Unsteady Hands: Quelling Essential Tremor?>

Unsteady Hands: Quelling Essential Tremor

by Tim Gower

It’s natural for your hands to become a bit less steady with age, but about 5 percent of people older than 60—and about 1 percent of the worldwide population—have a common movement disorder called essential tremor, an involuntary, rhythmic shaking of the hands and other body parts that occurs with movement but not while at rest.

Essential tremor can interfere with simple tasks like signing a check or tying a shoe, and some people may be bothered or embarrassed by tremors in social situations. Essential tremor is a chronic condition that can intensify over time. It’s sometimes mistaken for other maladies, especially Parkinson’s disease. For some people, lifestyle changes can manage essential tremor. Medications and surgical procedures are available for hard-to-treat cases.

Essential tremor is the most common type of tremor. It typically affects the hands and arms, but can also affect the head, vocal cords, and other body parts. A person who has essential tremor affecting the head might rock his or her head up and down or side to side. If it involves the vocal cords, the voice might become weak and halting. Some people with essential tremor have other symptoms, such as poor balance, and less commonly, shaking in the legs. The risk of essential tremor rises with advancing age, but it can also appear in children and young adults. Doctors diagnose essential tremor when tremors have persisted for at least three years and no other neurological signs or symptoms are present.

Essential tremor and Parkinson’s: How they differ

People who develop a tremor often worry they have Parkinson’s disease, a degenerative brain disorder that disrupts muscle movement and causes shaking, increasingly stiff and rigid muscles, loss of coordination, and other problems. But while Parkinson’s disease and essential tremor both involve the symptom of tremor, that’s just about all they have in common.

The tremor of Parkinson’s disease usually begins, or is more prominent on, one side of the body, while essential tremor usually affects both sides. People with Parkinson’s experience tremor when they’re at rest, such as relaxing in a chair. People with essential tremor typically don’t shake until they move, such as extending an arm to lift a cup or use a fork.

Handwriting offers another clue: People with Parkinson’s tend to write small but legible characters, while essential tremor produces wobbly, hard-to-read script.

While essential tremor’s cause remains unknown, some evidence suggests it’s linked to changes in a brain region called the cerebellum, which plays a key role in movement and muscle control. Scientists suspect that essential tremor may be caused by a variety of different abnormalities in this region of the brain. About 50 percent of people with essential tremor have a family history of the condition.

Lifestyle changes to try

Not everyone needs to be treated for essential tremor. In fact, researchers believe that many people never seek help for the condition. Some patients wait years or decades before they see a doctor about their tremors. If your symptoms are mild and not too bothersome, some simple lifestyle changes can help you manage a tremor:

  • Try to get plenty of sleep, as sleep deprivation seems to aggravate tremors.
  • Since stress and anxiety appear to worsen tremors, soothe your psyche with meditation, yoga, prayer, or any relaxation method that works for you.
  • Wear clothes that have Velcro fasteners and slip-on shoes (or use a shoehorn).
  • To avoid spills caused by an unsteady hand, sip beverages from a travel mug or use a straw. If you order a beverage, ask for a small serving in an extra-large cup.
  • If you smoke, quit—nicotine exacerbates shakiness.
  • Consider using adaptive devices (see next section) to help you perform daily activities.
  • Ask your doctor about occasionally drinking a small amount of alcohol to help quell a tremor. About half of the people with essential tremor say their hands are steadier if they sip a glass of wine or another alcoholic beverage. However, these benefits peak after about 90 minutes and symptoms may rebound or worsen afterward. Use alcohol judiciously, especially since its adverse effects are often greater than its benefits to reduce tremor.

Adaptive devices for managing tremor

Adaptive devices might help steady a trembling hand. For example, some people find that wrist weights help stabilize their hands when performing tasks such as grooming and dressing. Weighted pens may improve handwriting.

At the dinner table, weighted spoons and forks can help prevent spills; non-skid plates and bowls are available, too. For a high-tech solution, tremor-canceling eating utensils sense the direction of a hand tremor and automatically move the head of a spoon or fork in the opposite direction, making it less shaky. A modest amount of research suggests that tremor-canceling devices might make it easier to eat, though they’re expensive.

For more on adaptive devices and other aspects of essential tremor, visit the International Essential Tremor Foundation’s website.

Occupational therapy can also help you adapt to performing daily activities such as dressing, bathing, eating, and driving with tremor. Health insurance or Medicare may cover all or part of it.

6 Lesser-Known Tremor Disorders

In addition to essential tremor, several other conditions can cause shaking of the hands and other body parts. Here is a quick list.

Drugs for essential tremor

If essential tremor is disrupting your daily routine or causing you to withdraw from socializing, your doctor can prescribe medication that might help calm it. However, drugs can’t cure the condition, not everyone responds to medication, and side effects can outweigh the benefits for some patients. One of two drugs is typically used to treat essential tremor:

  • Propranolol (Inderal, InnoPran XL), a beta-blocker commonly prescribed for high blood pressure and some other conditions. Research suggests that daily propranolol use reduces shakiness by about half, on average, though about 30 to 50 percent of users don’t see any benefit. Reported side effects include bradycardia (a slow heart rate), light-headedness, fatigue, depression, gastrointestinal problems, skin rash, and airway constriction. If you don’t want to take propranolol every day (and thus avoid its side effects), you can choose to take the drug only as needed, such as before attending a social function.
  • Primidone (Mysoline), an antiseizure medication. This drug works about as well as propranolol and may be more effective at quieting limb tremor. However, that doesn’t always result in better functioning, studies show. Primidone reduces vocal tremor by half but seems to be less effective for head tremor. You must take this drug daily for it to be effective. Side effects include dizziness, fatigue, and malaise, though they often fade after a few days.

If either drug fails to relieve essential tremor, your doctor may switch you to the other or combine the two. However, their effectiveness declines in about a year, and your doctor may increase your dosage at that time. The decline could be due to the essential tremor worsening or increased tolerance to the drug.

About half of the patients who are prescribed propranolol or primidone eventually stop taking them, either because they don’t find them helpful or they can’t tolerate the side effects. If you don’t respond to either, you doctor may prescribe a different beta-blocker, a different antiseizure drug, or a calcium channel blocker, though there’s less evidence that any of those drugs help.

Injections of botulinum toxin type A (Botox) can be tried for essential tremor that doesn’t respond to oral medications. Botox is made from a toxin produced by a type of bacteria that can be deadly, but when administered in tiny doses it blocks nerve signals and relaxes muscles. Early studies found Botox to be effective for essential tremor, with a downside: 50 to 70 percent of patients developed hand weakness from the injections. Botox injections are also used to treat severe head and voice tremor.

For severe essential tremor

People with essential tremor that can’t be controlled with medication may be candidates for brain surgery. The FDA has approved two surgical procedures for the treatment of essential tremor:

  • Deep brain stimulation. In this procedure, a neurosurgeon implants an electrode in a region of the brain called the thalamus. The electrode is connected by wire to a device similar to a cardiac pacemaker, which is implanted in the chest. The device is programmed to send pulse signals that disrupt communication between nerve cells that produce tremors. Several studies indicate that deep brain stimulation reduces tremor by 60 to 90 percent. Symptoms can be reduced for as long as 10 years or more, although the device seems to lose some effectiveness over time, either because essential tremor worsens or the body adapts to the nerve stimulation. Surgical risks can include headaches, seizures, infection, and bleeding. Potential complications after the implant include device malfunction, balance and gait problems, slurred speech, and uncontrollable muscle contractions, most of which can be reduced by reprogramming the device.
  • Unilateral thalamotomy. Guided by magnetic resonance imaging, a neurosurgeon uses high-energy ultrasound to destroy tremor-causing brain cells. A study in The New England Journal of Medicine in 2016 found that patients with essential tremor who underwent unilateral thalamotomy experienced an average improvement of 8 points on a 32-point scale measuring tremor severity. However, some patients developed persistent side effects such as disturbed gait and numbness in the face and hands. Side effects such as these, as well as difficulty speaking and loss of balance, were more common with unilateral thalamotomy than with deep brain stimulation.

This article first appeared in the January 2020 issue of UC Berkeley Health After 50.

Also see Exercise May Reduce Parkinson’s Risk.