Essential tremor in older adults: shaky hands, causes and treatment

The National Tremor Foundation (NTF) describes essential tremor as a chronic condition with involuntary rhythmic tremor of a body part, most typically the hands and arms, which may be a slowly progressive disorder; in some people it eventually involves the head, voice, tongue, legs and trunk, while in many it is relatively non-progressive and may be mild throughout life. It says the tremor is often most visible when holding a fixed position, may worsen during tasks, and usually disappears during sleep.

Hand tremor can make writing, drinking from a cup, eating, sewing, shaving or dressing difficult. The NTF notes that the psychological and social effects may be embarrassing, and can lead to withdrawal from social activities. For some people unsteady, uncoordinated walking may also be present.

The NHS says everyone has a slight tremor, for example if you hold your hands out in front of you, and that it often becomes more noticeable with age, stress, tiredness, anxiety or anger, after caffeine, alcohol or smoking, or if you are very hot or cold. Some medicines and conditions also cause a tremor, and the NHS stresses speaking to your GP before stopping any prescribed medicine.

The NHS advises seeing a GP if the tremor is getting worse over time or affecting daily activities, because the doctor will want to make sure it is not caused by another condition. A mild tremor not caused by another condition does not usually need treatment, though the GP may monitor it. You may be referred to a specialist if the tremor could be a symptom of a condition such as Parkinson's disease or multiple sclerosis.

Parkinson's UK says essential tremor and dystonia are separate conditions from a Parkinson's tremor. A Parkinson's tremor usually appears at rest, often as a "pill-rolling" movement of the thumb and index finger, whereas an action tremor, appearing when moving or lifting the arms, is less common in Parkinson's. Doctors ask how often the tremor occurs, where on the body, any patterns, and any family history, and may use a brain scan called a DaTSCAN if still unsure; the NTF also says a DaTSCAN can distinguish essential tremor from the tremor of Parkinson's.

The NTF says diagnosis of essential tremor remains largely a visual one based on history and examination, with MRI or CT sometimes used to exclude other conditions and blood tests to rule out thyroid or copper metabolism problems. It advises seeing a doctor who understands tremor, or a neurologist. Medicines can also cause tremor; Parkinson's UK lists some antidepressants, asthma medications, epilepsy medications and anti-sickness pills as able to worsen a tremor, so a medicines review is routine.

The NHS says if a tremor affects your life, the GP may prescribe medicine, which will not cure the tremor but often helps reduce the shaking. You may need it all the time or only when needed, for example before a stressful situation. For head or voice tremor, injections to block the nerves and relax the muscles may be offered. The NTF says treatments available are symptomatic rather than curative, and lists medicines used for essential tremor including propranolol and primidone, with others such as topiramate, gabapentin, atenolol, sotalol, clonazepam, nadolol and diazepam; some of these can cause drowsiness, slow heart rate or low blood pressure, which matter in older people, so the choice is individual and made with the prescriber.

The NTF says alcohol temporarily improves tremor in some people but often rebounds and worsens it the next morning, so it is not a treatment. For severe, disabling tremor not responding to medicine, surgery can be considered. The NHS says rarely brain surgery may be an option; the NTF describes deep brain stimulation and MR-guided focused ultrasound, and says NHS England has determined the latter should be available as an NHS service. It gives surgical risk figures for deep brain stimulation, such as a small risk of bleeding or stroke; these are charity-quoted figures, so ask the neurosurgical team for current numbers for your situation.

The NTF says that by adapting how you do activities you can maintain independence, and its daily-living pages cover communication, diet, exercise, driving, work and keeping a diary of how tremor responds to medication. Parkinson's UK, writing about Parkinson's tremor, suggests several approaches that carers of people with other tremors also use: relaxation exercises, wrist weights suggested by a nurse or therapist, easy-grip cutlery and cups, and asking friends or family to help cut food when eating out. Anxiety and stress can worsen tremor, so relaxation and physical activity may help.

An occupational therapist can advise on equipment and techniques, and the NHS points to the National Tremor Foundation for information on surgery and daily living.