Tremor: Key Points

History (RACGP Approach)

• Onset, Duration, Progression: Acute vs. chronic development

• Location: Unilateral, bilateral, head involvement

• Pattern: Resting (at rest), postural (holding posture), intention (worsens with movement towards a target)

• Triggers: Caffeine, stress, alcohol (notably improves essential tremor)

• Family History: Autosomal dominant inheritance in essential tremor (ET)

• Medications: Including over-the-counter, possible drug-induced tremors

• Functional Impact: Effect on daily activities (writing, eating, social)

Types of Tremor

1. Resting Tremor (e.g., Parkinson’s Disease)

• Worst at rest, improves with voluntary movement.

• Often described as a “pill-rolling” tremor of the hands.

• More obvious with distraction (e.g. counting backward).

• Associated Parkinsonian features: Rigidity, bradykinesia, postural instability.

2. Action / Postural Tremors

Essential Tremor (ET)

• Onset typically >40 years.

• Often autosomal dominant pattern.

• Bilateral postural tremor, can persist during movement (slight amplitude increase).

• May involve the head (titubation) and affect speech/writing.

• Improves with alcohol, worsens with stimulants (caffeine).

• Normal gait (distinguishes it from cerebellar causes).

Other Causes of Action/Postural Tremor

• Hyperthyroidism

• Anxiety (adrenergic surge)

• Phaeochromocytoma

• Drug withdrawal: e.g., benzodiazepines, alcohol (in chronic use)

3. Intention Tremor

• Associated with cerebellar dysfunction (stroke, MS, mass lesion, chronic alcohol effects).

• Worsens as the limb approaches the target (finger-nose test).

• Cerebellar Signs:

  • Gait ataxia

  • Slurred speech (dysarthria)

  • Nystagmus

  • Dysmetria, dysdiadochokinesia