Essential Tremor: Care Staff Guide to Shaking Hands and Daily Support

A shaking hand can be a small nuisance or a daily barrier to eating, drinking, writing and dressing. Essential tremor is the most common cause of persistent tremor in adults, yet it is often confused with Parkinson's disease, and people who have it can feel embarrassed or be wrongly assumed to be nervous. This guide explains essential tremor for health and social care staff: how to recognise it, what can make it worse, how it is treated and how to support people to stay independent and keep their dignity.

What is essential tremor?

NIDirect, the Northern Ireland government health information service, describes essential tremor as an uncontrollable shake or tremble of part of the body that is more severe than normal tremor and tends to get worse over time. It calls it a common movement disorder affecting around four out of 100 adults over 40. NHS Scotland's Right Decisions service, which provides clinical factsheets for GPs, describes it as the most common adult movement disorder and says around 5% of people over 65 have it. It is usually progressive but, for most people, not severely disabling.

What does it look like?

According to NIDirect, most people notice a trembling, up-and-down movement of the hands. The arms, head, eyelids, lips and other muscles can also be affected, and a tremor in the voice box can make the voice sound shaky. The tremor is usually most noticeable when holding a position or doing hand tasks such as writing, rather than when the hand is completely at rest. It may affect the two sides of the body unequally, and it often starts mildly before becoming more severe.

The clinical factsheet describes essential tremor as an action tremor, appearing when a person is holding a cup or a pen, and says it is always bilateral, even if one side is worse. This is one of the clues clinicians use to tell it apart from the tremor of Parkinson's disease, which typically starts on one side, appears at rest and does not cause head tremor. Staff should not try to make the distinction themselves. Any new or changing tremor needs a clinician's assessment.

What can make it worse?

NIDirect lists several things that can temporarily worsen a tremor:

• tiredness, from strenuous activity or lack of sleep
• smoking
• caffeine in tea, coffee and some fizzy drinks
• being very hot or very cold
• certain medicines, including some antidepressants and asthma treatments

The Right Decisions factsheet adds that stimulants such as caffeine can worsen symptoms, and that beta agonist inhalers or nebulisers and some other drugs can aggravate or cause tremor. Stress, anxiety and anger also raise adrenaline and make any tremor more noticeable. Care teams can help by building rest into the day, offering decaffeinated drinks if the person agrees, and keeping the environment calm. If a tremor appears or worsens after a new medicine is started, tell the prescriber or pharmacist. This is a good example of why regular medicines reviews matter, as explained in our guide to polypharmacy and deprescribing. Never stop a prescribed medicine without clinical advice.

Causes and family history

NIDirect explains that essential tremor can run in families and that research suggests it is passed on by a faulty gene. It states that at least half of people with the condition have a relative who also has it, although the age of onset and severity can vary greatly within a family. Other conditions can cause tremor too, including an overactive thyroid, Parkinson's disease, multiple sclerosis, dystonia, peripheral neuropathy and alcohol withdrawal, which is why diagnosis involves ruling these out. Our guide to dystonia explains another movement disorder in which tremor can occur.

Diagnosis

There is no specific test for essential tremor. NIDirect says a GP will carry out a physical examination, ask about personal and family history, and may order tests to rule out other causes. The NHS Scotland factsheet advises that everyone with a tremor should have their thyroid function tested in primary care. A neurology referral is not always needed if the diagnosis is clear, but may be arranged for diagnostic uncertainty or when treatment is not working.

Treatment

NIDirect states that there is no cure, but medicines can improve symptoms in at least half of people. Many people, according to the Right Decisions factsheet, need only reassurance. Where treatment is needed, the factsheet lists propranolol, a beta-blocker, and primidone as first-line medicines, noting that sedation can limit how well primidone is tolerated and that it is harmful in pregnancy. Other medicines are used as second-line options under specialist advice. For people who are severely disabled by a tremor that does not respond to drugs, the factsheet says deep brain stimulation or MRI-guided focused ultrasound may be considered.

These decisions belong to the prescriber and specialist. Care staff play an important part by giving medicines exactly as prescribed, reporting side effects such as dizziness, tiredness or a slow pulse, and noticing whether the person feels better or worse.

Practical support in daily life

Good support focuses on helping the person do things themselves safely, rather than doing things for them. Occupational therapists can recommend equipment and techniques tailored to the individual. Ideas that are commonly used include:

• Drinking: a cup with two handles, a lidded cup or a straw, and not filling cups to the brim. Hot drinks need extra care to prevent scalds.
• Eating: weighted or built-up cutlery, plate guards, and non-slip mats. Allow plenty of time so the person does not feel rushed or watched.
• Writing and signing: thicker pens, weighted pens, or alternatives such as a tablet or voice-to-text where appropriate.
• Personal care: electric razors and toothbrushes, easy-fasten clothing, and supporting the elbow on a surface to steady the hand.
• Medicines: check that the person can open packaging, and ask a pharmacist about easy-open options.

Stress and being watched often make tremor worse, so be discreet and avoid commenting on the shaking. Treat the person with patience and respect.

Emotional impact

Because a tremor is visible, some people avoid eating out, signing documents or social events. Withdrawal, embarrassment or low mood are common and worth noticing. Staff can encourage participation in activities that suit the person, challenge unkind comments and flag worries to the GP.

When to ask for advice

Ask the GP or nurse for advice if a tremor is new, frequent or severe, if it appears after a medicine change, if it comes with other symptoms such as weakness, stiffness, slowness or changes in speech, or if it is stopping the person from eating, drinking or doing things that matter to them. Call 999 for sudden weakness, facial drooping or slurred speech, which could be a stroke.

Frequently asked questions

Is essential tremor the same as Parkinson's disease?

No. They are different conditions, although both involve tremor. Parkinson's tremor usually appears at rest and often starts on one side, whereas essential tremor typically appears with action and affects both sides.

Is essential tremor dangerous?

It is not usually life-threatening, but it can interfere with daily tasks and confidence, and should be assessed to rule out other causes.

Does alcohol help?

The Right Decisions factsheet notes that some people report a response to alcohol, but alcohol is not a treatment, and staff should never encourage drinking as a way of controlling tremor.

Keep building your knowledge

Understanding neurological conditions helps teams give respectful, person-centred care. Explore the health and social care learning available through Learnsignal CPD to keep your knowledge up to date.

This article is general information for care staff, based on published NHS guidance, and does not replace the advice of a person's own clinicians.