Essential Tremor Flashcards
Is essential tremor common?
Yes, one of the most common movement disorders in adults
What age does it typically effect?
Can effect anyone from childhood to old age, but prevelance increases significantly with age
Is it considered benign?
Yes but can be serious enough to limit functional capacity and cause severe lifestyle limitations
Is it more common in men or women?
Equal
What causes it?
Unknown - likely related to genetics, age, environmental toxins
Does the severity increase with age?
Yes - it is a chronic, progressive condition
Is there often a family history?
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
What is the likely inheritance pattern?
Autosomal dominant
Is it the most common cause of action tremor in adults?
Yes
Describe the features
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
Describe head tremor
Vertical 25%
Horizontal 75%
What is head tremor also called?
Titubation - essential tremor is most common cause
What is the tremor frequency?
Moderate to high
6-12 Hz
What are relieving factors?
Alcohol
What are exacerbating factors?
Anxiety
Excitement
Adrenergic stimulation
What other neurological features are there?
Tremor usually only one
Small number: ‘soft neurological signs’ - difficulty with tandem gait, mild cognitive impairment (typically memory), slight resting tremor
= essential tremor plus
How is diagnosed?
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
What routine tests are done to exclude common treatable causes of a physiological tremor?
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)
What is Wilson’s disease and why should it be considered if patient has a tremor?
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
What differentials are there for essential tremor?
Parkinson’s disease
Dystonic head tremor - isolated head and voice tremor
Spasmodic dysphonia - isolated tremor of voice
Physiological
Cerebellar related
Wilson disease
Describe the tremor differences to PD
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
Describe the differences with physiological tremor
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
How is it managed?
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
