Tremor Trouble

Your hands are shaky. Over the years, they've twitched every now and then whenever you wrote a note or used a tool or utensil. Now that you're older, those hand tremors are occurring a little more frequently, and you're concerned you might have something worrisome, like Parkinson's disease (PD).

Statistically speaking, you're more likely to be exhibiting signs of the most common type of movement disorder, benign familial essential tremor (ET), which is at least eight times more common than PD. Whatever the cause, if your tremors begin to affect your quality of life, it's time to find answers. "When should you be concerned about tremors?" asks neurologist Tarannum Khan, MD, a Cleveland Clinic Florida movement disorders specialist. With one episode of tremor, you should not be concerned at all. But, if it's more persistent and progressive over time, you should see a doctor.

Identifying Essential Tremor

ET often progresses slowly, and while for many patients it remains mild, for others it is life-altering. Several factors can help you and your doctor determine if your shakiness is from ET or if it's a Parkinsonian tremor. For instance, if you have a family history of tremor, you're more likely to have ET: More than half of patients with ET have a family history of the disorder, compared with less than 10% of those with Parkinsonian tremors. Additionally, ET usually affects both sides of the body and occurs when you try to hold a body posture against gravity, reach toward something, or lift something toward you. Conversely, PD usually begins on one side of the body before progressing to the other side, and it occurs more often at rest. (See box next page for other signs of ET versus PD.) "Also, for Parkinson's disease, there are many other symptoms that accompany the tremor that are red flags that a person should definitely see a doctor," Dr Khan says.

Finding The Cause

In some cases, your shakiness may not be a sign of ET or PD, but rather a different type of tremor or an underlying factor that your doctor must rule out, such as:

• Physiologic tremors, occurring in all healthy people and characterized by fine shaking of the hands and fingers.
• Other medical conditions, such as chronic liver or kidney disease, multiple sclerosis, low blood sugar, overactive thyroid (hyperthyroidism), traumatic brain injury, alcohol withdrawal, or severe anxiety.
• Use of medications/ substances that cause tremors as a side effect. Some examples include divalproex (Depakote®, used to treat seizures and bipolar disorder), certain anti-depressants, asthma medications, immunosuppressants (e.g, cyclosporine and tacrolimus), caffeine and nicotine. No biomarker tests have been developed to definitively diagnose ET or PD, so Dr Khan and other movement disorders specialists must rely more on their clinical expertise to pinpoint the cause of tremors. "If someone has persistent tremors, it's best to see a neurologist, preferably one who is a movement disorders specialist," she advises. "A good examination by a movement disorders specialist usually is able to get the diagnosis."

Treating ET

If ET is affecting your quality of life, blood pressure medications known as beta blockers -usually propranolol (Inderal ®) - or the anti-seizure medication primidone (Mysoline®) may be prescribed. The wrinkle fighter botulinum toxin (Botox®) may also help. "If it's bothersome, it's a very good idea to get on a medication. We have very good medications for essential tremor and Parkinsonian tremor," Dr Khan says. But, if it's mild, it's best left alone.

If these non-invasive treatments fail, a surgical procedure known as deep-brain stimulation can provide dramatic relief for people with severe ET. A pacemaker-like device placed in the chest delivers electrical stimulation via electrodes placed in the brain to reduce tremors. Like PD, ET is not curable, but its symptoms are manageable, Dr Khan says. Simple lifestyle changes, such as limiting or avoiding caffeine, getting seven to eight hours of sleep each night, and finding ways to relax may help ease your symptoms. Also, take advantage of special utensils and assistive devices that can help you function better. "Benign essential tremor is more of a nuisance than it is a disease, as opposed to Parkinson's disease," Dr Khan says. The biggest issue with essential tremor is to manage life.