A 52-year-old woman comes to the office due to a hand tremor that has been present for several months. It is most prominent while she is carrying out simple daily activities such as drinking from a glass or pouring from a tea kettle. When asked if anything improves the tremor, the patient mentions that it subsides somewhat when she drinks small amounts of alcohol. Family history is significant for similar problems in her mother. Vital signs are normal. Neurologic examination shows bilateral tremor in the upper extremities. Which of the following is the best treatment for this patient?

Question

A 52-year-old woman comes to the office due to a hand tremor that has been present for several months.  It is most prominent while she is carrying out simple daily activities such as drinking from a glass or pouring from a tea kettle.  When asked if anything improves the tremor, the patient mentions that it subsides somewhat when she drinks small amounts of alcohol.  Family history is significant for similar problems in her mother.  Vital signs are normal.  Neurologic examination shows bilateral tremor in the upper extremities.  Which of the following is the best treatment for this patient?

Quizplus · Accepted Answer

This patient has essential tremor, the most commonly diagnosed movement disorder. Essential tremor is also referred to as familial tremor as it often follows autosomal dominant inheritance. A positive family history of tremor can sometimes assist in making the diagnosis. Essential tremor classically worsens while maintaining a particular posture (eg, when holding an object). Patients commonly report that their symptoms improve with alcohol consumption. Propranolol is the first-line treatment for essential tremor. This nonselective β-adrenergic antagonist is thought to lessen the tremor via central nervous system effects. (Choice A) Benztropine is an anticholinergic agent that can be used to treat tremor in Parkinson disease and to counteract the extrapyramidal side effects of neuroleptic medications such as haloperidol. (Choices B and D) Haloperidol is most commonly used to treat the positive symptoms of psychosis (eg, delusions, hallucinations). Clozapine is an atypical antipsychotic that blocks D₂ (dopamine) and 5HT₂ (serotonin) receptors in the CNS. (Choice C) Diazepam is a benzodiazepine that is effective for treatment of seizures and alcohol withdrawal. This patient has had intention tremor for several months and family history is positive for essential tremor; these findings would make alcohol withdrawal very unlikely. (Choice E) L-DOPA, or levodopa, is used in combination with the DOPA decarboxylase inhibitor carbidopa to treat Parkinson disease. Patients with Parkinson disease have a resting tremor. Educational objective: Essential tremor is the most common movement disorder. Patients experience a slowly progressive, symmetric postural and/or kinetic tremor that most commonly affects the upper extremities. Essential tremor is often inherited in an autosomal dominant fashion (referred to as familial tremor). First-line treatment is the nonspecific β-adrenergic antagonist propranolol.

A 52-Year-Old Woman Comes to the Office Due to a Hand