Q: How can I help my patient better understand and cope with her recent diagnosis of essential tremor?
A: Essential tremor is one of the most common movement disorders. It's called "essential" because it's considered the primary diagnosis after other neurologic diseases, like Wilson's and Parkinson's, are ruled out. That's done with a thorough neurologic exam, medical history, and diagnostic testing.
Essential tremor typically involves the head and upper extremities. The Movement Disorder Society has suggested certain characteristics that are diagnostic of essential tremor:
[black small square] bilateral, primarily symmetrical postural or kinetic tremor of the hands and forearms; the tremor is visible and persistent
[black small square] possible additional or isolated tremor in the head with the absence of abnormal posturing.
The tremor usually decreases with specific activity using that extremity, with sleep, and with alcohol intake in moderation. Over time, as the tremor worsens, it can interfere with activities of daily living (ADLs).
The tremor isn't life-threatening, but most patients say that it decreases their quality of life. Each person is affected differently. For example, tremors may occur on one or both sides of the body, and they may be self-limiting or progressive. We aren't sure what causes essential tremor, but we think it has a genetic component. Abnormal communication between certain areas of the brain, including the cerebellum, thalamus, and brainstem, may be the cause, according to the International Essential Tremor Foundation.
Pharmacologic therapy isn't generally needed until essential tremor interferes with ADLs. First-line medications include propranolol (Inderal) and primidone (Myidone, Mysoline), and they successfully reduce tremors in three-quarters of patients. Second-line drug therapies include methazolamide (GlaucTabs, Neptazane), gabapentin (Neurontin), atypical neuroleptics like clozapine (Clozaril), antidepressants like mirtazapine (Remeron), and topiramate (Topamax). Local botulinum toxin type A (Botox) injections may reduce or stop hand tremors when other pharmacologic interventions don't work.
Don't forget nonpharmacologic interventions. Relaxation techniques, biofeedback, cutting back on caffeine, and using light arm weights may reduce tremors triggered by stress and anxiety. An occupational or physical therapist may also provide treatment options and adaptive devices.
Surgical intervention (such as stereotaxic thalamotomy and deep brain stimulation) is a last resort for patients who can't perform ADLs or who don't respond to medication.
The bottom line: Help your patients cope with essential tremor by reassuring and educating them and providing positive options for a better quality of life.
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