What is the most common cause of tremor in the elderly?

Most Common Cause of Tremor in the Elderly

Essential tremor is the most common cause of tremor in elderly patients, characterized by postural and kinetic tremor primarily affecting the upper extremities and head. 1, 2, 3

Epidemiology and Clinical Significance

• Essential tremor is the most common adult tremor disorder and the most prevalent movement disorder affecting elderly populations 1, 2, 3
• The condition affects between 5 and 10 million persons in the United States 4
• Essential tremor is a progressive neurologic disorder that can cause substantial functional disability, often forcing patients to change jobs or seek early retirement 1

Clinical Characteristics

Essential tremor presents as a postural and kinetic tremor with frequency between 4 and 8 Hz, most commonly involving the upper extremities and head. 2

• The tremor occurs with maintained posture and during movement, distinguishing it from Parkinsonian resting tremor 2
• Arms are the most commonly affected body part and cause the most functional disability 5
• Head and voice tremor may also occur 1, 5

Important Differential Diagnosis in the Elderly

Beta-agonist medications are especially likely to cause tremor in elderly patients, and high doses should be avoided unless necessary. 6

• Parkinsonian tremor is primarily a resting tremor (4-6 Hz) that may have postural components and can coexist with or be misdiagnosed as essential tremor 7
• Patients should be examined for bradykinesia, rigidity, and postural instability to rule out Parkinson's disease 7
• A comprehensive medication review is necessary to identify dopamine antagonists and other medications that can cause or worsen tremor, particularly in elderly patients with polypharmacy 7

Special Considerations in Elderly Patients

• Elderly patients with tremor have significantly increased fall risk, requiring assessment of fall history, feelings of unsteadiness, and concerns about falling 7
• Elderly patients often have medical comorbidities that may alter tremor management, and treatment planning should be adjusted accordingly 7
• Up to 40% of elderly patients may not be able to use metered dose inhalers satisfactorily due to tremor, impaired cognitive function, weak fingers, or poor coordination 6

Treatment Approach

Treatment should be initiated with either primidone or propranolol as first-line agents when tremor causes functional disability. 5, 4

• If either primidone or propranolol alone does not provide adequate control, the medications can be used in combination 5
• If primidone and propranolol do not provide adequate control, benzodiazepines (such as clonazepam), gabapentin, or topiramate may be helpful 5
• For disabling head or voice tremor, botulinum toxin injections into the affected muscles may provide relief 5
• Surgical options (thalamotomy or deep brain stimulation of the thalamus) provide adequate tremor control in approximately 90% of patients with medication-refractory tremor 5

Common Pitfalls to Avoid

• Do not assume all tremors are essential tremor, as worsening tremor on treatment may indicate an incorrect initial diagnosis, particularly if Parkinsonian features are present 7
• Avoid overlooking medication causes of tremor, especially beta-agonists which are particularly problematic in elderly patients 6, 7
• Do not delay treatment when tremor causes functional disability, as approximately 50% of patients can achieve improvement with currently available medications 5