Dr Tanvir Jamil discusses
Ron is a 45-year-old publican and comes to see you during the afternoon surgery. He has developed a tremor in his right hand which occasionally worsens in certain positions. It's often not present if he keeps still. He also tells you that his grandfather always had ‘trembling hands' ever since he could remember. You notice that Ron has had a few pints before coming to the surgery.
I think this is a tremor caused by alcoholism – can we go home now please?
Hang on a second. What happened to ideas, concerns and expectations? Why has the patient come to the surgery today? What are they worried about and what do they think is going on? It sounds a little MRCGPish but it works.
Ron may be worried about significant disease such as Parkinson's or perhaps his tremor is interfering with his drinking.
What kind of questions do I need to ask about the tremor itself?
There are many different types of tremors and a good history will often clinch the diagnosis:
• A resting tremor alleviated by movement indicates Parkinson's.
• Intention tremor can interfere with the patient's lifestyle and/or work. It is usually indicative of cerebellar disease, especially if accompanied by dysarthria and nystagmus.
• Postural tremors occur when the limbs are held in a certain position and worsen as greater precision is required, although never as severe as intention tremor. Examples include:
– Physiologic tremor: hyperthyroidism, anxiety, withdrawal states
– Benign essential tremor: often familial, often affects hands, head and neck, trunk, face, jaw, tongue and voice. Spares the lower limbs. The tremor may be a rhythmic ‘back-and-forth' or ‘to-and-fro' movement. Severity of the tremor can vary greatly from hour to hour and day to day. The tremor is often suppressed by small amounts of alcohol (large amounts can suppress other tremors also).
What about other symptoms that might point to the cause of the tremor?
Tremor accompanied by weight loss, palpitations and complaints of feeling hot and sweaty point to hyperthyroidism. Patients with anxiety may only complain of palpitations. Patients with benign essential tremor have no other linked symptoms.
Is it worth taking a drug history?
Drugs can certainly play a part in tremor. Some cause an exacerbation of physiologic tremor, eg Fluoxetine, haloperidol, metoclopromide, theophylline and sodium valproate. Caffeine can also have the same effect. ß-agonists, lithium and opiate withdrawal can all cause postural tremors.
What are some of the main concerns that Ron might have?
Patients often get embarrassed by their tremor, others worry that it may indicate serious disease.
Familial essential tremor can present in the 40s and sometimes even earlier. Understandably these patients need a lot of reassurance.
What are the key indicators to look for during the physical examination and what do they point to?
• Patient well and positive family history
– familial tremor.
• Smells of alcohol? – high suspicion in elderly men living alone.
• Mask-like facies, bradykinesia, postural instability, rigidity and festinant gait indicate Parkinson's.
• Pill-rolling tremor – Parkinson's.
• Intention tremor – cerebellar dysfunction.
• Abnormal gait and co-ordination, nystagmus, dysarthria – cerebellar dysfunction.
• Tachycardia – hyperthyroidism, anxiety or drug withdrawal.
Which investigations do I need to organise?
• Full blood count – look for macrocytosis (alcohol abuse).
• Thyroid function – may indicate hyperthyroidism.
• Liver function – indicates alcohol abuse and/or liver failure.
• Urea and electrolytes – look for renal failure.
• Serum caeruloplasmin/blood copper – look for Wilson's disease.
What kind of investigations might a specialist carry out in hospital?
• MRI – looking for CNS demyelination and tumours.
• Lumbar puncture – CSF electrophoresis may reveal MS; look for meningoncephalitis.
• Visual evoked potentials – prolonged in MS.
• Blood gases – look for carbon dioxide retention.
• Syphilis serology.
I find the drug options in Parkinson's a little confusing – any useful pointers?
Some GPs feel confident in initiating treatment for Parkinson's while others prefer to have the diagnosis confirmed by a specialist. Levodopa reduces tremor as well as improving bradykinesia and rigidity. When tremor is the predominant symptom or when it persists, an anticholinergic (eg benzhexol or benzatropine) may help.
Side-effects of these drugs – blurred vision, dry mouth, urinary problems, hallucinations and memory impairment – can be a limiting factor. Other drugs, mainly initiated by specialists, are helpful in patients whose tremor responds poorly to levodopa alone. These drugs include amantadine and dopamine agonists (eg pergolide, pramipexole, ropinirole, and bromocriptine).
Should I refer every case of tremor I see?
That's not a bad idea, although if it is very obvious that a patient has benign essential tremor then there is a lot you can do to help. Patients can be advised to use social tricks such as resting the hand on furniture to minimise the tremor.
Small amounts of alcohol can also relieve the tremor but this can lead to dependence. ß-blockers (eg propranolol 10-40mg up to qds) can often help. Diazepam or the anti-convulsant primidone are also useful if ß- blockers are contraindicated or ineffective. Patients who have tremor of the head and voice may be more resistant to treatment than patients with essential tremor of the hands.
Apart from the shaking, patients with benign essential tremor are usually fine?
Physically yes, psychologically often no. Essential tremor is a persistent and progressive condition. Only a small proportion of people seek medical advice. Most people with essential tremor are only mildly affected. However, most of the people who seek medical care are disabled to some extent, and many are socially handicapped by the tremor. A quarter of people receiving medical care for the tremor change jobs or retire because of essential tremor-induced disability.
Tanvir Jamil is a GP in Burnham, Bucks
• Parkinson's can present as frequent falls; look for other signs as well as tremor
• Anxiety and hyperthyroidism can mimic each other; have a low threshold for doing TFTs
• Drugs can often help tremor
• Consider referralThere are many different types of tremors and a good history will often clinch the diagnosis