Tremor Tremor has many different causes. If it is a primary tremor, you do not have to treat it unless it is functionally limiting or embarassing for the patient. If it is a secondary tremor, you can treat the underlying cause. Characterize Tremor Onset of Tremor During hospitalization (Toxic/metabolic causes common)
Prior to hospitalization
If tremor involving upper extremities Present at rest
Unilateral (PD)
Bilateral (PD or moderate-severe essential tremor)
If any of the above checked, do Parkinsonism screen: Present with action (ET, physiologic tremor, cerebellar tremor, drug-induced)
Postural (occurs when body part maintained against gravity)
Kinetic (occurs with any form of voluntary movement)
Intention (subtype of kinetic tremor, increased amplitude as target reached, cerebellar tremor)
Triggered by certain task, e.g. writing, playing instrument, etc. (Task-specific tremor)
If tremor involving other body parts Head tremor (essential tremor, midline cerebellar lesion)
Voice or lip tremor (essential tremor)
Jaw tremor (PD)
Resting leg tremor (PD)
Determining Underlying Etiology Exacerbating/Alleviating Factors Triggered only upon standing and improved when walking (orthostatic tremor)
Worsened by caffeine/fatigue and improved with alcohol (ET)
Medical History History of hyperthyroidism (enhanced physiologic tremor)
History of liver and/or kidney disease (metabolic myoclonus)
History of cerebellar or brainstem abnormality (cerebellar/rubral tremor)
History of cardiac or respiratory arrest (post-anoxic/hypoxic myoclonus)
History of liver disease and/or psychiatric symptoms (Wilson’s Disease)
Vascular risk factors + acute onset, unilateral abnormal movements (BG stroke)
Active Problems Hypoglycemia (enhanced physiologic tremor)
Non-ketotic hyperglycemia (hemi-chorea/hemi-ballismus)
Acute alcohol or opioid withdrawal (enhanced physiologic tremor)
Pregnant or Postpartum + new onset writhing movements/restlessness (chorea gravidarum)
Neuro-psychiatric symptoms and family hx of psychiatric conditions and/or movement disorders (HD)
Rapidly progressive dementia with myoclonus (CJD)
Medications/Substance Use Recent initiation of serotonergic medication (serotonin syndrome)
History of methamphetamine abuse (increased risk of PD)
Recent use of dopamine blockers (anti-emetics, anti-psychotics) (acute dystonic reaction, akathisia)
Chronic use of dopamine blockers (drug-induced parkinsonism, tardive dyskinesia)
Drug-induced tremor: Amiodarone
Procainamide
Valproic acid
Prednisone
Dexamethasone
Albuterol
Methylphenidate
Lithium
SSRIs
SNRIs
TCAs
Cyclosporine
Tacrolimus
Theophylline
Cytarabine
Should You Treat Functionally limiting, embarrassing, or interferes with ADL’s (indication for treatment)