfunction.
Paraneoplastic syndrome
Triad of gait disturbance, cognitive decline, and urinary incontinence.
Normal pressure hydrocephalus (NPH)
Industrial exposure to heavy metals or solvents may cause motor and cognitive changes.
Toxin exposure