August 20, 2015

Treating Essential Tremor

Common disorder raises uncommon issues for physicians

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Chances are good that you’ll encounter essential tremor (ET) in your primary care practice. It’s the most common movement disorder, affecting all age ranges and as many as 6 to 9 percent of people 60 and older according to prevalence studies.

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But due to embarrassment, fear or normalization, your patients may not volunteer that they’re having problems. That means you’ll have to rely more on observational and interview skills to uncover what’s going on and begin the diagnostic and treatment process, says Cleveland Clinic neurologist Michal Gostkowski, DO. Some advice on how to proceed:

Initial signs

ET involuntary movements most often involve the hands and occur during action, in contrast to Parkinson disease (PD) tremors, which occur at rest. ET patients may try to mask or hide their shaking, so Dr. Gostkowski watches their hands when they’re distracted and listens to vocal tremors, another distinctive ET symptom. He also asks if their activities have changed. ET patients may stop socializing or discontinue hobbies that are affected by their tremors. Those restrictions, in turn, may trigger depression, another indicator to watch for. Also, since alcohol can temporarily dampen ET tremors, sufferers may be vulnerable to alcohol overuse or addiction.

Other diagnostic aids

Though ET has its own complications, your patient’s biggest early concern may be that his or her tremors result from PD. A neurologist can make the definitive diagnosis, but for reassurance’s sake, some simple tests in your office — handwriting and water-pouring ability can help differentiate ET from PD. ET patients’ handwriting is large and scratchy-looking, while PD patients’ rigidity results in smaller and smaller printing (a condition called micrographia). ET patients also have trouble pouring water from one cup to another, a task that PD patients execute without spills because their tremors occur at rest.

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Patient questions

Your patients likely will ask what caused their ET and what course their disease will take. Though ET clearly has a strong genetic component, no ET-linked genes have been identified so far, and it is likely that some as-yet unknown environmental cofactors are involved. Tremors tend to become more severe as patients age, with some association between age of ET onset and how quickly ET progresses. Older-onset patients have a faster rate of progression.

Medical treatment

Unfortunately, medications are only modestly effective at reducing ET tremors. The beta-blocker propranolol and the anti-seizure drug primidone are the most studied and seemingly the more beneficial, but each lessens tremor in about half of ET patients. Other ET medications include benzodiazepines and anticholinergics, which should be used cautiously in older patients.

Surgery

Deep brain stimulation (DBS) of the thalamus has shown good results in ET. “It’s a very viable option,” Dr. Gostkowski says. “We expect 70 percent to 80 percent improvement in the tremor in about 90 percent of patients,” with minimal side effects. ET patients and their physicians should consider DBS when tremors begin to impair daily living activities.

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