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Tremor

Checked: 23-12-2019 by Rob Adams Next Review: 23-12-2020

Who to refer?

The majority of tremor seen in primary care is due to essential tremor and if this is characteristic without any other neurological signs then referral to secondary care is often not required.

Dr Konrad Szewczyk-Krolikowski, Consultant Neurologist at NBT with specialist interest in Movement Disorders has helped put together the following advice:

Isolated postural and action tremor of the upper limbs, without bradykinesia, rigidity or gait difficulty can be diagnosed as Essential Tremor and treated in the community.

The treatment options are:

Propranolol - licensed for use in Essential tremor.

Primidone - licensed for use in Essential tremor.

If the tremor is resistant to these treatment options then a referral should be considered to secondary care where unlicensed treatments such as topiramate or gabapentin may be tried.

If postural tremor coincides with resting tremor or other features of parkinsonism, then a referral should be made to secondary care.

Useful Links:

Tremor - assessment and management in primary care.

Abnormal voluntary movements

Please also consider checking the following Remedy pages:

Parkinson's Disease

Huntington's Disease

Before Referral

Take a history to characterise the tremor and exclude potential underlying causes (see Tremor link above) including drugs.

Examine the patient to look for neurological signs that may suggest underlying neurological disease.

NBT has a useful page which has a list of differential diagnoses: Movement disorders service -useful links.

Consider investigations if indicated:

Bloods: FBC,UE, LFT, TFT. Caeruloplasmin and copper levels if Wilson's disease suspected.
Imaging: CT or MRI if underling CNS disease is suspected.

Manage in primary care if a diagnosis of essential or physiological tremor can be made.

If other causes of tremor are suspected then refer as appropriate.

Referral

Referrals for patients with movement disorder/tremor/possible Parkinson’s can be submitted via eRS. Options for referral include:

Movement Disorder Clinics run by the Department of Medicine for Older People via eRS. They provide an excellent service which is generally quicker than the neurology service. While it is particularly appropriate for complex older patients, a comprehensive service is provided for all patients over the age of 40. The consultant movement disorder specialists are Dr Theresa Allain and Dr Meera Sritharan at UHB (patients are seen at South Bristol Community Hospital) and Dr Jarrod Richards and Dr Ronald Barber at NBT.
Neurology Clinic (NBT) via eRS. Patients who are not suitable for a Care of the Elderly service or who specifically need a neurology opinion can be referred to a neurologist. Please note that waits for neurology clinics can be long.

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.