Scott Webb (Host): Essential tremor can be frustrating for patients. It is a slowly progressing condition that can take years or even decades to severely affect patients. My guest today is here to explain essential tremor and share some of the treatment options that have proven to be effective. I'm joined today by Dr. Nima Beheshti. He's a neurologist with Salinas Valley Health.

This is Ask the Experts, the podcast from Salinas Valley Health. I'm Scott Webb. Doctor, it's nice to have you back on the podcast. Last time we talked about Parkinson's. Today, we're talking essential tremor, causes, symptoms, treatment. So, let's just start there as an introduction, you know, for listeners and myself even. When people search what is this condition and should I be worried, how do you explain it in simple everyday language?

Dr. Nima Beheshti: So, essential tremor is a very common neurologic disorder that the most common symptom is a tremor, usually in the arms, though it can also be present in the chin or the neck. And the kind of defining feature of this tremor is it's present when you're using your hands. So, most patients will tell me, "This is a tremor that occurs when I'm trying to drink my coffee or use a screwdriver or kind of carrying something, holding my phone," something like that. Generally speaking, it is not a dangerous condition. We don't think of it as something that progresses to severe disability or death. But it can be bothersome and, in many cases, it can get in the way of people doing their hobbies or doing things that they love. So, we still take it quite seriously.

Host: It makes me wonder, Doctor, like, what are some of the biggest maybe myths or misunderstandings that you hear about this condition that maybe you can, again, at the start here, sort of clear up for folks?

Dr. Nima Beheshti: Absolutely. I think the number one thing I want to clear up is essential tremor is not Parkinson's disease, and it is not some kind of pre-Parkinson's disease. It doesn't become Parkinson's later. You can get both essential tremor and Parkinson's, but the type of tremor they cause is different. Parkinson's tends to involve other parts of the body like balance or thinking or blood pressure. That essential tremor doesn't. And then, essential tremor has more of a genetic component than Parkinson's does. But generally speaking, just because you have essential tremor doesn't mean that you're doomed to get Parkinson's. Some people have both, but that's somewhat rare.

Host: Okay. Yeah, and you can see how folks, laypeople like us, would connect those dots. So, good to do a little myth-busting as we get started here. So then, what are the maybe earliest warning signs or symptoms that people should watch out for, and how do they usually show up in day-to-day life? So generally speaking, like, how would folks know and what might get them to speak with their providers?

Dr. Nima Beheshti: Most of the time, this tremor is the kind that people will talk to their provider about because it starts to get in the way of everyday activities. So, some examples are eating, you know, using a spoon to have soup or cereal can be more difficult because the spoon shakes. Writing can get harder, you know, holding a pencil. Some people have trouble buttoning their shirts because that takes fine motor movement. It's in general the kind of things that involve very fine dexterity. They're the ones that are first affected, and most people will bring that up to their primary doctor. So, it's one that I usually hear about this tremor when people have it in the earliest stages. It's rarely missed by patients.

Host: Yeah. When we think about risk factors, you mentioned there's a big genetic component to tremors, but age, family history, lifestyle, maybe other medical problems, do those increase our risk for developing essential tremors?

Dr. Nima Beheshti: We do know of some of them. You know, as I mentioned, family history is common. Many people will have a parent or grandparent who had a similar condition. But many don't, and it just happens randomly for some patients. It tends to happen in older patients, but it doesn't mean it can't happen in younger patients. You know, as early as in your 20s, it can begin. But I would say for the majority of people, it starts around age 50 or 60.

Now, compared to other illnesses, it is a slower progressing illness. And so, for a lot of my patients, I may diagnose the essential tremor, but it may go years without obviously worsening. And in some cases, they may go 10 or 20 years before it really starts to get bothersome. So for many people, it's a slowly progressive illness, and that's kind of unique in the neurologic world.

Host: Yeah, it sounds like it. And when we think about diagnosis and treatment, so if somebody does speak with their doctor, right? And they get referred to someone like yourself, worried they may have this condition, what does the diagnostic process look like, you know, from maybe that first visit and just having a conversation to real definitive answers?

Dr. Nima Beheshti: The most important thing for diagnosing essential tremor is the neurologic examination. So, there is no brain test like an MRI or CT scan, and there is no blood test that tells me if you have this tremor. So, it involves doing a detailed examination to kind of tease out your tremor with different maneuvers. And that's the only way to make the diagnosis.

Now, the other things that are important on our first visit is to look for other things that could be making the tremor worse. You know, rarely people will have thyroid issues that can worsen a tremor. There are some common medications that can worsen people's tremor. And so, part of my job is also not only to diagnose the tremor, but see is there another medicine or health condition that's affecting your tremor and making it worse because maybe that's part of the treatment.

Host: Let's talk the main treatment options anyway. Broadly speaking, from medications to some maybe newer therapies, what's been working for patients?

Dr. Nima Beheshti: The important part about discussing treatment for essential tremor is that I'll discuss some options, but none of our treatments either cure or even slow down the essential tremor. And so, they're purely for symptom relief. And so, when I talk to my patients about the treatment, if the tremor isn't bothersome or getting in the way of them living their life, I actually don't recommend treatment with pills or other—because it's not curative.

Now, if the tremor is getting in the way of their everyday life, whether that's, you know, tasks like eating or getting dressed or even hobbies like painting or writing, then we do have some treatment options at our disposal. We do have some medications, pills you would take on a daily basis that can calm down the tremor. And many patients get good relief from these treatments. We have to balance them with side effects as always, and some of them can cause fatigue or sleepiness. And so, that can be a limitation of treatment.

We also have some newer treatments and therapies, including what we call a deep brain stimulator. So, we can use a computer, and we can use electrodes in the brain to kind of stimulate the parts that are causing the tremor to calm down the tremor without needing to take pills. This technology has been around for about 25 or 30 years, and we're getting very good at treating the tremor using electrical stimulation.

Host: Yeah, I'm glad you brought up technologies, because I was thinking, "All right, you know, there's so much new stuff and cool stuff out there. Home monitoring devices, apps, telehealth, AI perhaps." Is any of that maybe at least changing the way you follow someone with tremors and manage their condition?

Dr. Nima Beheshti: It does help, and we do have some technologies that are being developed. Some of them are kind of in their earlier stages. For example, we have invented silverware that will have a gyroscope inside that can try to counteract your tremor. So when you're having something like soup or cereal, you won't spill as much out of the side. It doesn't work great. And so instead, we often actually recommend just good old-fashioned heavier silverware. It turns out that weighted utensils tend to trigger less of your tremor. And so, even though we are developing these kind of newer, fancier technologies, sometimes the older things just plain work better right now.

Host: Just a heavier spoon. Sure. Yeah

Dr. Nima Beheshti: Correct. Yeah. We have gloves that also provide some stimulation to the hands, some vibration stimulation, and that has been shown to help a little bit. These don't have a huge impact on the tremor, but the nice thing is they don't have side effects. And so, whatever treatments we have at our disposal that don't risk people having side effects, I'm always a fan of.

Host: Yeah. And as you said, there's no magic pill, there's no cure yet for essential tremors. But are there some, like everyday changes we can make? Let's say diet, exercise, better sleep, more sleep, stress management. Like, is there anything that we can do behavior and lifestyle-wise to help at least with the symptoms? Can we help ourselves in any way?

Dr. Nima Beheshti: Yeah, absolutely. Actually, we do know that regular exercise is the only treatment that can slow down the progression of essential tremor. We have studied various kinds of exercise and the type of exercise, whether it's walking or biking or swimming, that matters less. It's more about the intensity and the duration.

And so, we know with people who have essential tremor, regular aerobic exercise like walking 20 minutes a day or more can actually slow down the progression. And it can also help treat the intensity of the tremor. And so, that's the number one treatment to everyone who comes into my office with essential tremor, is we got to get a regular exercise regimen in. Because not only will it treat the tremor without side effects, but it's the only thing that'll slow down the progression

Host: All right. So, Doctor, I'm sure that this diagnosis can be frightening for patients, families. So, what do you say in those initial conversations maybe to help reduce fear and at least give them a sense of control?

Dr. Nima Beheshti: Most of my patients, their biggest worry is this Parkinson's or am I going to get Parkinson's? So my first thing is, you know, this is not Parkinson's. And while you can get Parkinson's in the future, don't think of this as being like a guarantee that that's going to come.

Host: Yeah, it's that pre-Parkinson's, right? yeah.

Dr. Nima Beheshti: Exactly. Exactly. And I also remind patients that, generally speaking, this is a slowly progressive illness. And so, many people will go, you know, five years, 10 years, maybe even sometimes 20 or 30 years without it meaningfully impacting what they do. And so, it being a slowly progressive illness is kind of working in our favor. And so, many patients can kind of just watch. And then, in the earlier stages, we can also get by with those behavioral modifications. There are people who will sew magnets instead of buttons into their shirt to still be able to wear what looks like a button-up shirt, but not require the manual dexterity that their tremor gets in the way of.

So, we have many techniques to help kind of adapt to the tremor and help account for it. So to keep people living their normal lives, doing the hobbies that they love, without having to worry about medications or side effects. So, there's a lot of avenues we have to kind of address this tremor for people's day-to-day lives.

Host: I'm thinking about motivation, right, Doctor? How do we just sort of deal with this and stay motivated? Are there support systems, family, community groups, online forums, mental health services even, that have made a difference for patients?

Dr. Nima Beheshti: We do think that there is a slightly increased risk of some word-finding and maybe even some anxiety or depression in patients with essential tremor. And so, I think staying well-connected to your primary doctor, but also having a therapist can be very helpful, because it can be a tough illness as it progresses for some people.

As far as online forums and groups, there are a number of online support groups. I actually like to show my patients the website essentialtremor.org. It has a lot of resources, both including explaining what this illness is, but also some practical things you can do to help alleviate the symptoms without medications, and even has a list of devices or things you can buy that they recommend that can get around some of the tough symptoms. And so, that's another resource I definitely recommend to my patients to be able to check out and learn more about this illness.

Host: Well, as I said when we started, it's always great to have you on. Parkinson's, we're doing tremors here. I'm sure we'll speak again in the future. But for today, let's just leave folks with some takeaways, like three key takeaways about essential tremors that you want folks to know, what would you leave them with?

Dr. Nima Beheshti: If you do get the diagnosis of essential tremor, it is not Parkinson's or pre-Parkinson's. It tends to be a slowly progressive illness. And so for many people, they remain without disability for a long time, even decades. And three, for the patients where they feel like the tremor is getting in the way of their day-to-day life or the things they want to do, we have a number of treatments ranging from kind of everyday adaptive devices to pills to even brain surgery to help treat the symptoms. So, we have many options at our disposal.

Host: Yeah, whenever I host these, doctor, I always want to feel optimistic, right? To understand these conditions and feel some level of optimism, to feel like we're in control a little bit. So as you said, you know, exercise, heavier spoons, there's things that we can do. So, as I said, great to have you on. Thanks so much.

Dr. Nima Beheshti: Of course. My pleasure. Take care.

Host: And to listen to more of our podcasts, please visit salinasvalleyhealth.com/podcasts. And if you found this podcast to be helpful, please be sure to tell a friend, neighbor, or family member. And subscribe, rate and review this podcast, and check out the entire podcast library for additional topics of interest. This is Ask the Experts from Salinas Valley Health. I'm Scott Webb. Stay well, and we'll talk again next time.