Management of Tremor in Older Adults

Initial Assessment and Diagnosis

The American Geriatrics Society recommends assessing tremor characteristics to determine if tremor occurs at rest, with intention, or with action/posture, and screening for medication-induced tremor by reviewing all medications for tremor-inducing agents, including beta-agonists, valproate, lithium, SSRIs, and stimulants 1, 3
The American Heart Association suggests ruling out metabolic causes by checking thyroid function, calcium/parathyroid hormone, and liver function, as hyperthyroidism, hyperparathyroidism, and hepatic encephalopathy can cause tremor 3, 4
The American Academy of Neurology recommends evaluating for enhanced physiologic tremor triggers, such as excessive caffeine intake, anxiety, stress, or recent strenuous exercise, before precision tasks 2

The American College of Cardiology recommends starting 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, with a reduction in tremor severity of approximately 50% 1, 2
The American Geriatrics Society suggests monitoring cardiovascular status, including blood pressure and cardiovascular risk factors, when using propranolol, although robust evidence does not support increased cerebrovascular/cardiovascular events from propranolol use in older adults 6

The American Academy of Neurology recommends reducing caffeine consumption, avoiding strenuous exercise before precision tasks, and implementing stress reduction techniques to address anxiety and stress that trigger enhanced physiologic tremor 2

The American Geriatrics Society recommends minimizing high-risk medications, particularly anticholinergics, benzodiazepines, and diphenhydramine, that increase fall risk and delirium, and avoiding the prescribing cascade by not misidentifying drug side effects as new medical conditions requiring additional prescriptions 1, 5
The Journal of the American Geriatrics Society suggests reassessing medication appropriateness regularly, considering discontinuation of interventions unlikely to provide meaningful benefit, and involving geriatric specialists for elderly patients with tremor causing significant functional impairment, frailty, or multiple comorbidities 1, 5