What is the best course of action for an elderly patient with dizziness, shakiness, leg pain, and tremors after taking Advil (ibuprofen) for 3 days?

Immediate Management of Elderly Patient with Tremors, Dizziness, and Leg Pain After NSAID Use

This patient requires immediate discontinuation of ibuprofen and urgent evaluation for NSAID-induced central nervous system toxicity, deep vein thrombosis (DVT) given the unilateral leg swelling with a palpable lump, and assessment for drug-induced movement disorders. 1, 2

Critical First Steps

Discontinue Ibuprofen Immediately

• NSAIDs, particularly in elderly patients, can cause rare but significant CNS adverse effects including tremor, confusion, dizziness, and somnolence 1
• The temporal relationship between ibuprofen initiation (3 days ago) and symptom onset (tremors starting "a couple days ago") strongly suggests drug-induced etiology 1
• Elderly patients are particularly vulnerable to NSAID CNS toxicity, with psychosis and cognitive changes being more common in this population 1

Urgent DVT Evaluation

• The unilateral left leg swelling with a palpable calf lump requires immediate ultrasound to rule out DVT 1
• NSAIDs have antiplatelet effects that could complicate bleeding risk if anticoagulation is needed 1
• Do not delay imaging—this is a time-sensitive evaluation

Assess for Delirium

• Evaluate for reversible causes of delirium including hypoxia, urinary retention, and constipation 1
• The combination of tremors, shuffling gait, and dizziness in an elderly patient on NSAIDs warrants systematic delirium screening 1
• Ensure adequate lighting and orientation during examination 1

Pain Management Alternatives

Immediate Substitution

• Replace ibuprofen with acetaminophen (paracetamol) as first-line analgesic for musculoskeletal pain in elderly patients 1
• Acetaminophen is non-inferior to NSAIDs for minor musculoskeletal trauma and has significantly better safety profile in elderly 1
• Dosing: Regular intravenous or oral administration every 6 hours unless contraindicated 1

If NSAIDs Are Absolutely Required

• Co-prescribe a proton pump inhibitor (PPI) for gastrointestinal protection 1
• Monitor closely for drug interactions, particularly if patient is on ACE inhibitors, diuretics, or antiplatelets 1
• Use lowest effective dose for shortest duration 2

Neurological Assessment

Tremor Evaluation

• Distinguish between drug-induced tremor versus essential tremor or parkinsonian features 3, 4
• The "bouncing" appearance of arms and legs with shuffling gait raises concern for either:
  • NSAID-induced movement disorder (rare but documented) 1
  • Underlying neurological condition unmasked by medication 1
• Document tremor characteristics: resting vs. action, frequency, amplitude 3

Gait and Balance Assessment

• Elderly dizzy patients commonly have concurrent leg muscle weakness and imbalance 5
• Test hip extension, knee extension, and ankle dorsiflexion strength 5
• Assess fall risk given baseline independent ambulation now deteriorated to shuffling 1

Monitoring and Follow-Up

Immediate Laboratory Work

• Renal function (creatinine, eGFR) to assess for NSAID-induced acute kidney injury 1
• Complete blood count to evaluate for NSAID-related hematologic effects 1
• Consider ibuprofen level if severe toxicity suspected, though clinical management doesn't depend on this 2

Expected Timeline for Improvement

• If symptoms are NSAID-induced, expect improvement within 24-48 hours after discontinuation 1, 2
• Ibuprofen half-life is 2-5 hours; CNS effects should resolve as drug clears 2
• If tremors persist beyond 72 hours post-discontinuation, pursue alternative neurological diagnoses 3, 4

Critical Pitfalls to Avoid

• Do not attribute all symptoms to age or "benign" causes without excluding drug toxicity 1
• Do not restart NSAIDs if symptoms resolve—this confirms causation and prevents recurrence 1
• Do not overlook the DVT risk with unilateral leg findings—this requires same-day imaging 1
• Do not use benzodiazepines for tremor management in this acute setting, as they increase fall risk and can worsen confusion in elderly 1, 6
• Avoid combining multiple CNS-active medications (opioids, benzodiazepines, muscle relaxants) which potentiate adverse effects 1

Disposition Planning

If Symptoms Improve After NSAID Discontinuation

• Transition to acetaminophen-based pain regimen 1
• Physical therapy referral for gait training and fall prevention 5
• Home safety assessment given increased fall risk 1

If Symptoms Persist or Worsen

• Neurology consultation for movement disorder evaluation 3, 4
• Consider brain imaging if focal neurological signs develop 1
• Evaluate for other causes of tremor (thyroid dysfunction, medication interactions, essential tremor) 3, 4, 7