This 72-year-old man complained of bilateral hand tremors since his teenage years, very slowly progressive. It had only been over the last 5 years that he felt the tremor had affected his dexterity and begun to interfere with his social life, his ability to play the guitar, and put together airplane models, one of his hobbies. He occasionally spilled coffee and had to shave with an electrical razor to avoid cuts. He had difficulty operating the computer mouse and did very little handwriting given the illegibility of his notes. His voice may occasionally quiver. He was not aware of head movements, which had been brought to his attention by others. He continued to work full-time in an executive position. Alcohol attenuated the severity of his tremor. He denied anosmia, constipation, or depression. He had been on no treatments for his tremor but wished to pursue some. A prior trial with low-dose propranolol was discontinued for lack of efficacy. His mother had tremor and two of his six children also did.

Tremors are rhythmic, oscillatory behaviors whereby a set of agonist and antagonist muscles activate in an alternating (as in the case of essential tremor and Parkinson disease, for instance) or synchronous fashion (as in the case of dystonic tremor). Our patient had the characteristic features for essential tremor, exemplified by a long history of slowly progressive, alcohol-response, often familial, postural, and kinetic tremor (Fig. 53.1). The examination also showed normal arm swinging during walking and macro- rather than micrographia, nullifying the possibility of Parkinson disease and no jerky, irregular, position-specific, action-induced tremor that would have supported dystonic tremor instead.