Tremors: Clinical workflow for PCPs

Clinical pearls for front-line PCPs

Philip A. Bain

A 76-year-old man makes an appointment for an evaluation of shakiness.

The patient’s past medical history is notable for hypertension, depression and mild COPD. Medications include lisinopril, sertraline and fluticasone/salmeterol.

As part of the rooming process, the medical assistant (MA) asks the patient specific questions about his shaking and documents the information about the shakiness using the smartphrase “.tremorMA.” The patient was asked to sign a HIPAA waiver, and the MA noted that the patient’s handwriting was completely illegible due to significant shaking of his right hand while signing.

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Source: Philip A. Bain, MD FACP

The MA asks the patient to sign and print his name and draw an Archimedes’ circle. She then summarizes the patient’s presentation for the primary care physician:

“Doc, this patient comes in for an evaluation of tremor. It seems to have gotten worse in the past year and now affects many aspects of his life, including signing his name (take a look at his HIPAA form) and holding a cup of coffee still. He no longer goes out to eat in public because he is so self-conscious about his shaking. In fact, he no longer plays cards with his buddies because of the shaking. The last time that he went out for lunch with his wife, he spilled his coffee all over the table and was mortified. He just wonders what can be done about his shaking.”

The PCP reviews the MA’s documentation and then evaluates the patient. She notes that he is on the above medications. He drinks 3 to 4 cups of coffee per day and two alcoholic drinks per day, often to “calm his nerves.” A few weeks ago, he was involved in a fender bender and with the stress of the accident, he shook significantly. He noted that his father and perhaps his brother had similar tremors as well.

On exam, the PCP notes that the patient is indeed very self-conscious about his tremor. He sits with his hands tightly clenched on his lap. The PCP drops her pen and when he reaches to pick it up, the tremor is readily apparent. The PCP asks the patient to reposition his arms with fifth fingers down and thumbs up to see if this provoked the tremors. She asks him to extend his arms out, holding it for 10 seconds. She then has him hold both outstretched arms to the side for 10 to 20 seconds. She asks him to walk from the exam table to the door, looking at his gait. She then asks him to touch the tip of his index finger to his nose, first one side and then the other. He asks for a glass of water and after she gives it to him, he spills half of it while attempting to drink from the glass.

The PCP makes the initial diagnosis of benign familial tremor (benign essential tremor with primary relatives with similar tremor).

Initial recommendations are as follows:

1. Since his mild COPD has been very stable, she asks him to cut down on his fluticasone/salmeterol inhaler to one puff per day for 1 week, then stop.
2. She asks him to slowly transition from 4 cups of caffeinated coffee per day to completely stopping caffeinated coffee and switching to decaf.
3. She refers the patient to occupational therapy to assess which activities of daily living (ADLs) are most affected by the tremor — drinking from a cup, buttoning his shirts and signing his checks — to see if there are “gadgets “that can help with ADLs.
4. She starts him on mysoline 25 mg nightly.

The patient returns in 6 weeks reporting a 25% improvement in his tremors. On the advice of his occupational therapist, he purchased a button helper, a foam rubber utensil handle, a coffee cup with a top on it with a small hole and an electronic signature stamp. She increases the mysoline to 50 mg nightly.

The patient returns every 6 to 12 weeks with an update. The PCP gradually tapered up on the mysoline until he was taking 100 mg nightly. This caused daytime grogginess and she lowered it back to 50 mg nightly and added low-dose propranolol 10 mg twice daily with an extra dose taken before an activity that likely would provoke increased shaking (such as tying a fly-fishing fly, playing cards, etc.).

At the 6-month anniversary from the first visit for tremors, the patient notes that his tremor is much better. In fact, he no longer thinks about it every day. He has started to go back out to eat lunch with his wife and has even started playing cards again with his buddies.

Lessons learned:

• Tremor is very common, especially in older patients.
• The most common causes are benign essential/familial tremor, Parkinson’s disease, physiologic tremor and intention (cerebellar) tremor. For an excellent short video regarding tremors, watch Stanford Medicine’s “Stanford 25: Approach to Tremor.”
• Eliminate or significantly reduce all nicotine, caffeine and alcohol.
• Pay attention to medications such as beta agonists, certain antidepressants, thyroid hormone replacement, lithium, valproic acid and amiodarone.
• First-line treatments for essential tremor include mysoline, beta blockers and gabapentin.
• Sometimes, lower doses of two medications are better tolerated than a higher dose of one medication.
• Have a tremor-specific physical exam in mind to differentiate between essential tremor, Parkinson’s disease, intention (cerebellar) tremor and physiologic tremor.
• Occupational therapists can be extremely helpful in identifying ADLs most affected by tremor and recommending helpful gadgets to make the ADLs easier.

If you have any suggestions to make this column more relevant to you, the front-line PCP, email primarycare@healio.com with the subject line “clinical pearls.”

References:

• Bhatia KP, et al. J Mov Disord. 2017;doi:10.1002/mds.27121.
• Essential tremor. https://www.ncbi.nlm.nih.gov/books/NBK499986/. Published July 11, 2022. Accessed April 20, 2023.
• Essential tremor (ET) and HopeNet. http://hopenet.org/. Accessed April 20, 2023.
• Essential tremor: What it is, causes, symptoms and treatment. https://my.clevelandclinic.org/health/diseases/11886-essential-tremor. Accessed April 20, 2023.
• Evaluation of patients with tremor. https://practicalneurology.com/articles/2018-may/evaluation-of-patients-with-tremor. Published May 2018. Accessed April 20, 2023.
• Improving function for individuals with essential tremor: An occupational therapy perspective. https://essentialtremor.org/resource/improving-function-for-individuals-with-essential-tremor-an-occupational-therapy-perspective/. Accessed April 14, 2023.
• International Essential Tremor Foundation. https://essentialtremor.org/. Accessed April 20, 2023.
• Overview of tremor. https://www.uptodate.com/contents/overview-of-tremor. Accessed April 20, 2023.
• Stanford 25: Approach to Tremor. https://stanfordmedicine25.stanford.edu/blog/archive/2013/Stanford-25-Approach-to-Tremor.html. Published Nov. 6, 2013. Accessed April 20, 2023.
• Tremor. https://www.parkinson.org/understanding-parkinsons/movement-symptoms/tremor. Accessed April 20, 2023.
• Tremor: Sorting through the differential diagnosis. https://www.aafp.org/pubs/afp/issues/2018/0201/p180.html. Published Feb. 1, 2018. Accessed April 20, 2023.