Tremor
Tremor is caused by many disorders
Fine
Unlikely to have a neurological cause
Coarse
More likely to have a neurological cause
Consider:
- enhanced physiological tremor
- hyperthyroidism
- anxiety
- high-dose beta agonist use
- rest
- resting tremor, particularly asymmetrical, is suggestive of Parkinson's (PD)
- best seen with the arms relaxed on the thighs
- remember, many PD patients do not have tremor at all
- posture
- arms out in front, fingers slightly spread
- usually PD tremor will briefly vanish, then re-emerge
- abnormal posturing of the hand suggests dystonia
- action
- finger-nose testing
- tremor during these movements is not typical of PD
- site
- arms, legs, jaw - common in PD
- head tremor ("no-no"-;"yes-yes") is more likely to be essential or dystonic tremor, both of which are common and can look very like PD
Green Flags for PD
- slowness of movement MUST be present
- other motor symptoms to look out for:
- difficulty turning in bed
- dream enactment
- urinary urgency
- shuffling gait
- reduced arm swing
- non-motor clues:
- loss of smell
- depression
- dream enactment or fragmented sleep
- nocturia, urinary urgency, constipation
Red Flags for PD
- early hallucinations, cognitive decline - think dementia with Lewy bodies
- early falls - think progressive supranuclear palsy
- early autonomic symptoms - orthostatic hypotension, erectile dysfunction, bladder disturbance, odd nocturnal breathing patterns - think multiple system atrophy
- drugs - anti-emetics (stemetil, betahistine, metoclopramide), antipsychotics - think drug-induced
Referral Recommendations
- please refer all patients untreated for assessment
- diagnosis remains clinical and mis-diagnosis rates are high - please bear this in mind if planning to discuss your concerns with patients
- brain imaging is the exception rather than the rule
- all patients with suspected or confirmed PD will require long-term, specialist follow up