From the Guidelines
The most appropriate initial step in managing a 75-year-old patient with intermittent tremors is to conduct a comprehensive neurological examination to characterize the tremor pattern and identify potential causes, followed by a detailed medical history and laboratory tests to assess for underlying conditions that may be contributing to the tremors. This approach is crucial in determining the etiology of the tremors, which could range from essential tremor to parkinsonian tremor, and guiding the treatment plan accordingly. The examination should focus on identifying any associated neurological symptoms, and the medical history should include inquiries about medication use, family history of movement disorders, and any previous diagnoses of neurological conditions [ 1 ].
Initial Evaluation
Initial evaluation should include:
- A detailed medical history
- Laboratory tests to assess thyroid function, liver function, electrolytes, glucose levels, and vitamin B12 status
- Neuroimaging with MRI of the brain to rule out structural lesions
Treatment Considerations
For treatment of essential tremor, which is common in this age group, first-line pharmacotherapy includes propranolol (starting at 10-20 mg twice daily, gradually increasing to 40-120 mg daily as tolerated) or primidone (starting at 12.5-25 mg at bedtime, gradually increasing to 50-250 mg three times daily) [ 1 ]. For parkinsonian tremor, levodopa/carbidopa (starting at 25/100 mg three times daily) may be effective. Medication selection should consider the patient's cardiovascular status, as beta-blockers are contraindicated in certain cardiac conditions.
Additional Therapies
Physical and occupational therapy can help with adaptive strategies, while weighted utensils may improve function. Strategies such as superimposing alternative, voluntary rhythms on top of the existing tremor, using the unaffected limb to dictate a new rhythm, and assisting the person to relax the muscles in the limb can be beneficial [ 1 ]. For severe, medication-resistant tremors, referral to a movement disorder specialist for consideration of deep brain stimulation may be appropriate. Treatment decisions should be individualized based on tremor characteristics, impact on quality of life, comorbidities, and patient preferences.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Diagnostic Approach
- A thorough diagnostic workup is necessary to determine the underlying cause of tremors in a 75-year-old patient, considering essential tremor and Parkinson's disease as potential diagnoses 2, 3.
- The patient's medical history, family history, and physical examination findings, such as the presence of postural and kinetic tremors, rest tremors, and other neurological signs, will guide the diagnostic process 4.
Treatment Options
- For essential tremor, treatment options include beta blockers (e.g., propranolol), anticonvulsants (e.g., primidone), and other medications, which can reduce tremor severity by half 5, 6.
- In cases of medication-refractory essential tremor, alternative therapies such as botulinum toxin injections, deep brain stimulation, and magnetic resonance-guided focused ultrasound may be considered 5, 6.
- For Parkinson's disease, levodopa is the mainstay of pharmacologic therapy, although other agents, such as dopamine agonists and anticholinergics, may also be used 2, 3.
Considerations for Elderly Patients
- When treating elderly patients with tremors, it is essential to consider the potential side effects of medications, such as mental side effects from anticholinergics 3.
- The patient's overall health status, comorbidities, and medication regimen should be taken into account when selecting a treatment plan 2, 6.