Red Flag Symptoms - Tremor

The underlying cause of this symptom should be determined, says Dr Pipin Singh.

CT scan of Parkinson’s disease (Photograph: SPL)
CT scan of Parkinson’s disease (Photograph: SPL)

Tremor is an involuntary movement of one or more body parts, commonly the hands. It can also affect the legs, face and trunk.

It is important to have a basic understanding of common aetiologies, classification and assessment of tremor, treatments in primary care and recognition of when to refer.

Important features in the history include onset, times at which the tremor is worse, body parts affected, associated neurological symptoms and a drug and alcohol history.

If thyrotoxicosis is suspected, ask about weight loss, change in bowel habit, intolerance to temperature extremes and neck swellings. Anxiety may be a contributing factor.

Intention tremor
Intention tremor is associated with pathology related to the cerebellum. This is a large amplitude tremor that is worse on reaching for something. It may also be associated with other cerebellar signs.

These can include dysdiadokinesia, truncal ataxia, nystagmus, staccato speech and hypotonia. Enquire about any family history of neurological conditions. Cerebellar signs warrant referral to a neurologist for further assessment.

Possible causes
  • Benign essential tremor.
  • Parkinson's disease.
  • Cerebellar lesion.
  • Thyrotoxicosis.
  • Anxiety.

Resting tremor
The presence of resting tremor should alert the physician to a diagnosis of Parkinson's disease (PD) or causes of parkinsonism, such as antipsychotics.

Symptoms suggestive of PD include cogwheel ridigity on examination, postural instability, bradykinesia and micrographia.

Additional conditions may include postural hypotension (suggestive of progressive supranuclear palsy) dementia and depression.

If PD is suspected then an urgent referral to a specialist is essential.

Exaggerated physiological response

Exaggerated physiological response can be normal but is also caused by thyrotoxicosis, anxiety and medications, such as tricyclic antidepressants, beta agonists and alcohol withdrawal. Caffeine can also lead to tremor.

Essential tremor
Essential tremor is a common cause of tremor and not present at rest. It generally appears when the affected body part is used or in certain positions. There is a genetic predisposition to this and generally no other neurological symptoms are associated. Patients can feel very embarrassed by their symptoms and this can affect the ability to function on a daily basis, particularly at work.

Treatment options may include medication such as betablockers. Safe use of alcohol can be permitted.

Investigating tremor in primary care
History and examination are the crucial components but investigations may include:

  • Bloods (U&Es and TFTs).
  • Hospital anxiety and depression score.

Dr Singh is a GP in Northumberland

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