Essential Tremor

Question 1

Is essential tremor common?

Answer 1

Yes, one of the most common movement disorders in adults

Question 2

What age does it typically effect?

Answer 2

Can effect anyone from childhood to old age, but prevelance increases significantly with age

Question 3

Is it considered benign?

Answer 3

Yes but can be serious enough to limit functional capacity and cause severe lifestyle limitations

Question 4

Is it more common in men or women?

Answer 4

Equal

Question 5

What causes it?

Answer 5

Unknown - likely related to genetics, age, environmental toxins

Question 6

Does the severity increase with age?

Answer 6

Yes - it is a chronic, progressive condition

Question 7

Is there often a family history?

Answer 7

Yes - approximately 50% have a FH of ET
First degree relatives about 5x more likely to dev contain than general population
Early onset (before 40) almost always a FH

Question 8

What is the likely inheritance pattern?

Answer 8

Autosomal dominant

Question 9

Is it the most common cause of action tremor in adults?

Answer 9

Yes

Question 10

Describe the features

Answer 10

Upper extremity tremor - particularly hands and arms
Exacerbated by intentional movements, usually absent at rest
Worsen on holding arms outstretched and on finger nose testing
Can progress to involve trunk, voice, head

Question 11

Describe head tremor

Answer 11

Vertical 25%

Horizontal 75%

Question 12

What is head tremor also called?

Answer 12

Titubation - essential tremor is most common cause

Question 13

What is the tremor frequency?

Answer 13

Moderate to high

6-12 Hz

Question 14

What are relieving factors?

Answer 14

Alcohol

Question 15

What are exacerbating factors?

Answer 15

Anxiety
Excitement
Adrenergic stimulation

Question 16

What other neurological features are there?

Answer 16

Tremor usually only one
Small number: ‘soft neurological signs’ - difficulty with tandem gait, mild cognitive impairment (typically memory), slight resting tremor

= essential tremor plus

Question 17

How is diagnosed?

Answer 17

Clinically
4 criteria:
- isolated tremor: bilateral upper limb action tremor, with no other significant motor abnormalities
- greater than 3 years
- with/without tremor in other locations
- absence of other neurological signs e.g dystonia, ataxia, Parkinsonism

Question 18

What routine tests are done to exclude common treatable causes of a physiological tremor?

Answer 18

Electrolytes and urea - hypocalcaemia can cause tremor
TFT - hyperthyroidism

If other signs/symptoms of Wilson disease: serum ceruloplasmin and serum copper (low ceruloplasmin and high copper)

Question 19

What is Wilson’s disease and why should it be considered if patient has a tremor?

Answer 19

Genetic disorder - abnormally high levels of copper, which accumulates in organs including eyes, brain, liver
Symptoms include: jaundice, liver failure, tremors in arms, legs and head, bradykinesia, problems with language and speech, psychiatric symptoms

Question 20

What differentials are there for essential tremor?

Answer 20

Parkinson’s disease
Dystonic head tremor - isolated head and voice tremor
Spasmodic dysphonia - isolated tremor of voice
Physiological
Cerebellar related
Wilson disease

Question 21

Describe the tremor differences to PD

Answer 21

In PD, typically at rest
Both may affect head, up PD tends to affect lips and jaw whereas ET tends to affect head itself
Lower limb tremor uncommon in ET
PD typically presents with unilateral tremor, whereas ET bilateral
PD may have other features of the condition

Question 22

Describe the differences with physiological tremor

Answer 22

Physiological tremor exacerbated by caffeine, ET is not
Typically physiological tremor has an identifiable cause e.g muscle fatigue, fever, hypoglycaemia, withdrawal from substances, secondary to medications
Present with a shorter duration of tremor, ET tend to present after many years

Question 23

How is it managed?

Answer 23

Depends on severity and impact on life
First line: propranolol or primidone - reduce by 50%, unlike to subside completely
If required, both at same time
Second line: gabapentin, nimodipine, topiramate