Introduction

If you’re an older adult, you may have dismissed trembling hands or a shaking head as a normal part of the aging process. But it’s more likely your shakiness is a sign of a movement disorder called essential tremor.

Although essential tremor can affect almost any part of your body, trembling occurs most often in your hands, especially when you try to do simple tasks such as drinking a glass of water, tying your shoelaces, writing or shaving. Sometimes, you may also have trembling of your head, voice or arms.

Essential tremor is the most common of the many movement disorders. It’s far more common than Parkinson’s disease, with which it may sometimes be confused. Unlike Parkinson’s disease, however, essential tremor doesn’t lead to serious complications. In fact, the word “essential” in essential tremor means the disorder isn’t linked to other diseases.

For some people, essential tremor may be distressing but not debilitating. Others may find that their tremors make it difficult to work, perform everyday tasks that require fine-motor skills or do the things they enjoy. Severe tremors can lead to social withdrawal and isolation. Fortunately, a variety of treatments exist that may help bring your tremors under control.

Signs and symptoms

Essential tremor often begins gradually. Sometimes it appears during adolescence. More often, though, tremors begin in mid- to late life.

The most common sign is a trembling, up-and-down movement of your hands, although your arms, legs, head and even your tongue and voice box (larynx) also may be affected. Most people have tremors in both hands. Some people have tremors in only one hand, though the tremors often progress to include both hands.

Tremors usually occur only when you engage in a voluntary movement, such as drinking a glass of water, writing or threading a needle. Actions requiring fine-motor skills — using utensils or small tools, for example — may be especially difficult. Fatigue, anxiety and temperature extremes make the signs worse, but tremors usually disappear when you’re asleep or at rest.

Some people have relatively mild tremors throughout their lives, while others develop more severe tremors and increased disability over time. Effects of worsening tremors may include:

• Difficulty holding a cup or glass without spilling
• Difficulty eating normally
• Difficulty putting on makeup or shaving
• Difficulty talking, if your voice box or tongue is affected
• Difficulty writing — handwriting may become increasingly large, shaky and illegible
• The inability to perform actions requiring fine-motor skills, such as playing an instrument or drawing

Essential tremor vs. Parkinson’s disease
Many people associate tremors with Parkinson’s disease, a serious movement disorder. But essential tremor and Parkinson’s disease aren’t related, and the two conditions differ in key ways:

• When tremors occur. Essential tremor of the hands typically occurs when your hands are in use. Tremors from Parkinson’s are most prominent when your hands are at your sides or resting in your lap. This type of tremor usually decreases with movement of the hands.
• Associated conditions. Essential tremor doesn’t cause other health problems, whereas Parkinson’s is associated with a stooped posture, slow movement, a shuffling gait, speech problems other than tremor and sometimes memory loss.
• Parts of body affected. Essential tremor can involve your hands, legs, head and voice. Tremors from Parkinson’s typically affect your hands, but not your head or voice.

Causes

About half of all cases of essential tremor appear to occur because of a genetic mutation. This is referred to as benign familial tremor. Genes are information centers in your cells that control your body’s growth, development and function. A mutation in just one gene can greatly alter the way your body works. Researchers have identified two genes that appear to be involved in essential tremor. It’s possible that mutations in other genes may also lead to the condition.

Exactly what causes essential tremor in people without a known genetic mutation isn’t clear. Doctors do know that the problem occurs in the brain circuits that control your movements. Studies using an imaging technique called positron emission tomography (PET) scanning show that certain parts of the brain — including the thalamus — have increased activity in people with essential tremor. More research is needed to understand the precise mechanism behind the disease.

Risk factors

Benign familial tremors are an autosomal dominant disorder, which means that a defective gene from just one parent is needed to pass on the condition. If you have a parent with a genetic mutation for essential tremor, you have a 50 percent chance of developing the disorder yourself. The only other known risk factor is older age. Although essential tremor can affect people of all ages, it usually appears in late middle age or later.

When to seek medical advice

See your doctor if tremors make it hard to perform daily activities or prevent you from living your life as fully as you’d like. Your doctor can determine whether essential tremor is causing your problem and may be able to suggest treatments that will ease your symptoms.

Screening and diagnosis

You’ll receive a diagnosis of essential tremor only after your doctor has ruled out other possible causes for your symptoms. For that reason, you may undergo blood, urine and neurological tests to check for problems such as thyroid disease, heavy metal poisoning, drug side effects and Parkinson’s disease.

In addition, your doctor will take a complete medical history and perform a thorough physical and neurological exam that may include checking your tendon reflexes, your muscle strength and tone, your ability to feel certain sensations, and your posture and coordination.

The tremor itself may be evaluated in several ways, including performance tests in which you’re asked to write, drink from a glass or hold a piece of paper.

Treatment

Most people with essential tremor don’t need treatment beyond reassurance that the condition isn’t a sign of a more serious disease. Lifestyle changes — which include getting plenty of rest and avoiding stressful situations and stimulants such as caffeine — may help ease the tremors. Most people with essential tremor find that fatigue, anxiety, sleep deprivation and even temperature extremes make their tremors worse.

If lifestyle changes don’t help and tremors are keeping you from doing the things you enjoy, your doctor may recommend these options:

Medications
Medications provide relief from tremors roughly half the time. They include:

• Beta blockers. Normally used to treat high blood pressure, beta blockers, such as propranolol (Inderal), help relieve tremors in some people. Because beta blockers are especially likely to cause dizziness, confusion and memory loss in older adults, they may be a better choice for younger people. They may not be an option if you also have asthma, diabetes or certain heart problems.
• Anti-seizure medications. These drugs, especially primidone (Mysoline), may be effective in people who don’t respond to beta blockers. The main side effects are drowsiness and flu-like symptoms, which usually disappear within a short time.
• Tranquilizers. Doctors sometimes use drugs such as diazepam (Valium) and alprazolam (Xanax) to treat people whose tremors are made much worse by tension or anxiety. Side effects can include confusion and memory loss. Additionally, these medications should be used with caution because they can be habit-forming.
• Botulinum toxin type A (Botox) injections. You’re probably familiar with Botox as a treatment for facial wrinkles, but it can also be useful in treating some types of tremors, especially of the head and voice. Botox injections can improve problems for up to three months at a time. When used to treat hand tremors, Botox can sometimes cause weakness in your fingers.

Surgery
Surgery may be an option for people whose tremors are severely disabling and who don’t respond to medications. Deep brain stimulation (DBS) is a treatment involving a brain implant device called a thalamic stimulator may be appropriate if you have severe tremors and if medications aren’t effective. A pacemaker-like chest unit transmits electrical pulses through a wire to a lead implanted in your thalamus. The pulses, which are painless, may interrupt signals from your thalamus that help cause tremors. You turn the pulse generator on and off by passing a magnet over your chest.

Self-care

The following suggestions can sometimes help reduce or relieve tremors:

• Avoid caffeine. Caffeine can cause your body to produce more adrenaline, which may make your tremors worse. Avoid other stimulants as well.
• Use alcohol sparingly. Some people notice that their tremors improve for up to an hour after they drink alcohol, but drinking isn’t a good solution for people with essential tremor. That’s because tremors tend to worsen once the effects of alcohol wear off. What’s more, larger amounts of alcohol eventually are needed to relieve tremors, which can lead to chronic alcoholism. If you have essential tremor, it’s best to drink sparingly or not at all.
• Learn to relax. Stress tends to make tremors worse, and a relaxed state often improves them. Although it’s not possible to eliminate all stress from your life, you can change how you react to stressful situations using a range of relaxation techniques. These include deep breathing, progressive muscle relaxation, guided imagery and massage as well as disciplines such as yoga and tai chi. Many people also find that physical exercise — walking, jogging, swimming or biking — is a great stress reliever.
• Rest well. Fatigue can exacerbate tremors. Try to get at least seven hours of sound sleep every night. If you have trouble falling asleep, wake up repeatedly or awaken early and can’t go back to sleep, talk to your doctor.
• Strengthen your hands. Your doctor may recommend working with a specialist to learn exercises to promote more stability in your hands and wrists. These usually involve using 1- to 2-pound weights strapped to your wrists. You can continue doing these exercises at home.
• Consider joining a support group. For many people, essential tremor can have serious social and psychological consequences. If the effects of essential tremor are making it hard to live your life as fully as you once did, consider joining a support group for people with the disorder. Support groups aren’t for everyone, but you may find it helpful to have the encouragement of people who understand what you’re going through. Or you might want to consider seeing a counselor or social worker who can help you meet the challenges of living with essential tremor.

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