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Tremor...medical consulting

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Key Points about Tremor










Tremors can be classified based on when they occur—whether at rest (resting tremor) or when moving (action tremor)—and action tremors can be classified as those occurring at the end of a movement toward a target or during any voluntary movement (kinetic tremor) when moving toward a target (intention tremor) or when holding a limb outstretched (postural tremor).




Most tremors are physiologic (normal) tremors and some are essential tremor or are caused by other disorders.




Tremors that occur during rest are often caused by Parkinson disease.




Doctors can usually identify the cause based on the history and physical examination.




If a tremor begins suddenly or is accompanied by other neurologic symptoms people should see a doctor right away.




If people are under 50 have a tremor but do not have a family history of essential tremors they should see a doctor soon.




The cause of the tremor is treated if possible but otherwise some simple strategies (such as avoiding circumstances that trigger tremors) and sometimes drugs can help control the tremors.





Causes of Tremor











Many disorders can cause tremor.



Most commonly tremors are





Physiologic tremor (most common overall)




Essential tremor




Due to Parkinson disease




Due to a stroke or multiple sclerosis affecting parts of the brain that control movement




Due to severe liver disease




Due to alcohol withdrawal




Due to an overactive thyroid gland (hyperthyroidism)




Due to hereditary disorders involving the cerebellum such as Friedreich ataxia and spinocerebellar ataxias




Due to use of certain drugs or exposure to certain toxic substances




Psychogenic tremor (due to psychologic factors)






Sometimes there is more than one cause of the tremors. For example a person may have essential tremor and Parkinson disease.


Treatment of Tremor











Any specific cause of the tremor is treated when possible—for example by stopping a drug that is causing the tremor or by treating hyperthyroidism. Parkinson disease can be treated with levodopa and other drugs.



For mild tremor no treatment is needed. If tremors become bothersome some simple measures can help:





Grasping objects firmly and holding them close to the body to avoid dropping them




Avoiding uncomfortable positions




Avoiding other circumstances that trigger the tremor (such as consumption of caffeine lack of sleep or fatigue)




Using assistive devices as instructed by an occupational therapist






Assistive devices may include rocker knives utensils with large handles and particularly if the tremor is severe button hooks Velcro fasteners (instead of buttons or shoe laces) zipper pulls straws and shoe horns.

Physiologic tremor

Eliminating or minimizing the trigger may lessen the tremor. For example avoiding caffeine getting enough sleep and minimizing stress may help.



If many daily activities (such as using utensils and drinking from a glass at mealtime) become difficult or if the person's work requires steady hands drug therapy may help.



People with a physiologic tremor and anxiety may benefit from taking a low dose of a benzodiazepine (a sedative) such as lorazepam. However these drugs should be taken only occasionally.



If a physiologic tremor is worsened by taking prescribed drugs that are necessary or by feeling very anxious propranolol (a beta-blocker) may help.

Essential tremor

For some people drinking alcohol in moderation may lessen the tremor but doctors do not recommend this tactic as a treatment. Heavy drinking followed by suddenly stopping makes the tremor worse.



Antiseizure drugs (primidone topiramate or gabapentin) or propranolol may also be used if needed to control the tremor.



Benzodiazepines may be used to treat essential tremor if other drugs are ineffective.

Intention tremors

Intention tremors are difficult to treat but if the condition causing it can be corrected the tremor may resolve.



If the condition cannot be corrected a therapist may put wrist and ankle weights on the affected limb to reduce the tremor. Or people may be taught to brace the limb during activity. These measures sometimes help.

Deep brain stimulation

For this procedure tiny electrodes are placed in the area of the brain involved in tremors—the basal ganglia (collections of nerve cells that help smooth out muscle movements). The electrodes send small amounts of electricity to the specific area of the basal ganglia responsible for the tremors and thus help relieve symptoms.



Deep brain stimulation is sometimes done when drugs cannot control a severe disabling tremor. Sometimes essential tremors or tremors due to Parkinson disease or another disorder require such treatment. Such treatments are used only when drug therapy has been tried and has been not been effective. These treatments are available only at special centers.



Essentials for Older People: Tremor











Many older people think that developing a tremor is a part of normal aging and may not seek medical attention. Nonetheless older people should talk to their doctor who can ask them questions and do a physical examination to check for possible causes of tremor. Doctors may then recommend strategies or possibly drugs to lessen the tremor.



Also older people are more likely to be taking drugs that cause tremor and are more vulnerable to side effects of these drugs. Thus when prescribing such drugs to older people doctors try to prescribe the lowest effective dose. Such a dose may be lower than the doses used to treat younger adults. Doctors if possible avoid using anticholinergic drugs in older people.



Tremor can significantly affect quality of life in older people interfering with their ability to function especially if they have other physical or mental impairments. Physical and occupational therapists can provide simple coping strategies and assistive devices may help older people maintain quality of life.


Types of Tremors











Tremors can be





Normal (physiologic)




Abnormal (pathologic) caused by a disorder or drug






Tremors are usually classified based on when they occur:





Resting tremor: Occurring mainly at rest




Action tremor: Occurring when a body part is moved voluntarily






Action tremors include





Intention tremor: Triggered by movement toward a target (for example reaching for a glass)




Kinetic tremor: Appearing at the end of a movement toward a target or during any voluntary movement such as moving the wrists up and down or closing and opening the eyes




Postural tremor: Triggered by holding a limb outstretched in one position






Tremors can also be classified by what causes them as follows:





Physiologic (the normal tremors that everyone has to some degree)




Essential (a common hereditary disorder that rarely causes any other symptoms)




Cerebellar (caused by damage to part of the brain called the cerebellum)




Secondary (caused by a disorder or drug)




Psychogenic (caused by psychologic factors)






Other important characteristics of tremors are





How fast the shaking is (frequency): Slow to fast




How wide the movement is (amplitude): Fine to coarse




How often the tremor occurs: Intermittent to constant




How severe it is




How rapidly it appears: Sudden to gradual




Physiologic tremor

Physiologic tremor is the normal tremor that everyone has to some degree. For example most people's hands when held outstretched usually tremble slightly. Such slight rapid tremor reflects the precise moment-by-moment control of muscles by nerves. In most people the tremor is barely noticeable. However a normal tremor may become more noticeable under certain conditions and may worry people. For example the tremor may be more noticeable when people





Feel stressed or anxious




Are deprived of sleep




Stop drinking alcohol or taking a sedative (such as a benzodiazepine) or an opioid




Consume caffeine




Take certain drugs including theophylline and albuterol (which are used to treat asthma and chronic obstructive pulmonary disease or COPD) corticosteroids or recreational drugs (such as cocaine or amphetamines)




Have certain disorders such as an overactive thyroid gland (hyperthyroidism) that is causing other symptoms




Essential tremor

Essential tremor results from a problem in the nervous system but people with this tremor rarely have any other symptoms of nervous system dysfunction (neurologic symptoms). The cause is unclear but the tremor often runs in families.



Essential tremor usually begins during early adulthood but can begin at any age. The tremor slowly becomes more noticeable as people age. Thus it is sometimes incorrectly called senile tremor. The tremor usually involves the arms and hands and sometimes affects the head. When it affects the head people may look as if they are nodding yes or shaking their head no. These tremors are usually worsened by holding a limb outstretched (against gravity) or by moving a limb.



Usually essential tremor remains mild. However it can be troublesome and embarrassing. It can affect handwriting and make using utensils difficult. In some people the tremor gradually worsens over time eventually resulting in disability. Symptoms may resemble those of Parkinson disease and sometimes essential tremor is misdiagnosed as Parkinson disease. Rarely people have Parkinson disease and essential tremor.

Resting tremor

Resting tremor occurs when muscles are at rest. An arm or a leg shakes even when a person is completely relaxed. The tremor becomes less noticeable or disappears when the person moves the affected muscles. Resting tremors are often slow and coarse.



These tremors develop when nerve cells in the part of the brain called the basal ganglia are disturbed. The basal ganglia help initiate and smooth out intended (voluntary) muscle movements. Such disturbances usually result from





Parkinson disease or disorders that cause the same symptoms as Parkinson disease (parkinsonism)






However resting tremors can also result from use of drugs that can affect this part of the brain such as antipsychotic drugs and some drugs used to relieve nausea.



Resting tremors may be socially embarrassing but because they go away when people try to do something (such as drinking a glass of water) they typically do not interfere with daily activities.

Intention tremor

This tremor occurs during a purposeful movement as when reaching for an object with the hand. People may miss the object because of the tremor. Intention tremors worsen as people get closer to the targeted object. These tremors are relatively slow and wide (coarse).



Intention tremors result from damage to the cerebellum the part of the brain responsible for balance and coordination. Thus cerebellar tremor and intention tremor may be used as synonyms.



Common causes of intention tremor include





Certain hereditary disorders that affect the cerebellum (called spinocerebellar ataxias)




Multiple sclerosis






Other disorders and drugs can also cause the cerebellum to malfunction resulting in an intention tremor. They include





Stroke




A tumor




Alcoholism




Overuse of sedatives or antiseizure drugs











Did You Know...










Everyone has tremors to some degree.




If the tremor is mild some simple measures such as holding objects close to the body can make functioning easier.


















Postural tremor

This type of tremor is most obvious when a limb is held in a position that requires resisting the pull of gravity as when people hold their arms outstretched.



The most common postural tremors are





Essential tremor




Physiologic (normal) tremor




Complex tremor

Complex tremor is a tremor that has features of more than one type of tremor.



Common causes of complex tremors are





Psychologic factors




Widespread nerve damage such as that caused by diabetes or Guillain-Barré syndrome






Evaluation of Tremor











The following information can help people decide when a doctor's evaluation is needed and help them know what to expect during the evaluation.

Warning signs

The following symptoms are cause for concern:





Tremors that start abruptly




Tremors in people who are under 50 years old and have no relatives who have had essential tremors




Other neurologic symptoms such as a change in mental status muscle weakness changes in the way a person walks and difficulty speaking




A rapid heart rate and agitation




When to see a doctor

People with warning signs should see a doctor immediately.



People without warning signs should see a doctor as soon as possible.



If people are under 50 years old and do not have a family history of essential tremors they should see a doctor soon. Being evaluated by a doctor is important to make sure that the cause is not another disorder or a drug.

What a doctor does

Doctors first ask questions about the person's symptoms and medical history and then do a physical examination. What doctors find during the history and physical examination often suggests a cause and the tests that may need to be done (see table Some Causes and Features of Tremor).



Doctors ask about the tremor:





Whether the tremor began gradually or suddenly




Which body parts are affected




What triggers it (such as movement rest or standing)




What relieves or worsens it (such as alcohol caffeine stress or anxiety)











Did You Know...










Small amounts of alcohol may help relieve some types of tremors but chronic alcoholism can cause brain damage that results in a tremor.




















If the tremor began suddenly doctors ask about events that may have triggered it (such as a recent injury or use of a new drug).



Doctors review the person's past medical history looking for conditions associated with tremor. They ask about tremors in close relatives. They review the drugs taken and ask about use of caffeine alcohol and recreational drugs (particularly whether the person recently stopped using such drugs).



Doctors do a physical examination paying particular attention to the neurologic examination (including the way the person walks). Doctors note which body parts are affected by the tremor. They observe how fast the shaking movements are in various situations:





When the affected body parts are at rest and when they are fully supported (for example hands in the person's lap)




While the person maintains certain positions (such as holding the arms outstretched)




While the person is walking or doing tasks with the affected body part






The quality of the person's voice may be observed when holding a long note.



Doctors can usually identify the type of tremor based on its characteristics and results of the medical history and physical examination—for example





Tremors that develop gradually: Usually physiologic or essential tremor




A postural tremor that starts suddenly: Possibly psychologic factors a poison a disorder (such as hyperthyroidism) stopping use of alcohol or another drug (such as a sedative) or use of a drug known to cause tremor







Table










Some Causes and Features of Tremor






Cause




Features*




Tests








Postural tremor (tremor when a limb is held outstretched)






Alcohol or a sedative (such as a benzodiazepine) when use is stopped




Agitation and a fine tremor starting 24–72 hours after the last use of alcohol or a benzodiazepine



Sometimes high blood pressure a rapid heart rate or fever especially in people who are hospitalized




A doctor's examination






Drugs such as





Amitriptyline (an antidepressant)




Beta-adrenergic drugs (used to treat asthma)




Cocaine




Haloperidol (used to treat schizophrenia)




Lithium (used to treat bipolar disorder)




SSRIs (a type of antidepressant)




Tamoxifen (used to treat breast cancer)




Valproate (an antiseizure drug)







History of drug use




Stopping the drug to see whether the tremor goes away






Hormonal metabolic and toxic abnormalities that affect the brain:





Brain damage due to lack of oxygen (anoxic encephalopathy)




Liver failure (causing brain dysfunction called hepatic encephalopathy)




An overactive thyroid gland (hyperthyroidism)




Kidney failure (causing brain dysfunction called uremic encephalopathy




Overactive parathyroid glands (hyperparathyroidism)




Low blood sugar (hypoglycemia)




Poisons including heavy metals such as lead







A tremor plus one or more of the following:





Coma or lethargy (suggesting brain dysfunction)




Quick lightning-like muscle contractions (called myoclonus)




Symptoms of an underlying disorder such as hyperthyroidism






For hyperthyroidism: Difficulty tolerating heat excessive sweating an increased appetite weight loss bulging eyes and frequent bowel movements




Tests to help identify the cause such as blood tests





To evaluate how well the liver thyroid gland kidneys and parathyroid glands are functioning




To measure blood sugar




To check for poisons









Essential tremor




A coarse or fine slow tremor that





Worsens slowly over many years




Usually affects both arms and sometimes the head and voice




Often occurs in people with a family history of tremor






No other symptoms of nervous system malfunction




A doctor's examination






Physiologic tremor




A fine rapid tremor that





Occurs in otherwise healthy people




May become more noticeable when people take or stop taking certain drugs or feel stressed or anxious




Usually lessens when people drink small amounts of alcohol or take low doses of sedatives







A doctor's examination






Resting tremor






Parkinsonism triggered by a drug such as certain antipsychotic drugs and drugs used to relieve nausea




A history of drug use




Stopping the drug to see whether the tremor goes away






Parkinson disease




A slow alternating tremor that





Often involves moving the thumb against the index finger as if rolling moving small objects around (called pill rolling)




Sometimes also affects the chin or a leg




Usually starts on one side




Is accompanied by other symptoms such as muscle stiffness shaky and tiny handwriting slow movements and a shuffling walk






Often no family history of tremor and no lessening of tremor after drinking alcohol




A doctor's examination



Use of the drug levodopa to see whether improvement occurs






Progressive supranuclear palsy




A sometimes coarse or jerky tremor that is often inconspicuous



In older people who have difficulty looking down and eventually looking up muscle stiffness difficulty moving early falls and dementia




A doctor's examination






Intention tremor






Cerebellar disorders:





Chronic alcoholism




Friedreich ataxia




Hemorrhage




Head injury




Multiple sclerosis




Spinocerebellar ataxias




Stroke




Tumor







A slow tremor that





Usually occurs on one side of the body




Is accompanied by lack of coordination (ataxia) especially when attempting to touch or grasp a targeted object or perform rapid alternating movements




Affects the muscles used in speech making the voice tremble






In some people a family history of the disorder (as for Friedreich ataxia or spinocerebellar ataxias)




MRI of the brain






Drugs such as





Alcohol




Antiseizure drugs (such as phenytoin and valproate)




Beta-agonists




Cyclosporine




Lithium




Tacrolimus







A history of drug use




Stopping the drug to see whether the tremor goes away






Complex tremors






Disorders that affect many of the nerves outside the brain and spinal cord (polyneuropathies):





Guillain-Barré syndrome




Diabetes







A tremor that





Varies in speed and width




Often occurs when people reach for an object and worsens as they get closer to the object




Often worsens when people hold a limb outstretched




Is accompanied by other symptoms of nerve damage such as weakness a pins-and-needles sensation and loss of sensation







Electromyography (stimulating muscles and recording their electrical activity)



Other tests to identify the cause






Psychogenic tremor (due to psychologic factors)




A tremor that





Begins suddenly or may stop just as suddenly




Varies in speed and width




Lessens when people are distracted







A doctor's examination








* Features include symptoms and results of the doctor's examination. Features mentioned are typical but not always present.






MRI = magnetic resonance imaging; SSRIs = selective serotonin reuptake inhibitors (a type of antidepressant).















Testing

Brain imaging with magnetic resonance imaging (MRI) or computed tomography (CT) is done if





The person has other neurologic symptoms that suggest a brain disorder such as a stroke a tumor or multiple sclerosis.




The tremor started suddenly or progresses rapidly.






Blood tests may be done to check for possible causes when the cause is unclear. Tests may include





Measurement of blood sugar




Tests to evaluate how well the thyroid and parathyroid glands liver and kidneys are functioning






Electromyography (stimulating muscles and recording their electrical activity) is rarely done. But if the cause is thought to be nerve damage it may be done.



simple explanation



A tremor is an involuntary rhythmic shaking movement of part of the body such as the hands head vocal cords trunk or legs. Tremors occur when muscles repeatedly contract and relax.


(See also Overview of Movement Disorders.)


Tremors can be


Normal (physiologic)


Abnormal (pathologic) caused by a disorder or drug


Tremors are usually classified based on when they occur:


Resting tremor: Occurring mainly at rest


Action tremor: Occurring when a body part is moved voluntarily


Action tremors include


Intention tremor: Triggered by movement toward a target (for example reaching for a glass)


Kinetic tremor: Appearing at the end of a movement toward a target or during any voluntary movement such as moving the wrists up and down or closing and opening the eyes


Postural tremor: Triggered by holding a limb outstretched in one position


Tremors can also be classified by what causes them as follows:


Physiologic (the normal tremors that everyone has to some degree)


Essential (a common hereditary disorder that rarely causes any other symptoms)


Cerebellar (caused by damage to part of the brain called the cerebellum)


Secondary (caused by a disorder or drug)


Psychogenic (caused by psychologic factors)


Other important characteristics of tremors are


How fast the shaking is (frequency): Slow to fast


How wide the movement is (amplitude): Fine to coarse


How often the tremor occurs: Intermittent to constant


How severe it is


How rapidly it appears: Sudden to gradual


Physiologic tremor is the normal tremor that everyone has to some degree. For example most people's hands when held outstretched usually tremble slightly. Such slight rapid tremor reflects the precise moment-by-moment control of muscles by nerves. In most people the tremor is barely noticeable. However a normal tremor may become more noticeable under certain conditions and may worry people. For example the tremor may be more noticeable when people


Feel stressed or anxious


Are deprived of sleep


Stop drinking alcohol or taking a sedative (such as a benzodiazepine) or an opioid


Consume caffeine


Take certain drugs including theophylline and albuterol (which are used to treat asthma and chronic obstructive pulmonary disease or COPD) corticosteroids or recreational drugs (such as cocaine or amphetamines)


Have certain disorders such as an overactive thyroid gland (hyperthyroidism) that is causing other symptoms


Essential tremor results from a problem in the nervous system but people with this tremor rarely have any other symptoms of nervous system dysfunction (neurologic symptoms). The cause is unclear but the tremor often runs in families.


Essential tremor usually begins during early adulthood but can begin at any age. The tremor slowly becomes more noticeable as people age. Thus it is sometimes incorrectly called senile tremor. The tremor usually involves the arms and hands and sometimes affects the head. When it affects the head people may look as if they are nodding yes or shaking their head no. These tremors are usually worsened by holding a limb outstretched (against gravity) or by moving a limb.


Usually essential tremor remains mild. However it can be troublesome and embarrassing. It can affect handwriting and make using utensils difficult. In some people the tremor gradually worsens over time eventually resulting in disability. Symptoms may resemble those of Parkinson disease and sometimes essential tremor is misdiagnosed as Parkinson disease. Rarely people have Parkinson disease and essential tremor.


Resting tremor occurs when muscles are at rest. An arm or a leg shakes even when a person is completely relaxed. The tremor becomes less noticeable or disappears when the person moves the affected muscles. Resting tremors are often slow and coarse.


These tremors develop when nerve cells in the part of the brain called the basal ganglia are disturbed. The basal ganglia help initiate and smooth out intended (voluntary) muscle movements. Such disturbances usually result from


Parkinson disease or disorders that cause the same symptoms as Parkinson disease (parkinsonism)


However resting tremors can also result from use of drugs that can affect this part of the brain such as antipsychotic drugs and some drugs used to relieve nausea.


Resting tremors may be socially embarrassing but because they go away when people try to do something (such as drinking a glass of water) they typically do not interfere with daily activities.


This tremor occurs during a purposeful movement as when reaching for an object with the hand. People may miss the object because of the tremor. Intention tremors worsen as people get closer to the targeted object. These tremors are relatively slow and wide (coarse).


Intention tremors result from damage to the cerebellum the part of the brain responsible for balance and coordination. Thus cerebellar tremor and intention tremor may be used as synonyms.


Common causes of intention tremor include


Certain hereditary disorders that affect the cerebellum (called spinocerebellar ataxias)


Multiple sclerosis


Other disorders and drugs can also cause the cerebellum to malfunction resulting in an intention tremor. They include


Stroke


A tumor


Alcoholism


Overuse of sedatives or antiseizure drugs


Everyone has tremors to some degree.


If the tremor is mild some simple measures such as holding objects close to the body can make functioning easier.


This type of tremor is most obvious when a limb is held in a position that requires resisting the pull of gravity as when people hold their arms outstretched.


The most common postural tremors are


Essential tremor


Physiologic (normal) tremor


Complex tremor is a tremor that has features of more than one type of tremor.


Common causes of complex tremors are


Psychologic factors


Widespread nerve damage such as that caused by diabetes or Guillain-Barré syndrome


Many disorders can cause tremor.


Most commonly tremors are


Physiologic tremor (most common overall)


Essential tremor


Due to Parkinson disease


Due to a stroke or multiple sclerosis affecting parts of the brain that control movement


Due to severe liver disease


Due to alcohol withdrawal


Due to an overactive thyroid gland (hyperthyroidism)


Due to hereditary disorders involving the cerebellum such as Friedreich ataxia and spinocerebellar ataxias


Due to use of certain drugs or exposure to certain toxic substances


Psychogenic tremor (due to psychologic factors)


Sometimes there is more than one cause of the tremors. For example a person may have essential tremor and Parkinson disease.


The following information can help people decide when a doctor's evaluation is needed and help them know what to expect during the evaluation.


The following symptoms are cause for concern:


Tremors that start abruptly


Tremors in people who are under 50 years old and have no relatives who have had essential tremors


Other neurologic symptoms such as a change in mental status muscle weakness changes in the way a person walks and difficulty speaking


A rapid heart rate and agitation


People with warning signs should see a doctor immediately.


People without warning signs should see a doctor as soon as possible.


If people are under 50 years old and do not have a family history of essential tremors they should see a doctor soon. Being evaluated by a doctor is important to make sure that the cause is not another disorder or a drug.


Doctors first ask questions about the person's symptoms and medical history and then do a physical examination. What doctors find during the history and physical examination often suggests a cause and the tests that may need to be done (see table Some Causes and Features of Tremor).


Doctors ask about the tremor:


Whether the tremor began gradually or suddenly


Which body parts are affected


What triggers it (such as movement rest or standing)


What relieves or worsens it (such as alcohol caffeine stress or anxiety)


Small amounts of alcohol may help relieve some types of tremors but chronic alcoholism can cause brain damage that results in a tremor.


If the tremor began suddenly doctors ask about events that may have triggered it (such as a recent injury or use of a new drug).


Doctors review the person's past medical history looking for conditions associated with tremor. They ask about tremors in close relatives. They review the drugs taken and ask about use of caffeine alcohol and recreational drugs (particularly whether the person recently stopped using such drugs).


Doctors do a physical examination paying particular attention to the neurologic examination (including the way the person walks). Doctors note which body parts are affected by the tremor. They observe how fast the shaking movements are in various situations:


When the affected body parts are at rest and when they are fully supported (for example hands in the person's lap)


While the person maintains certain positions (such as holding the arms outstretched)


While the person is walking or doing tasks with the affected body part


The quality of the person's voice may be observed when holding a long note.


Doctors can usually identify the type of tremor based on its characteristics and results of the medical history and physical examination—for example


Tremors that develop gradually: Usually physiologic or essential tremor


A postural tremor that starts suddenly: Possibly psychologic factors a poison a disorder (such as hyperthyroidism) stopping use of alcohol or another drug (such as a sedative) or use of a drug known to cause tremor


Cause


Features*


Tests


Postural tremor (tremor when a limb is held outstretched)


Alcohol or a sedative (such as a benzodiazepine) when use is stopped


Agitation and a fine tremor starting 24–72 hours after the last use of alcohol or a benzodiazepine


Sometimes high blood pressure a rapid heart rate or fever especially in people who are hospitalized


A doctor's examination


Drugs such as


Amitriptyline (an antidepressant)


Beta-adrenergic drugs (used to treat asthma)


Cocaine


Haloperidol (used to treat schizophrenia)


Lithium (used to treat bipolar disorder)


SSRIs (a type of antidepressant)


Tamoxifen (used to treat breast cancer)


Valproate (an antiseizure drug)


History of drug use


Stopping the drug to see whether the tremor goes away


Hormonal metabolic and toxic abnormalities that affect the brain:


Brain damage due to lack of oxygen (anoxic encephalopathy)


Liver failure (causing brain dysfunction called hepatic encephalopathy)


An overactive thyroid gland (hyperthyroidism)


Kidney failure (causing brain dysfunction called uremic encephalopathy


Overactive parathyroid glands (hyperparathyroidism)


Low blood sugar (hypoglycemia)


Poisons including heavy metals such as lead


A tremor plus one or more of the following:


Coma or lethargy (suggesting brain dysfunction)


Quick lightning-like muscle contractions (called myoclonus)


Symptoms of an underlying disorder such as hyperthyroidism


For hyperthyroidism: Difficulty tolerating heat excessive sweating an increased appetite weight loss bulging eyes and frequent bowel movements


Tests to help identify the cause such as blood tests


To evaluate how well the liver thyroid gland kidneys and parathyroid glands are functioning


To measure blood sugar


To check for poisons


Essential tremor


A coarse or fine slow tremor that


Worsens slowly over many years


Usually affects both arms and sometimes the head and voice


Often occurs in people with a family history of tremor


No other symptoms of nervous system malfunction


A doctor's examination


Physiologic tremor


A fine rapid tremor that


Occurs in otherwise healthy people


May become more noticeable when people take or stop taking certain drugs or feel stressed or anxious


Usually lessens when people drink small amounts of alcohol or take low doses of sedatives


A doctor's examination


Resting tremor


Parkinsonism triggered by a drug such as certain antipsychotic drugs and drugs used to relieve nausea


A history of drug use


Stopping the drug to see whether the tremor goes away


Parkinson disease


A slow alternating tremor that


Often involves moving the thumb against the index finger as if rolling moving small objects around (called pill rolling)


Sometimes also affects the chin or a leg


Usually starts on one side


Is accompanied by other symptoms such as muscle stiffness shaky and tiny handwriting slow movements and a shuffling walk


Often no family history of tremor and no lessening of tremor after drinking alcohol


A doctor's examination


Use of the drug levodopa to see whether improvement occurs


Progressive supranuclear palsy


A sometimes coarse or jerky tremor that is often inconspicuous


In older people who have difficulty looking down and eventually looking up muscle stiffness difficulty moving early falls and dementia


A doctor's examination


Intention tremor


Cerebellar disorders:


Chronic alcoholism


Friedreich ataxia


Hemorrhage


Head injury


Multiple sclerosis


Spinocerebellar ataxias


Stroke


Tumor


A slow tremor that


Usually occurs on one side of the body


Is accompanied by lack of coordination (ataxia) especially when attempting to touch or grasp a targeted object or perform rapid alternating movements


Affects the muscles used in speech making the voice tremble


In some people a family history of the disorder (as for Friedreich ataxia or spinocerebellar ataxias)


MRI of the brain


Drugs such as


Alcohol


Antiseizure drugs (such as phenytoin and valproate)


Beta-agonists


Cyclosporine


Lithium


Tacrolimus


A history of drug use


Stopping the drug to see whether the tremor goes away


Complex tremors


Disorders that affect many of the nerves outside the brain and spinal cord (polyneuropathies):


Guillain-Barré syndrome


Diabetes


A tremor that


Varies in speed and width


Often occurs when people reach for an object and worsens as they get closer to the object


Often worsens when people hold a limb outstretched


Is accompanied by other symptoms of nerve damage such as weakness a pins-and-needles sensation and loss of sensation


Electromyography (stimulating muscles and recording their electrical activity)


Other tests to identify the cause


Psychogenic tremor (due to psychologic factors)


A tremor that


Begins suddenly or may stop just as suddenly


Varies in speed and width


Lessens when people are distracted


A doctor's examination


* Features include symptoms and results of the doctor's examination. Features mentioned are typical but not always present.


MRI = magnetic resonance imaging; SSRIs = selective serotonin reuptake inhibitors (a type of antidepressant).


Brain imaging with magnetic resonance imaging (MRI) or computed tomography (CT) is done if


The person has other neurologic symptoms that suggest a brain disorder such as a stroke a tumor or multiple sclerosis.


The tremor started suddenly or progresses rapidly.


Blood tests may be done to check for possible causes when the cause is unclear. Tests may include


Measurement of blood sugar


Tests to evaluate how well the thyroid and parathyroid glands liver and kidneys are functioning


Electromyography (stimulating muscles and recording their electrical activity) is rarely done. But if the cause is thought to be nerve damage it may be done.


Any specific cause of the tremor is treated when possible—for example by stopping a drug that is causing the tremor or by treating hyperthyroidism. Parkinson disease can be treated with levodopa and other drugs.


For mild tremor no treatment is needed. If tremors become bothersome some simple measures can help:


Grasping objects firmly and holding them close to the body to avoid dropping them


Avoiding uncomfortable positions


Avoiding other circumstances that trigger the tremor (such as consumption of caffeine lack of sleep or fatigue)


Using assistive devices as instructed by an occupational therapist


Assistive devices may include rocker knives utensils with large handles and particularly if the tremor is severe button hooks Velcro fasteners (instead of buttons or shoe laces) zipper pulls straws and shoe horns.


Eliminating or minimizing the trigger may lessen the tremor. For example avoiding caffeine getting enough sleep and minimizing stress may help.


If many daily activities (such as using utensils and drinking from a glass at mealtime) become difficult or if the person's work requires steady hands drug therapy may help.


People with a physiologic tremor and anxiety may benefit from taking a low dose of a benzodiazepine (a sedative) such as lorazepam. However these drugs should be taken only occasionally.


If a physiologic tremor is worsened by taking prescribed drugs that are necessary or by feeling very anxious propranolol (a beta-blocker) may help.


For some people drinking alcohol in moderation may lessen the tremor but doctors do not recommend this tactic as a treatment. Heavy drinking followed by suddenly stopping makes the tremor worse.


Antiseizure drugs (primidone topiramate or gabapentin) or propranolol may also be used if needed to control the tremor.


Benzodiazepines may be used to treat essential tremor if other drugs are ineffective.


Intention tremors are difficult to treat but if the condition causing it can be corrected the tremor may resolve.


If the condition cannot be corrected a therapist may put wrist and ankle weights on the affected limb to reduce the tremor. Or people may be taught to brace the limb during activity. These measures sometimes help.


For this procedure tiny electrodes are placed in the area of the brain involved in tremors—the basal ganglia (collections of nerve cells that help smooth out muscle movements). The electrodes send small amounts of electricity to the specific area of the basal ganglia responsible for the tremors and thus help relieve symptoms.


Deep brain stimulation is sometimes done when drugs cannot control a severe disabling tremor. Sometimes essential tremors or tremors due to Parkinson disease or another disorder require such treatment. Such treatments are used only when drug therapy has been tried and has been not been effective. These treatments are available only at special centers.


Many older people think that developing a tremor is a part of normal aging and may not seek medical attention. Nonetheless older people should talk to their doctor who can ask them questions and do a physical examination to check for possible causes of tremor. Doctors may then recommend strategies or possibly drugs to lessen the tremor.


Also older people are more likely to be taking drugs that cause tremor and are more vulnerable to side effects of these drugs. Thus when prescribing such drugs to older people doctors try to prescribe the lowest effective dose. Such a dose may be lower than the doses used to treat younger adults. Doctors if possible avoid using anticholinergic drugs in older people.


Tremor can significantly affect quality of life in older people interfering with their ability to function especially if they have other physical or mental impairments. Physical and occupational therapists can provide simple coping strategies and assistive devices may help older people maintain quality of life.


Tremors can be classified based on when they occur—whether at rest (resting tremor) or when moving (action tremor)—and action tremors can be classified as those occurring at the end of a movement toward a target or during any voluntary movement (kinetic tremor) when moving toward a target (intention tremor) or when holding a limb outstretched (postural tremor).


Most tremors are physiologic (normal) tremors and some are essential tremor or are caused by other disorders.


Tremors that occur during rest are often caused by Parkinson disease.


Doctors can usually identify the cause based on the history and physical examination.


If a tremor begins suddenly or is accompanied by other neurologic symptoms people should see a doctor right away.


If people are under 50 have a tremor but do not have a family history of essential tremors they should see a doctor soon.


The cause of the tremor is treated if possible but otherwise some simple strategies (such as avoiding circumstances that trigger tremors) and sometimes drugs can help control the tremors.
  • The Author: wikbe
 
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