What are the treatment options for an older adult diagnosed with essential tremors?

Treatment of Essential Tremor in Older Adults

Start with propranolol (80-240 mg/day) or primidone as first-line therapy, which provide tremor control in up to 70% of patients, and only initiate treatment when tremor interferes with function or quality of life. 1, 2

First-Line Pharmacological Management

Propranolol

• Propranolol is the most established medication for essential tremor with over 40 years of demonstrated efficacy and remains the only FDA-approved treatment for this condition. 1, 3
• Dose range: 80-240 mg/day 1, 2
• Provides dual benefits in patients with coexisting hypertension 1
• Critical contraindications in older adults include:
  • Chronic obstructive pulmonary disease or asthma (risk of bronchospasm) 1, 2, 4
  • Decompensated heart failure 1, 4
  • Second- or third-degree heart block, sick sinus syndrome without pacemaker, or sinus bradycardia <50 bpm 4
• Monitor elderly patients closely for excessive heart rate reduction, dizziness, hypotension, lethargy, depression, and exercise intolerance 1, 4

Primidone

• Equally effective first-line alternative to propranolol 1, 2
• Requires 2-3 months for full clinical benefit to become apparent—allow adequate trial period before concluding inefficacy 2, 4
• Therapeutic benefit occurs even when derived phenobarbital levels remain subtherapeutic, confirming primidone itself has anti-tremor properties 2
• Does not require dose adjustment for impaired renal function 2
• Adverse effects include behavioral disturbances, irritability, and sleep disturbances, particularly at higher doses 2
• Counsel women of childbearing age about teratogenic risks (neural tube defects) 2

Alternative Beta-Blockers

If propranolol causes adverse effects, consider: 1

• Nadolol 40-320 mg daily 1
• Metoprolol 25-100 mg extended release daily or twice daily 1
• Timolol 20-30 mg/day 1
• Atenolol (limited evidence for moderate effect) 1

Second-Line Pharmacological Options

If first-line agents fail or are contraindicated: 1

• Gabapentin (limited evidence for moderate efficacy) 1
• Topiramate 5
• Carbamazepine (generally less effective than first-line therapies) 1
• Benzodiazepines (clonazepam) for intermittent use during stress-induced tremor exacerbations 6

Combination therapy with primidone plus propranolol can be used if monotherapy provides inadequate control. 6

Non-Pharmacological Interventions

Occupational Therapy Techniques

For functional tremor management: 7

• Superimpose alternative voluntary rhythms on existing tremor, gradually slowing all movement to complete rest 7
• For unilateral tremor: use the unaffected limb to dictate a new rhythm (tapping/opening and closing hand) to entrain tremor to stillness 7
• Assist with muscle relaxation to prevent cocontraction 7
• Control tremor at rest before progressing to activity 7
• Use gross rather than fine movements (e.g., marker on whiteboard with large lettering rather than normal handwriting) 7
• Discourage cocontraction or tensing of muscles as a tremor suppression method—this is not a helpful long-term strategy 7

Equipment and Adaptive Aids

• Avoid aids and equipment in the acute phase as they interrupt normal automatic movement patterns and cause maladaptive functioning 7
• If aids are necessary for safe discharge: 7
  • Consider as short-term solution only
  • Issue with minimalist approach
  • Establish plan to progress from equipment use
  • Assess patient with new equipment and teach correct use
  • Schedule follow-up to monitor use and support progression toward independence

Surgical Interventions for Medication-Refractory Tremor

Consider surgical options when medications fail due to lack of efficacy at maximum doses, dose-limiting side effects, or medical contraindications. 1, 2

Magnetic Resonance-Guided Focused Ultrasound (MRgFUS) Thalamotomy

• Preferred for unilateral tremor or patients with medical comorbidities due to lowest complication rate (4.4%) compared to radiofrequency thalamotomy (11.8%) and DBS (21.1%) 1, 2
• Shows sustained tremor improvement of 56% at 4 years 1, 2
• Early adverse effects: gait disturbance (36%) and paresthesias (38%), decreasing to 9% and 14% respectively by 1 year 1
• Serious adverse events rare (1.6%), with most being mild or moderate (98.4%) and >50% resolving by 1 year 1
• Contraindications: 1
  • Cannot undergo MRI
  • Skull density ratio <0.40
  • Bilateral treatment needed
  • Contralateral to previous thalamotomy

Deep Brain Stimulation (DBS)

• Preferred for younger patients, bilateral tremor involvement, or those requiring adjustable/reversible treatment 1, 4
• Ventral intermediate nucleus (VIM) of thalamus is established target 4
• Provides adjustable, reversible tremor control optimized over time 4
• Complication rate 21.1% 1
• Patient eligibility requires: 4
  • No dementia or severe depression
  • Sufficient residual motor function to expect improvement
  • No cerebral atrophy or focal basal ganglia lesions on MRI
  • Failed first-line medication therapy

Radiofrequency Thalamotomy

• Available but carries higher complication risk (11.8%) than MRgFUS 1
• Only considered when DBS or MRgFUS not possible 1

Treatment Algorithm

1. Initiate treatment only when tremor interferes with function or quality of life 1, 2
2. Start with propranolol 80-240 mg/day OR primidone 1, 2
   • Choose propranolol if patient has coexisting hypertension
   • Choose primidone if beta-blocker contraindications exist
3. If monotherapy inadequate, combine propranolol plus primidone 6
4. If first-line agents fail, switch to or add second-line medications (gabapentin, topiramate, carbamazepine) 1
5. For medication-refractory tremor causing significant disability: 1, 2
   • Unilateral tremor or medical comorbidities → MRgFUS thalamotomy
   • Bilateral tremor or MRgFUS contraindications → DBS
   • Younger patients requiring adjustability → DBS

Monitoring and Follow-Up

• Regular assessment of tremor severity and medication side effects is essential 1, 2
• Dose adjustments based on clinical response and tolerability 1, 2
• For primidone, allow 2-3 months before concluding inefficacy 2, 4
• In elderly patients on beta-blockers, monitor for excessive heart rate reduction, dizziness, hypotension, lethargy, and depression 1, 4

Critical Pitfalls to Avoid

• Do not prescribe beta-blockers to patients with asthma, COPD, decompensated heart failure, or significant bradycardia 1, 2, 4
• Avoid non-selective beta-blockers in insulin-treated diabetic patients as they mask hypoglycemia symptoms 4
• Do not conclude primidone failure before 2-3 month trial period 2, 4
• If resting tremor emerges in a patient with essential tremor, immediately reconsider the diagnosis—this suggests Parkinsonism, not essential tremor 4
• Avoid providing adaptive equipment in acute phase as it interrupts normal movement patterns 7