What is the history of tremors (Tremors) in this patient?

From the Guidelines

When taking a history for tremors, it is crucial to focus on characterizing the tremor type, onset, progression, and exacerbating factors to guide appropriate management strategies and improve patient outcomes in terms of morbidity, mortality, and quality of life. To achieve this, begin by asking when the tremor started, how it has evolved over time, and whether it affects one or both sides of the body. Determine if the tremor occurs at rest (like in Parkinson's disease), with sustained posture (essential tremor), or during intentional movement (cerebellar tremor) 1. Some key points to consider when taking a history for tremors include:

• Asking about family history of tremors, as essential tremor often has a hereditary component
• Inquiring about alcohol consumption, as essential tremor typically improves temporarily with alcohol
• Documenting all medications, as many drugs can cause tremors, including bronchodilators, antidepressants, lithium, valproic acid, and stimulants
• Asking about caffeine intake and stress levels, which can worsen physiologic tremors
• Exploring associated symptoms like bradykinesia or rigidity (suggesting parkinsonism), balance problems, or speech changes
• Questioning about impact on daily activities like writing, eating, or drinking
• Asking about previous treatments tried and their effectiveness This comprehensive history helps distinguish between common causes like essential tremor, Parkinson's disease, enhanced physiologic tremor, and medication-induced tremor, guiding appropriate management strategies 1. For example, in the case of essential tremor, propranolol has been used as a treatment for over 40 years, and other beta-blockers like metoprolol may also be effective depending on the case 1. In contrast, for Parkinson's disease, the clinical presentation is characterized by resting tremor, bradykinesia, and rigidity, and the estimated interval between initial loss of dopaminergic neurons and the appearance of symptoms is approximately 5 years 1. By prioritizing the most recent and highest quality studies, such as those published in 2022 and 2020 1, healthcare providers can make informed decisions about the best course of treatment for patients with tremors, ultimately improving their morbidity, mortality, and quality of life.

From the FDA Drug Label

Parkinson's disease is a progressive, neurodegenerative disorder of the extrapyramidal nervous system affecting the mobility and control of the skeletal muscular system. Its characteristic features include resting tremor, rigidity, and bradykinetic movements.

The key points to consider when taking a history of tremors in patients with Parkinson's disease are:

• Resting tremor: a characteristic feature of Parkinson's disease
• Rigidity: another characteristic feature of Parkinson's disease
• Bradykinetic movements: slow movements, also a characteristic feature of Parkinson's disease When evaluating a patient with a history of tremors, it is essential to consider these features and how they relate to Parkinson's disease. However, the provided drug labels do not directly answer the question of how to take a history of tremors. 2 3

From the Research

History Taking for Tremors

When taking a history for tremors, it is essential to consider the following factors:

• The location of the tremor, such as upper limbs, head, or voice 4, 5, 6, 7, 8
• The type of tremor, including essential tremor, Parkinson's disease, or other causes 7
• The severity of the tremor and its impact on daily activities 4, 5, 6, 8
• The presence of any associated symptoms, such as dystonic posturing of limbs 4
• The patient's medical history, including any previous treatments or responses to medications 5, 6, 8
• The patient's family history, as essential tremor can be hereditary 7

Essential Tremor

Essential tremor is the most common cause of tremor involving upper limbs, head, and voice 4. The first line of treatment for limb tremor is pharmacotherapy with propranolol or primidone 4, 5, 6, 8. However, these medications may only reduce tremor severity by half 4. Alternative forms of therapy, such as botulinum toxin injections or surgical interventions, may be considered for medication-refractory and functionally disabling tremor 4, 5, 6, 8.

Treatment Options

Treatment options for essential tremor include:

• Pharmacotherapy: propranolol, primidone, topiramate, alprazolam, and botulinum toxin type A 4, 5, 6, 8
• Surgical interventions: deep brain stimulation, magnetic resonance-guided focused ultrasound, and thalamotomy 4, 5, 6, 8
• Botulinum toxin injections for limb, voice, and head tremor 4, 5, 8