A 63-year-old man comes to the office due to a 3-year history of tremor. The tremor initially started in the left hand but over the last 6 months has progressed to involve both hands. The patient is a professional illustrator for a marketing agency and has been having difficulty performing at his job due to constant shaking. His other medical condition includes asthma, for which he uses albuterol and fluticasone inhalers. Vital signs are normal. Examination reveals a moderate tremor with hands outstretched; the tremor worsens during finger-to-nose testing. Muscle tone, gait, and limb coordination are normal. Serum TSH is normal. Which of the following is the most appropriate treatment for this patient?

Question

A 63-year-old man comes to the office due to a 3-year history of tremor.  The tremor initially started in the left hand but over the last 6 months has progressed to involve both hands.  The patient is a professional illustrator for a marketing agency and has been having difficulty performing at his job due to constant shaking.  His other medical condition includes asthma, for which he uses albuterol and fluticasone inhalers.  Vital signs are normal.  Examination reveals a moderate tremor with hands outstretched; the tremor worsens during finger-to-nose testing.  Muscle tone, gait, and limb coordination are normal.  Serum TSH is normal.  Which of the following is the most appropriate treatment for this patient?

Quizplus · Accepted Answer

11ec25c8_d5d3_b0ce_bc81_833bba02059b_MD0003_00 This patient has a worsening tremor of the distal upper extremities that becomes more pronounced with extension of the arms and at the end of an intended action (eg, finger-to-nose test). In the absence of other neurologic manifestations, these findings are most consistent with essential tremor (ET). Features are highly variable, but ET most often affects the wrists and hands, especially when the arms are extended. It worsens with movement (ie, action tremor) and improves, but may not completely abate, at rest. ET is not typically unilateral, but it may be asymmetric (as in this patient) and is often slowly progressive. Many patients do not require medical therapy for mild ET. However, those with tremor-related disability (eg, interference with work, impaired activities of daily living) or embarrassment/anxiety should be offered therapy. Propranolol, a nonselective beta blocker that reduces tremors via blockade of peripheral adrenergic receptors on muscle fibers, is typically the initial drug of choice. However, nonselective beta blockers are relatively contraindicated in patients with reactive airway disease (eg, asthma, chronic obstructive pulmonary disease) or heart block. Therefore, primidone, a centrally acting anticonvulsant, is often used in this population. (Choices A and E) Carbidopa-levodopa (medications that increase dopamine in the substantia nigra) and trihexyphenidyl (an antimuscarinic) are used to treat Parkinson disease. In contrast to ET, Parkinson disease classically results in a resting tremor that improves with intentional movement and is associated with rigidity, bradykinesia, and postural instability. (Choice B) Because ET is often worsened by anxiety, benzodiazepine anxiolytics such as clonazepam may partially reduce tremor. However, due to the potential for dependence, abuse, and worsening of tremor with drug withdrawal, it is considered a second-line agent and should be used only after failure of multiple other therapies. (Choice C) Clonidine is a centrally acting alpha-2 adrenergic agonist that is typically used as an adjunctive agent for severe hypertension. It is not effective in treating ET. Educational objective: Essential tremor most often presents as an action tremor of the hands that is not associated with other neurologic symptoms. First-line treatment includes propranolol, which exerts its effects due to peripheral beta-adrenergic receptor blockade, and primidone, a centrally acting anticonvulsant.

A 63-Year-Old Man Comes to the Office Due to a 3-Year