How to manage tremor in an older adult?

Management of Tremor in Older Adults

Start with propranolol 80-240 mg/day as first-line pharmacological treatment for essential tremor in older adults, after excluding secondary causes and assessing cardiovascular contraindications. 1, 2

Initial Assessment and Diagnosis

Identify Tremor Type and Exclude Secondary Causes

• Assess tremor characteristics: Determine if tremor occurs at rest (Parkinsonian), with intention (cerebellar), or with action/posture (essential tremor). 3, 4, 5

• Screen for medication-induced tremor: Review all medications for tremor-inducing agents including beta-agonists, valproate, lithium, SSRIs, and stimulants. 1

• Rule out metabolic causes: Check thyroid function (hyperthyroidism causes action tremor), calcium/parathyroid hormone (hyperparathyroidism), and liver function (hepatic encephalopathy causes asterixis). 6, 3

• Evaluate for enhanced physiologic tremor triggers: Assess for excessive caffeine intake, anxiety, stress, or recent strenuous exercise before precision tasks. 2

• Consider neuroimaging for intention tremor: Order MRI brain with and without contrast if cerebellar signs present (gait instability, dysarthria, truncal ataxia) to identify structural lesions, demyelinating disease, or stroke. 3

Apply Geriatric Assessment Framework

• Assess functional impact: Evaluate how tremor affects activities of daily living, social interactions, and quality of life to determine treatment intensity. 1

• Review polypharmacy: Reconcile all medications for drug-drug interactions and high-risk medications (anticholinergics, benzodiazepines) that increase fall risk. 6, 1

• Estimate prognosis: Use validated tools to prioritize interventions likely to provide benefit within the patient's life expectancy. 1

• Determine what matters most: Align treatment goals with patient preferences, as concordance improves adherence. 1

Pharmacological Management

First-Line Treatment for Essential Tremor

• Propranolol 80-240 mg/day: Most effective first-line agent with over 40 years of demonstrated efficacy, reducing tremor severity by approximately 50%. 2, 7, 8

• Start low and titrate slowly: Begin with low doses in elderly patients due to altered pharmacokinetics, and monitor for excessive heart rate reduction. 1, 2

• Monitor cardiovascular status: Check blood pressure regularly and assess for cardiovascular risk factors, though robust evidence does not support increased cerebrovascular/cardiovascular events from propranolol use in older adults. 6

• Contraindications to avoid: Do not use beta-blockers in patients with chronic obstructive pulmonary disease, bradycardia, or congestive heart failure. 2

Alternative Beta-Blockers

• Consider nadolol, metoprolol, or atenolol: If propranolol causes intolerable side effects, these alternatives have evidence for tremor control. 2, 7, 8

Second-Line Pharmacological Options

• Primidone: Can be used as monotherapy or combined with propranolol if either agent alone provides inadequate tremor control. 7, 8, 9

• Topiramate or gabapentin: Consider as alternative antiepileptic drugs if first-line agents fail. 7, 8

• Benzodiazepines (e.g., clonazepam): May provide benefit particularly in patients with associated anxiety, but use cautiously due to increased fall risk and delirium risk in elderly. 6, 7

Treatment for Parkinsonian Rest Tremor

• Levodopa/carbidopa combination: Effectively reduces rest tremor in Parkinson's disease by crossing the blood-brain barrier and converting to dopamine in the brain. 1, 4, 5

• Carbidopa reduces peripheral side effects: Inhibits peripheral decarboxylation of levodopa, reducing nausea/vomiting and allowing more levodopa to reach the brain. 4, 5

Non-Pharmacological Management

Lifestyle Modifications for Enhanced Physiologic Tremor

• Reduce caffeine consumption: Limit or eliminate caffeine intake, which increases catecholamine release. 2

• Avoid strenuous exercise before precision tasks: Time physical activity appropriately to minimize tremor during important activities. 2

• Implement stress reduction techniques: Address anxiety and stress that trigger enhanced physiologic tremor. 2

Supportive Therapies

• Rhythm modification techniques: Use music or alternative rhythms to help control tremor during specific tasks. 2

• Occupational therapy: For mild to moderate tremor, adaptation of coping strategies may provide adequate control. 9

Invasive Treatments for Refractory Cases

Indications for Advanced Therapies

• Consider for severe, disabling tremor: When medications fail due to lack of efficacy or intolerable side effects and tremor significantly impairs function. 1, 2, 9

Surgical Options

• Deep brain stimulation (DBS): Established alternative therapy providing tremor control in approximately 90% of patients with low morbidity/mortality; preferred for bilateral procedures. 1, 7, 9

• Focused ultrasound thalamotomy: Newer therapy attracting increasing interest for unilateral procedures. 9

• Thalamotomy: Comparable efficacy to DBS but with more complications, particularly with bilateral procedures. 7, 9

Botulinum Toxin Injections

• For head or voice tremor: May provide relief when injected into affected muscles. 7, 10

• Avoid for hand tremor: Results in bothersome hand weakness and is not widely used. 7

Critical Pitfalls to Avoid

• Do not apply single-disease guidelines rigidly: Elderly patients with multimorbidity require individualized assessment to avoid unnecessary or potentially harmful care. 1

• Avoid the prescribing cascade: Do not misidentify drug side effects as new medical conditions requiring additional prescriptions. 1

• Minimize high-risk medications: Particularly avoid anticholinergics (cyclobenzaprine, oxybutynin, tricyclic antidepressants), benzodiazepines, and diphenhydramine that increase fall risk and delirium. 6, 1

• Do not use cholinesterase inhibitors: These are ineffective for tremor and may increase adverse effects and mortality risk in older adults. 6

• Reassess medication appropriateness regularly: Reevaluate at every healthcare transition and periodically in outpatients, considering discontinuation of interventions unlikely to provide meaningful benefit. 1

Multidisciplinary Collaboration

• Involve geriatric specialists: For elderly patients with tremor causing significant functional impairment, frailty, or multiple comorbidities, collaboration addresses the multifactorial nature of disability. 1

• Use interdisciplinary team assessment: Monitor adherence and treatment complexity, as complex regimens increase risk of nonadherence and adverse reactions. 1