Essential Tremor

Condition: Essential Tremor

Brief Overview: According to UpToDate, “Essential tremor (ET) is the most common cause of action tremor in adults. It classically involves the hands and is brought out by arm movement and sustained antigravity postures, affecting common daily activities such as writing, drinking from a glass, and handling eating utensils. ET is slowly progressive and can involve the head, voice, and rarely the legs, in addition to the upper limbs. ET often runs in families and can be referred to as "familial tremor" when there is a family history.”

Prevalence: According to UpToDate, “ET is the most common cause of action tremor, with an estimated prevalence worldwide of 1 percent overall and approximately 5 percent in adults over the age of 60 years. The prevalence of ET is similar in males and females, although some studies report a slight male predominance.”

Etiology: The exact biological cause of essential tremor is not fully understood.

Essential tremor is currently defined primarily as a clinical syndrome rather than by one established underlying cause. Genetic factors appear to contribute in many patients, and essential tremor commonly occurs in families, but no single gene explains most cases.

The neurological pathways involved in controlling coordinated movement, including cerebellar and related brain networks, are believed to play a role.

Risk Factors:

Increasing age.
Family history of essential tremor or another similar tremor disorder.
Genetic susceptibility.

Many patients have no clearly identifiable risk factor other than age.

Commonly Associated Conditions: Essential tremor is primarily a movement disorder, but studies have identified additional concerns that may occur more frequently in people with ET, including:

Anxiety.
Depression.
Social anxiety or embarrassment related to tremor.
Sleep disturbance.
Reduced independence with activities of daily living.
Balance or gait difficulties in some patients.
Increased fall risk in some older patients.
Mild cognitive changes have been reported in some studies, particularly in older adults, although the relationship between ET and cognitive disorders continues to be studied.

Care Coordinator Note: New cognitive decline, significant gait changes, rigidity, bradykinesia, or other neurological findings should not automatically be attributed to essential tremor. These may indicate another neurological or medical condition and should be reported to the patient's neurologist.

Common Medications: Not every patient with essential tremor requires medication. Treatment is generally considered when tremor interferes with daily activities, independence, work, eating, writing, communication, or quality of life.

Propranolol
Primidone
Second line: Topiramate, benzodiazepines, gabapentin

Common Labs, Imaging, and Tests: Per UpToDate, “The diagnosis of ET is based primarily on clinical features. Imaging, blood work, and other evaluations are not necessary to make a diagnosis, but they can be used to exclude other potential causes of tremor.”

Labs: serum electrolytes, liver and thyroid function studies
MRI/CT of the brain
DaTscan

Common Treatments:

Medications (see above)
Discontinuation of any exacerbating medications, substances
Adaptive devices: wrist-worn neuromodulation devices, biomechanical loading devices, tremor cancellation devices, local vibration therapy devices
Botulinum toxin
Physical/occupational therapy

Common Symptoms:

Hand and Arm Tremor

Rhythmic shaking of one or both hands.
Tremor while holding objects.
Tremor when reaching for something.
Difficulty drinking from a cup.
Spilling food or liquids.
Difficulty using eating utensils.
Difficulty writing legibly.
Difficulty using a phone or keyboard.
Difficulty buttoning clothing.
Difficulty with grooming or other fine-motor activities.

Tremor is typically most apparent during posture or voluntary movement rather than when the limb is completely at rest.

Head Tremor

Some patients develop rhythmic:

"Yes-yes" vertical head movement.
"No-no" horizontal head movement.

Isolated head tremor without hand tremor should prompt consideration of another diagnosis such as dystonic tremor rather than automatically being classified as ET.

Voice Tremor

Patients may describe:

Shaky voice.
Quivering voice.
Difficulty maintaining a steady tone.

Voice tremor can interfere with communication even when hand tremor is relatively mild.

Functional Effects

Patients may report difficulty:

Eating or drinking.
Preparing meals.
Writing.
Signing their name.
Handling money or cards.
Taking medications from containers.
Using a phone.
Applying makeup.
Shaving.
Performing hobbies.
Completing occupational tasks.

Physical Findings:

Bilateral postural tremor of the hands or arms.
Kinetic tremor during voluntary movements.
Tremor during handwriting or spiral drawing.
Tremor while bringing a cup or utensil toward the mouth.
Head tremor.
Voice tremor.

Typical essential tremor should not include definite bradykinesia, rigidity, dystonia, or other clear neurological abnormalities.

Potential Complications and Contraindications: Essential tremor itself generally does not cause medical emergencies, but significant tremor can lead to:

Difficulty eating or drinking independently.
Difficulty preparing food safely.
Difficulty taking medications accurately.
Reduced ability to write or communicate.
Difficulty completing personal-care activities.
Loss of independence.
Reduced participation in hobbies or social activities.
Embarrassment or social withdrawal.
Anxiety or depression.
Balance difficulty and fall risk in some patients.

General Health and Lifestyle Guidance:

Take medications exactly as prescribed.
Maintain regular neurology follow-up.
Track changes in tremor and the activities it affects.
Use adaptive utensils, cups, writing devices, or other equipment when helpful.
Consider occupational therapy if tremor is interfering with activities of daily living.
Maintain physical activity appropriate for the patient's health and mobility.
Address fall risk if balance is impaired.
Obtain adequate sleep because fatigue may worsen tremor.
Consider reducing caffeine if the patient notices that it worsens tremor.
Use stress-management strategies if anxiety or stress worsens symptoms.
Avoid using alcohol as a tremor treatment.
Review all new medications with the healthcare team when tremor changes.
Do not stop a medication believed to be worsening tremor without discussing it with the prescribing healthcare provider.

Common Tremor Triggers or Aggravating Factors

Tremor severity may fluctuate. Potential aggravating factors include:

Stress.
Anxiety.
Fatigue.
Sleep deprivation.
Excessive caffeine or other stimulants.
Acute illness.
Some prescription medications.
Some OTC medications or stimulants.
Alcohol withdrawal.
Hyperthyroidism.
High or low blood glucose in patients with diabetes.
Metabolic illness.

Care Coordinator Note: If tremor changes after a medication is started or adjusted, report the timing to the patient's healthcare provider. Do not instruct the patient to discontinue the medication independently.

Suggested Questions to Ask Patients:

Tremor Assessment

Has your tremor changed since our last call?
Is it staying about the same, improving, or becoming worse?
Which parts of your body are affected?
Is the tremor affecting one hand or both hands?
Do you notice it primarily when you are using your hands, or does it also occur when your hands are completely at rest?
Have you developed tremor in a new area, such as your head or voice?
Are there certain times of day when your tremor is worse?
Have you noticed anything that consistently makes the tremor worse?

Daily Function

Is the tremor making it harder to eat or drink?
Are you spilling food or liquids?
Are you having difficulty preparing meals?
Has handwriting become more difficult?
Are you able to use your phone normally?
Are you having difficulty buttoning clothing, grooming, or completing other personal-care activities?
Does tremor make it difficult to organize or take your medications?
Have you stopped doing any activities because of your tremor?

Mobility and Safety

Have you noticed any new problems with your balance?
Have you fallen or almost fallen since our last call?
Are you walking differently than usual?
Have you developed stiffness or difficulty starting movements?
Are you moving more slowly than you used to?

Medication Assessment

Are you taking medication for your tremor?
Are you taking it exactly as prescribed?
Have you noticed improvement since starting treatment?
Have you experienced dizziness, unusual sleepiness, low blood pressure, weakness, or balance difficulty?
Have you had any recent medication changes?
Have you started any new OTC medications or supplements?
Are you having difficulty obtaining or affording your medication?

Follow-Up

When did you last see your neurologist?
When is your next neurology appointment?
Has your neurologist been informed of your current tremor symptoms?
Have you ever worked with occupational or physical therapy for your tremor?
Do you feel your current treatment is adequately controlling the symptoms that interfere with your daily life?

⚠️ Standard Neurology Symptom-Change Guidance

For any new neurologic symptom or change/worsening of an existing neurologic symptom, advise the patient or caregiver to contact the patient's neurologist to report the change.

This includes a new or worsening:

Tremor.
Weakness.
Numbness or tingling.
Balance or walking difficulty.
Falls.
Rigidity or slowed movement.
Vision change.
Speech change.
Swallowing difficulty.
Cognitive or behavioral change.
Change in alertness.
Other neurological symptom.

Care coordinators should not independently determine that a new or worsening neurological symptom is simply an expected part of the patient's existing essential tremor.

If symptoms meet criteria for urgent or emergency evaluation, do not delay appropriate care while waiting for the neurologist to respond. Follow organizational escalation policies and direct the patient to the appropriate level of urgent or emergency evaluation.

⚠️ Telephone Escalation Guidance

Essential tremor usually develops gradually. Sudden onset and stepwise deterioration are not characteristic of typical ET and are specifically considered exclusionary features in current Movement Disorder Society classification.

Emergency — Call 911 / Emergency Evaluation

Follow organizational emergency protocol for tremor or shaking associated with:

Sudden facial droop.
Sudden one-sided weakness or numbness.
Sudden speech difficulty.
Sudden severe balance or coordination difficulty.
New inability to walk.
New severe confusion or altered consciousness.
Seizure.
Loss of consciousness.
Sudden severe headache with neurological symptoms.
Severe chest pain, breathing difficulty, or another medical emergency.
Serious fall with head injury, significant bleeding, loss of consciousness, or inability to get up.

Do not assume an acute neurological event is caused by the patient's known essential tremor.

Prompt Clinical/Neurology Follow-Up

Advise the patient to contact the neurologist to report:

New tremor.
Clear worsening or change in usual tremor.
Tremor beginning to occur primarily at rest.
Tremor spreading to a new body area.
New stiffness or rigidity.
New slowing of movement.
New gait or balance difficulty.
Falls or near-falls.
New weakness or sensory changes.
Tremor significantly interfering with eating, drinking, medication administration, or other activities of daily living.
New neurological symptoms following a medication change.
Medication adverse effects.
Current treatment no longer adequately controlling tremor.

If any symptom warrants urgent or emergency evaluation based on organizational protocol, follow the escalation pathway rather than waiting for routine neurology follow-up.

Suggested Talking Points:

Explaining essential tremor

"Essential tremor causes involuntary shaking, most commonly when you're using your hands or holding them in a certain position."

Explaining progression

"Essential tremor can gradually become more noticeable over time. We still want your neurologist to know if you notice a new symptom or a change in your usual tremor."

Distinguishing a change

"If your tremor suddenly changes, or you develop new weakness, stiffness, walking difficulty, numbness, or another neurological symptom, we don't want to automatically assume it's from essential tremor."

Discussing function

"One of the most important things for us to know is how the tremor is affecting what you're able to do—things like eating, drinking, writing, taking your medications, or getting dressed."

Discussing treatment

"Treatment doesn't always eliminate tremor completely, but medications and other therapies may reduce it enough to make daily activities easier."

Discussing triggers

"Stress, fatigue, and sometimes caffeine can make tremor more noticeable. Keeping track of when your symptoms are better or worse can help identify patterns."

Discussing alcohol

"Some people notice that alcohol temporarily reduces their tremor, but alcohol isn't recommended as a treatment because the effect is temporary and tremor can worsen afterward."

Discussing adaptive equipment

"If tremor is making everyday tasks difficult, occupational therapy can sometimes recommend simple tools—like heavier utensils or larger-grip pens—that make those activities easier."

Suggested SMART Goal Examples

1. Symptom Tracking
"I will record the severity of my tremor and activities that make it better or worse at least 3 days per week for the next 4 weeks to review with my neurologist."

2. Neurology Follow-Up
"I will schedule and attend my recommended neurology appointment within the next ___ days."

3. Medication Adherence
"I will take my tremor medication exactly as prescribed each day for the next 30 days and report any side effects or concerns to my healthcare provider."

4. Adaptive Utensils
"I will try an adaptive or weighted eating utensil during at least one meal each day for the next 2 weeks to determine whether it makes eating easier."

5. Caffeine Reduction
For a patient who notices caffeine worsens tremor:
"I will reduce my caffeinated beverages from ___ per day to ___ per day for the next 2 weeks and track whether my tremor changes."

6. Sleep
"I will follow a consistent bedtime and wake time at least 5 days per week for the next 4 weeks to help reduce fatigue that may worsen my tremor."

7. Fall Prevention
"I will remove loose rugs and clutter from my main walking areas within the next 7 days to reduce my risk of falling."

8. Occupational Therapy
"I will discuss an occupational therapy referral with my healthcare provider within the next 30 days because tremor is interfering with my daily activities."

9. Functional Independence
"I will identify one adaptive tool or strategy within the next 2 weeks that makes writing, eating, drinking, or another difficult activity easier."

10. Trigger Identification
"I will keep a symptom log for the next 2 weeks noting my tremor, sleep, caffeine intake, stress, and medication timing to identify patterns to discuss with my neurologist."

Sources:

⚠️ Medical Disclaimer

This resource is provided for educational and informational purposes only and is not intended to replace professional medical advice, diagnosis, or treatment. The information presented is general in nature and may not apply to every individual or health situation.

Individuals should consult their physician or other qualified healthcare professional for personalized medical advice, diagnosis, or treatment recommendations related to their specific health conditions and should not begin any new exercise program or change their diet or medications without consulting their healthcare professional.

Call 911 if you are experiencing a medical emergency.