What is the approach to history taking in a patient with tremors?

From the Guidelines

When taking a history from a patient with tremors, it is crucial to focus on characterizing the tremor and identifying potential causes, as this approach helps distinguish between common causes like essential tremor, Parkinson's disease, medication effects, or physiologic tremor, guiding appropriate management strategies. To achieve this, begin by determining the tremor's onset, duration, and progression, as outlined in the 2020 occupational therapy consensus recommendations for functional neurological disorder 1. Ask about the specific location (hands, head, voice, etc.), whether it occurs at rest or with action, and any exacerbating or relieving factors such as stress, caffeine, or alcohol. Inquire about associated symptoms like balance problems, stiffness, or speech changes. A thorough medication history is essential, as many drugs can cause tremors, including beta-agonists, antipsychotics, antidepressants, and stimulants, as noted in the 2019 acc/aha/hrs guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay 2. Document family history of tremors or neurological disorders, as conditions like essential tremor are often hereditary. Ask about past medical history, particularly thyroid disease, stroke, or liver disease. Assess the impact on daily activities and quality of life, considering the patient's characteristics, expectations, and preferences, as emphasized in the 2023 European Association of Urology guidelines on the management of non-neurogenic male lower urinary tract symptoms 3. Note any sleep disturbances, anxiety, or depression. A comprehensive social history should cover alcohol use (including withdrawal), smoking, and caffeine intake. Some key points to consider when taking a history from a patient with tremors include:

• Characterizing the tremor and identifying potential causes
• Determining the tremor's onset, duration, and progression
• Asking about associated symptoms and exacerbating or relieving factors
• Conducting a thorough medication history
• Documenting family history of tremors or neurological disorders
• Assessing the impact on daily activities and quality of life
• Considering the patient's characteristics, expectations, and preferences
• Noting any sleep disturbances, anxiety, or depression
• Covering alcohol use, smoking, and caffeine intake in the social history. By following this approach, healthcare providers can gather essential information to guide the diagnosis and management of patients with tremors, ultimately improving their morbidity, mortality, and quality of life.

From the Research

History Taking in Patients with Tremors

When taking a history from a patient with tremors, it is essential to consider the following factors:

• The type of tremor: action tremor (postural, kinetic, or intention tremor) or resting tremor 4, 5, 6
• The activation condition: when the tremor occurs, such as at rest or with voluntary movement 4, 5, 6
• The topographic distribution: which body parts are affected by the tremor 4, 5, 6
• The frequency: how often the tremor occurs 4, 5, 6

Common Types of Tremors

The most common types of tremors include:

• Essential tremor: a pathologic tremor that affects 0.4% to 6% of the population, often transmitted in an autosomal-dominant fashion 4
• Parkinsonian tremor: typically unilateral, occurs at rest, and becomes less prominent with voluntary movement 4, 7, 8
• Enhanced physiologic tremor: can be caused by anxiety, medication use, caffeine intake, or fatigue 4
• Psychogenic tremor: characterized by abrupt onset, spontaneous remission, changing tremor characteristics, and extinction with distraction 4

Diagnostic Approach

The diagnostic approach to tremors involves:

• A detailed tremor history 5, 6
• A focused neurologic examination to establish the type of tremor and its characteristics 5, 6
• Formulating differential diagnoses based on the type of tremor: action tremor or resting tremor 5, 6
• Considering other diagnostic tests, such as single-photon emission computed tomography or transcranial ultrasonography, if necessary 4