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JAMA Neurology Clinical Challenge
May 2017

Action Tremor, Impaired Balance, and Executive Dysfunction in Midlife

Author Affiliations
  • 1Department of Developmental Disability Neuropsychiatry, School of Psychiatry, UNSW Australia, Sydney, Australia
  • 2Centre for Healthy Brain Ageing, School of Psychiatry, UNSW Australia, Sydney, Australia
JAMA Neurol. 2017;74(5):603-604. doi:10.1001/jamaneurol.2016.4063

A 58-year-old man presented with a 1-year history of severe and progressive action tremor in his dominant hand when writing. When questioned, he described subtle balance problems without falls developing over the past 3 years. With the exception of profound difficulties with handwriting, motor symptoms did not affect livelihood or activities of daily living. There was no tremor reported in the nondominant hand or other limbs or symptoms of autonomic dysfunction. Neither he nor his wife reported any changes in cognitive function. His medical history comprised surgeries of the hand (laceration repair), leg (fracture repair), knee (reconstruction), and ear (stapedectomy); these were not related to the presenting symptoms. He had a family history of ischemic heart disease (both parents) but no family history of neurological disorder. He exercised regularly (5 times per week) and consumed 2 to 4 standard drinks per week. He was a former smoker with a 2-year pack history and denied any illicit drug use.