Tremor

INTRODUCTION

Tremor is an important symptom to evaluate correctly. A common mistake is to misdiagnose the tremor of essential tremor for that of Parkinson disease.

CLASSIFICATION

Resting tremor—Parkinsonian

The tremor of Parkinson disease is present at rest. The hand tremor is most marked with the arms supported on the lap and during walking. The characteristic movement is ‘pill-rolling’. See 391.

Action or postural tremor

This fine tremor is noted by examining the patient with the arms outstretched and the fingers apart. Causes include:

• essential tremor (also called familial tremor or benign essential tremor)

• senile tremor

• physiological

• anxiety/emotional

• hyperthyroidism

• alcohol

• drugs (e.g. drug withdrawal—heroin, cocaine, alcohol, dexedrine, lithium)

Intention tremor (cerebellar disease)

This coarse oscillating tremor is absent at rest but exacerbated by action and increases as the target is approached. It is tested by ‘finger–nose–finger’ touching.

Flapping (metabolic tremor)

A flapping or ‘wing-beating’ tremor is observed when the arms are extended with hyperextension of the wrists. Typically caused by metabolic disorders such as uraemia, hepatic failure, Wilson syndrome and respiratory failure.

Essential tremor

Called benign, familial, senile or juvenile tremor.

Triad of features

• +ve family history

• Tremor with little disability, incl. head movement (titubation)

• Normal gait

Management

• Explanation and reassurance

• Drugs usually not needed

• Discreet use of alcohol beneficial

If necessary: propranolol (first choice) 10–40 mg (o) bd or primidone