Tremor 🤲
Guide to assessing tremor on the ward: classify rest vs action tremor, reversible causes, red flags, examination, investigations, and when to refer neurology.
🧭 Clinical workflow
- 1. Stabilise and triage on the phone: vitals, capillary glucose, new vs chronic tremor, rest/postural/action, distribution, rigidity/gait/ataxia/confusion, recent drugs and alcohol.
- 2. Classify the tremor using the table below. Distribution and triggers matter more than “how much it shakes”.
- 3. Treat reversible causes first (see next section). Do not give benzodiazepines by default; use only for alcohol withdrawal, severe agitation, or on senior advice.
- 4. Examine and investigate. Document tremor type, associated signs, and plan.
- 5. Escalate if red flags (below). Refer new rest tremor with parkinsonism, progressive tremor, or diagnostic uncertainty to neurology.
🔬 Tremor types at a glance
Parkinson's (rest)
- When prominent
- At rest; may lessen with voluntary movement
- Typical distribution
- Asymmetric rest tremor: hand, leg, chin
- Associated signs
- Bradykinesia, rigidity, reduced arm swing, masked face
- Think of
- New or progressive degenerative disease; drug-induced parkinsonism
Essential tremor
- When prominent
- Postural and kinetic: holding arms out, writing, pouring
- Typical distribution
- Bilateral hands ± head/voice; legs less common
- Associated signs
- Often family history; may improve slightly with alcohol
- Think of
- Known ET; anxiety; caffeine; thyrotoxicosis
Cerebellar (intention)
- When prominent
- During goal-directed movement near target
- Typical distribution
- Limbs ± trunk; wide-based gait if cerebellar syndrome
- Associated signs
- Dysmetria, dysdiadochokinesia, nystagmus, slurred speech
- Think of
- Stroke, MS, toxicity, alcohol-related cerebellar disease
Metabolic / drug-induced
- When prominent
- Variable; often postural/kinetic, may be generalised
- Typical distribution
- Generalised or hands; depends on cause
- Associated signs
- Thyrotoxicosis, agitation, confusion, tachycardia, myoclonus
- Think of
- Hypoglycaemia, alcohol withdrawal, thyrotoxicosis, electrolytes, lithium, antipsychotics, salbutamol, SSRIs, valproate, steroids
| Feature | Parkinson's (rest) | Essential tremor | Cerebellar (intention) | Metabolic / drug-induced |
|---|---|---|---|---|
| When prominent | At rest; may lessen with voluntary movement | Postural and kinetic: holding arms out, writing, pouring | During goal-directed movement near target | Variable; often postural/kinetic, may be generalised |
| Typical distribution | Asymmetric rest tremor: hand, leg, chin | Bilateral hands ± head/voice; legs less common | Limbs ± trunk; wide-based gait if cerebellar syndrome | Generalised or hands; depends on cause |
| Associated signs | Bradykinesia, rigidity, reduced arm swing, masked face | Often family history; may improve slightly with alcohol | Dysmetria, dysdiadochokinesia, nystagmus, slurred speech | Thyrotoxicosis, agitation, confusion, tachycardia, myoclonus |
| Think of | New or progressive degenerative disease; drug-induced parkinsonism | Known ET; anxiety; caffeine; thyrotoxicosis | Stroke, MS, toxicity, alcohol-related cerebellar disease | Hypoglycaemia, alcohol withdrawal, thyrotoxicosis, electrolytes, lithium, antipsychotics, salbutamol, SSRIs, valproate, steroids |
⚡ Reversible causes & ward management
- Hypoglycaemia: treat immediately per hypoglycaemia protocol.
- Alcohol withdrawal: withdrawal scale, thiamine (Pabrinex if indicated), senior-led benzodiazepine protocol, monitor obs. Do not use quetiapine for tremor alone.
- Thyrotoxicosis: check TFTs and treat cause.
- Sepsis / delirium: treat infection; see agitation/delirium topic.
- Drug-induced: review recent starts/dose changes; stop culprit if safe (discuss with senior/pharmacy). Avoid metoclopramide/prochlorperazine in suspected Parkinson’s.
- Electrolytes: correct hypomagnesaemia, hypocalcaemia, uraemia.
- Anxiety/caffeine: address trigger before labelling as primary neurological disease.
- Do not start levodopa without neurology diagnosis, except missed doses in established PD (confirm with team).
- Propranolol/primidone for ET: usually specialist/GP initiation unless known ET with clear continuation plan.
🚨 Red flags & neurology referral
- Acute focal neurology, headache, or reduced consciousness: urgent CT brain and senior review (?stroke, structural lesion). Phone neurology if still unwell.
- Fever, neck stiffness, or declining GCS: ?meningoencephalitis. Urgent senior and infectious workup.
- New rest tremor with bradykinesia/rigidity: ?parkinsonism. Neurology referral; exclude drug-induced cause.
- Severe autonomic instability with alcohol history: ?withdrawal or Wernicke’s. Thiamine and monitored benzodiazepines.
- Suspected lithium toxicity or ingestion: urgent levels and toxicology advice.
- Thyrotoxic storm features: emergency medical review.
- Progressive tremor, cerebellar syndrome, significant disability, or functional vs organic uncertainty: neurology referral per local pathway.
🩺 History & examination
- History: onset, progression, symmetry, functional impact, family history (ET, Parkinson’s), OTC/recreational drugs. Collateral if tremor fluctuates with attention (?functional; discuss with neurology).
- Rest tremor: hands in lap, “pill-rolling”, ~4–6 Hz in PD.
- Postural tremor: arms extended, palms down.
- Intention tremor: finger–nose, heel–shin.
- Parkinsonism: bradykinesia, cogwheel rigidity, masked face, micrographia, reduced arm swing, shuffling gait.
- Cerebellar signs (DANISH): Dysdiadochokinesia, Ataxia (gait), Nystagmus, Intention tremor, Speech (dysarthria), Heel–shin test.
- General: thyroid, hydration, withdrawal signs. Gait and postural stability.
🧪 Investigations
- Capillary glucose at bedside if acute or unknown.
- Bloods: FBC, U&E, LFTs, glucose, calcium, magnesium, TFTs, CRP; lithium/valproate level if on therapy.
- ECG if tachycardic, on QT-prolonging drugs, or electrolyte disturbance.
- CT brain if acute focal signs, first seizure, rapid decline, or trauma.
- EEG only if seizure considered.
🔗 Related topics
Note Template
Ready-to-use clinical note structure
🕒 12 / 07 / 2026 — 18:24 ATRP re: tremor assessment Patient: [age] [sex] Location: [ward / ED] Admission Dx: [reason for admission] 🤲 Tremor character: • Onset & course: [new / worsening / chronic] • Type: [rest / postural / kinetic / intention] • Distribution: [hands / head / voice / legs — uni- vs bilateral] • Functional impact: [writing, feeding, mobility, speech] 📋 Associated features: • Parkinsonism: [bradykinesia / rigidity / gait change / none] • Cerebellar: [ataxia / dysmetria / dysarthria / none] • Autonomic / systemic: [tachycardia, fever, confusion, sweating] • Drugs / substances: [recent changes, alcohol, caffeine] 🩺 Exam & bedside: • Vitals: [HR, BP, temp, SpO₂] • Capillary glucose: [__ mmol/L] • Key findings: [document tremor at rest vs action, gait, tone] 🧪 Investigations: • Bloods sent/results: [FBC, U&E, LFTs, glucose, Ca, Mg, TFTs, levels if applicable] • Imaging: [CT brain — indication and result / not indicated] 💊 Management: • Reversible cause treated: [hypoglycaemia / withdrawal / drug stopped / infection / other] • Medications given: [thiamine, benzodiazepine protocol, other — with senior approval] • Neurology: [referral made / phone consult / outpatient plan] 📌 Plan: • [Observations, repeat exam, chase results, driving advice if new diagnosis] 👤 [Your Name], [Role] IMC: _______