What can be done for an 82-year-old female with Type 2 Diabetes Mellitus (DM II), obesity, Gastroesophageal Reflux Disease (GERD), Hypertensive Heart Disease (HHD) with Congestive Heart Failure (CHF), and Paroxysmal Atrial Fibrillation (PAF) who is experiencing coarse tremors of the upper extremities (UE) and lower extremities (LE) with exertion while undergoing physical therapy (PT)?

Management of Exertional Tremors in an 82-Year-Old with Multiple Comorbidities

Yes, this tremor can be managed, but first you must determine whether this is enhanced physiologic tremor from exertion/medications, a parkinsonian tremor, or a functional tremor—each requires a completely different treatment approach.

Initial Diagnostic Characterization

The first critical step is to precisely characterize this tremor during physical therapy sessions:

• Activation pattern: Does the tremor occur at rest and improve with movement (parkinsonian), worsen with sustained postures or goal-directed movements (action tremor), or only appear during exertion (enhanced physiologic)? 1, 2

• Frequency and amplitude: Coarse tremors suggest lower frequency (3-6 Hz), which could indicate parkinsonian tremor, cerebellar dysfunction, or enhanced physiologic tremor 1, 2

• Distribution: Involvement of both upper and lower extremities is unusual for essential tremor (typically upper extremity predominant) and raises concern for parkinsonian syndromes, metabolic causes, or medication effects 1, 3

• Relationship to exertion: If tremor appears only with physical therapy exertion and resolves with rest, this strongly suggests enhanced physiologic tremor from catecholamine release, deconditioning, or medication effects 4

Medication Review is Critical

Review all current medications immediately, as drug-induced tremor is extremely common and often overlooked in elderly patients with polypharmacy. 1, 2

Common culprits in this patient population include:

• Beta-agonists for any respiratory conditions
• Valproate (if used for any indication)
• Lithium
• Antipsychotics or antiemetics (metoclopramide, prochlorperazine)
• Selective serotonin reuptake inhibitors
• Amiodarone (given her atrial fibrillation history) 1, 5

Consider Metabolic and Cardiac Factors

Given her complex medical history, several factors may contribute:

• Hypoglycemia: In diabetic patients on certain medications, exertional hypoglycemia can trigger tremor 6

• Cardiac decompensation: With CHF and paroxysmal atrial fibrillation, inadequate cardiac output during exertion could manifest as tremor from catecholamine surge 6, 7

• Electrolyte disturbances: Hypokalemia, hypomagnesemia, or hypocalcemia from diuretics can cause tremor 1

Specific Management Based on Tremor Type

If Enhanced Physiologic Tremor (Most Likely Given Exertional Pattern):

Propranolol 80-240 mg/day is the most effective first-line treatment for enhanced physiologic tremor, with over 40 years of demonstrated efficacy. 4

However, critical contraindications exist in this patient:

• Her CHF is an absolute contraindication to beta-blockers in standard doses 4
• At 82 years, she is at high risk for serious adverse events from excessive heart rate reduction 4

Alternative non-pharmacological approaches should be prioritized:

• Modify physical therapy to avoid strenuous exercise immediately before precision tasks 4
• Implement shorter, more frequent PT sessions rather than prolonged intensive sessions 6
• Ensure adequate hydration before and during PT (17 ounces 2 hours prior) 6
• Reduce caffeine intake if applicable 4
• Use rhythm modification techniques during PT: superimpose alternative voluntary rhythms and gradually slow movement to rest 8, 4

If Functional/Psychogenic Tremor:

Look for these distinguishing features:

• Variable frequency, amplitude, and direction 8
• Worsens with attention, improves with distraction 8
• Entrainability (tremor frequency changes when the unaffected limb performs rhythmic movements) 8

Treatment approach:

• Provide clear, empathetic explanation acknowledging the involuntary nature while explaining the functional diagnosis 8
• Use entrainment techniques: have the patient use the unaffected limb to dictate a new rhythm, gradually slowing to stillness 8
• Incorporate music to override the tremor pattern during PT 8
• Minimize adaptive equipment—aids are generally unhelpful and may reinforce illness behavior in functional disorders 8

If Parkinsonian Features Present:

Red flags requiring neurological evaluation:

• Resting tremor that improves with voluntary movement 9, 1
• Bradykinesia, rigidity, or postural instability 9
• Early prominent gait dysfunction and falls (suggests atypical parkinsonism like PSP or MSA rather than Parkinson's disease) 9
• Poor response to levodopa trial 9

At 84 years with multiple comorbidities, atypical parkinsonian syndromes (PSP, MSA) are more likely than classic Parkinson's disease if parkinsonian features are present 9.

Practical Exercise Modifications for This Patient

Given her age, diabetes, obesity, CHF, and atrial fibrillation, exercise must be carefully tailored:

• Start at very light intensity (20% VO2 reserve, RPE 10) and progress gradually 6
• Use intermittent exercise periods of 10 minutes until she can tolerate 20-30 minutes continuous 6
• Focus on non-weight-bearing activities if tremor impairs balance: stationary cycling, recumbent cycling, aquatic exercise 6
• Avoid explosive movements and high-impact activities 6
• Monitor for atypical cardiac symptoms (she may have silent ischemia given diabetes) 6
• Ensure proper footwear and daily foot inspection given diabetes and peripheral neuropathy risk 6

Immediate Action Steps

1. Document tremor characteristics precisely during next PT session (rest vs. action, frequency, entrainability) 1, 2
2. Complete medication review for tremor-inducing agents 1
3. Check basic metabolic panel, magnesium, calcium, and glucose monitoring around PT sessions 1
4. Assess cardiac status: Is her CHF optimally managed? Is rate control adequate for atrial fibrillation during exertion? 6, 7
5. Trial of rhythm modification techniques during PT as both diagnostic and therapeutic 8, 4

Common Pitfalls to Avoid

• Do not prescribe beta-blockers without cardiology consultation given her CHF 4
• Do not assume this is "just anxiety" or deconditioning without proper tremor characterization 8, 1
• Do not provide excessive adaptive equipment if functional tremor is suspected, as this reinforces disability 8
• Do not push aggressive exercise intensity in this deconditioned 82-year-old with cardiac disease—gradual progression is essential 6

The tremor is likely enhanced physiologic tremor from exertion in a deconditioned patient, potentially exacerbated by medications or metabolic factors, and can be managed with PT modifications and addressing underlying contributors rather than pharmacotherapy given her contraindications 4, 1.