Approach to Tremor 2018-01-30T16:36:27+08:00

Differential diagnosis

  • Endocrine
    • Hyperthyroidism
    • Phaeochromocytoma
    • Hypoglycaemia
  • Neurological
    • Parkinsonism
    • Cerebellar disease
  • Drugs
    • Caffeine
    • Salbutamol
    • Theophylline
    • Phenytoin
    • Lithium
    • Cyclosporine and tacrolimus
    • Alcohol (including alcohol withdrawal)
    • Illicit drugs (including drug withdrawal)
  • Wilson’s disease
  • Essential tremor
  • Psychological

Relevant points in the history

  • Tremor
    • When did you first notice it?
    • Is in in one hand or both?
    • Is it worse at rest or when you try to do something?
    • Does anything make it better?
    • Does anything make it worse?

Examination

  • Parkinsonism
    • Bradykinesia
    • Rigidity
    • Cogwheeling
    • Gait
    • Hypophonia
  • Cerebellar
    • Nystagmus
    • Intention tremor
    • Dysmetria
    • Dysdiadochokinesis
    • Staccato speech
  • Hyperthyroidism
    • Pulse
    • Ophthalmopathy
    • Lid lag
    • Goitre
    • Thyrocardiac disease
    • Pre-tibial myxoedema

 

Investigations

  • Full blood count, renal function and liver function if on drugs which may cause tremor
  • Cyclosporine / tacrolimus levels as tremor may be dose-dependent
  • Thyroid function tests
  • Blood sugar level (hypoglycaemia)
  • Consider plasma metanephrines if history suggestive of phaeochromocytoma
  • Consider magnetic resonance imaging of the brain if Parkinsonism present to rule out CVA, SOC

Management

  • Multidisciplinary
  • Patient education – e.g. avoid using laser pointers, computer mice
  • Occupational therapy for adjuncts, e.g. wrist weights
  • Withdrawal of offending drug
  • Essential tremor
    • Propranolol (40 – 240mg/day) or primidone (anticonvulsant) as a first line
    • May combine both if either not effective
  • Parkinsonism
    • Consider anti-cholinergics for tremor-predominant PD
    • Levodopa may improve other symptoms

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