Tremor or shaking hands

Everyone has a small tremor: hold your hands out in front of you and look closely at the fingers, because perfectly still they are not. That tremor grows with cold, lack of sleep, hunger, strong coffee, nerves and a high temperature, and once the cause goes it settles back to its old level. People notice it at the moments when a hand has to be accurate: a full spoon, a key in a lock, a signature.

A tremor that does not go away along with the tiredness and the nerves is not "just nerves" and not a feature of your character — it is a symptom with a cause. The causes vary widely: some are harmless, some need treatment, and a few need it urgently. Sorting out which is which usually happens at the very first appointment, and the key question there is an unexpected one: not "how badly does it shake" but "at what moment".

The main distinction: in movement or at rest

The first thing done with a tremor is to split it into two groups, and almost everything else follows from that.

• Tremor on moving and on holding a position. The hands rest quietly on your knees and do not shake. But the moment you reach for a cup, hold it in the air or write, the tremor appears and gets in the way. What suffers most is accuracy at the end of a movement: getting a full spoon to your mouth, threading a needle.
• Tremor at rest. The hand lies there doing nothing and shakes anyway, often on one side only and often as though a pill were being rolled between thumb and index finger. Pick something up and the tremor eases or stops; let the hand down again and it comes back.

The difference is not in how strongly the hand shakes but in how the shaking behaves, and it separates two completely different illnesses: the first pattern is most often essential tremor, the second is the classic sign of Parkinson's disease.

Checking is easy: rest your relaxed hands on your knees for a couple of minutes without looking at them, then slowly bring a finger to your nose. What happens at each of those two moments is the most useful thing you can tell a doctor.

Essential tremor

This is the commonest cause of a persistent tremor of the hands. Usually both hands shake, though one is more obvious; over the years a slight "no-no" movement of the head and a wavering voice may join in. The legs stay out of it.

It has recognisable markers:

• it grows with coffee, lack of sleep, nerves and other people's attention — hands shake more in company than at home;
• a small amount of alcohol reduces it noticeably for a while;
• it often runs in families: a similar tremor is or was present in parents, brothers, sisters;
• it builds up slowly, over years rather than weeks;
• there is nothing else besides the tremor — walking, speech, smell and grip strength are unchanged.

That it settles with alcohol is useful for the doctor to know but no help to the patient: the amount that works keeps creeping up, the condition does not go away because of it, and a dependence gets added to the tremor.

Treatment exists and usually helps. When the tremor stops you working, writing or eating in front of others, beta blockers or certain anti-epileptic medicines are prescribed; for tremor of the head and voice, injections of botulinum toxin are used, and in severe cases neurosurgical options are discussed. Which medicine and what dose is the doctor's choice.

Tremor at rest: the hands are not the only thing looked at

Parkinson's disease almost never arrives as tremor alone, and its companions often appear earlier — they simply do not get connected to one another.

• Slowness: ordinary jobs take longer and fine movements become harder — buttons, brushing teeth, shoelaces.
• Walking in short shuffling steps, with difficulty setting off and difficulty turning round.
• One arm swings less than the other while walking; relatives usually spot this before the person does.
• The voice gets quieter and flatter, the face less expressive.
• Handwriting shrinks towards the end of a line and a signature "slides".
• Sense of smell fades or disappears years before anything else.
• Restless, acted-out dreams with shouting and movement, stubborn constipation, muscle stiffness.

One or two items from that list mean nothing on their own. But if tremor at rest goes together with several of them, do not put the appointment off: the condition is lifelong, yet treatment improves movement and wellbeing markedly, and it is better started now than in two years' time. A similar picture is also produced by certain medicines, which is the subject of the section below.

Thyroid, low blood sugar, caffeine and anxiety

There is a group of causes in which the tremor is fine and fast, involves both hands and arrives with other signs alongside. All of them are picked up by simple tests.

An overactive thyroid gland. The fine fast tremor comes in company with weight loss despite a good appetite, a racing heart, poor tolerance of heat, sweating, irritability and loose stools. A blood test for thyroid hormones is what is needed; the condition responds well to treatment and the tremor goes with it.

Low blood sugar. Shaking together with sweating, sudden hunger, a pounding heart and anxiety is the typical set for hypoglycaemia, and it mostly concerns people treating diabetes with insulin or with tablets that lower blood sugar. At that moment fast-acting carbohydrate is needed rather than waiting; if confusion or loss of consciousness appears, that is a reason to call an ambulance.

Caffeine, nicotine and anxiety. The tremor is real, but it is an exaggerated physiological tremor rather than a disease; an anxiety disorder adds a pounding heart, a lump in the throat and a feeling of not getting enough air. It is worth counting honestly the cups of coffee and tea, the energy drinks and the training supplements: five cups a day produce a tremor for which neurological causes then get hunted.

Medicines that make hands shake

Drug-induced tremor is one of the commonest causes and at the same time the easiest to remove. Check the leaflets if the tremor appeared or got worse within a few weeks of a new prescription or a dose increase.

• The inhalers that open the airways in asthma and chronic lung disease: shaky hands after a dose are familiar to many people and usually ease off over time.
• Antidepressants of various groups.
• Lithium and some anti-epileptic medicines, particularly at high doses.
• Thyroid hormone preparations at an excessive dose.
• Certain anti-sickness medicines and those used in psychiatry: these tend to give tremor at rest and stiffness instead, that is, a picture resembling parkinsonism, which clears once they are stopped.
• Steroid hormones, some medicines taken after an organ transplant, and drugs for heart rhythm disorders.

A prescribed medicine is not stopped on your own initiative and its dose is not lowered "to see what happens": some of these cannot be stopped abruptly, and some treat problems more dangerous than shaky hands. The right route is to come with a full list of everything you take, supplements included, and discuss a change or the dose with a doctor.

Alcohol: both a cause of shaking and a dangerous withdrawal

Drinking over many years damages the nervous system in its own right, and the tremor becomes permanent. But the main risk lies not in the drinking but in stopping.

In someone with alcohol dependence, withdrawal begins within hours of the last drink: the hands shake, and with them come sweating, a fast pulse, nausea, sleeplessness, anxiety and a rise in blood pressure. This is not "a state you have to sit out" but the start of a road that leads to a fit and to alcohol-withdrawal delirium, with clouded consciousness, hallucinations and a high temperature. The delirium is life-threatening.

So stopping alcohol abruptly after a long spell of heavy drinking is not something to do alone. If the shaking builds up after stopping and confusion, visions or fits are added, that is a call for an ambulance and not a reason to wait until morning; the single European emergency number is 112. Giving up alcohol where there is dependence is planned together with a doctor, who will prescribe the medicines that cover the withdrawal safely.

When tremor needs help immediately

Tremor on its own is rarely urgent, but there are combinations where the hours count.

• Tremor or clumsiness in a hand has come on suddenly and with it there is difficulty speaking, weakness in an arm or leg, a drooping face, double vision or loss of balance. That is how a disturbance of the brain's blood supply shows itself: an ambulance is needed, number 112.
• Tremor with a high temperature and confusion. A severe infection can be the cause — call an ambulance.
• Tremor and jerking together with muscle stiffness, sweating, fever and agitation in someone recently started on a psychiatric medicine or whose dose has recently gone up: this is a serious drug complication needing immediate help.
• Tremor after a blow to the head, and tremor that builds not over years but over days and weeks.

What gets worked out at the appointment

With tremor, the examination tells the doctor more than most tests do. You will be asked to hold your hands out and keep them there, bring a finger to your nose, draw a spiral, write a sentence and walk across the room; the doctor will watch what the hands do at rest and assess stiffness, facial expression and arm swing while you walk.

Then come the questions: when the tremor started and how fast it grew, at what moment it shows, what makes it worse and what eases it, whether anyone in the family has anything similar, what medicines you take and how much coffee and alcohol you drink. Of the tests, a blood sample with thyroid hormones and glucose is usually needed; if the tremor began at a young age, copper is added, because that is how Wilson's disease is looked for — uncommon, but manageable when treated in time. A brain scan is not done for everyone, only when the picture is atypical or the tremor came on quickly.

A mild tremor that does not interfere and is not caused by another condition needs no treatment: keeping an eye on it and a few plain measures are enough — less caffeine, decent sleep, heavy crockery and weighted cutlery, which damp the shaking down. If the tremor gets in the way of living, treatment is chosen according to the cause rather than the size of the shake.

Online consultation

An online appointment suits a first assessment well. The doctor will ask at what moment the hands shake, what appeared before the tremor did and how things are changing, will go through the list of your medicines and supplements with you, help make sense of tests you already have, and say whether more are needed. It is often here that the cause turns out to be a new medicine or the amount of coffee.

There is a separate advantage: a short video filmed at home, because hands behave differently there than in a consulting room. The doctor will suggest what to record and how, explain which specialist to see and what to bring, and warn you if your situation calls for an examination that same day rather than a conversation. What an online consultation cannot do is replace a neurological examination, but it does save unnecessary trips.

This material is for information only and does not replace medical advice.