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NEUROLOGIC
DISEASES AND
DISORDERS
PART 1
OBJECTIVES
Know and understand:
• The symptoms and management of
cerebrovascular disease
• The headache type that occurs primarily in
older patients
• The presentation of disorders of the peripheral
nerves
Slide 2
TOPICS COVERED
• Cerebrovascular Diseases
• Subdural Hematoma
• Headaches
• Other Common Neurological Disorders Affecting
the Geriatric Population
 Amyotrophic Lateral Sclerosis
 Myelopathy
 Radiculopathy
 Peripheral Neuropathy
 Myopathy
Slide 3
SUBTLE NEUROLOGIC ABNORMALITIES
OFTEN OBSERVED IN OLDER ADULTS
Diminished arm swing
Hyperreflexia in arms
Absent pupillary response
Diminished toe position sense
Percentage of patients
30
25
Diminished toe vibration sense
Unequal nasolabial folds
Babinski's sign
Reduction in arm strength
29
21
20
15
10
5
10
9
9
7
5
5
0
Slide 4
STROKE: A LEADING CAUSE OF
DISABILITY AND DEATH
• The fatality rate within 1 month of an acute
stroke is 20% to 30% across all age groups
• Mortality is highest among older people
• Survival in part depends on the location and
severity of the stroke
• The most important predictor is the severity of
neurologic signs
Slide 5
Incidence per 1000
INCIDENCE OF STROKE IN MEN
10
9
8
7
6
5
4
3
2
1
0
9.3
4.5
2.1
55-64
65-74
Age
75-84
Slide 6
RISK FACTORS FOR STROKE
• Hypertension
 Most prevalent risk factor
 Treatment substantially reduces risk
• Heart disease
• Diabetes mellitus
• Cigarette smoking
• Elevated blood lipids
• Excessive alcohol use
Slide 7
STROKE-RELATED
CAUSES OF DEATH
Neurologic causes
Medical causes
• Brain injury itself
• Myocardial infarction
• Resulting edema
• Arrhythmia
• Heart failure
• Aspiration pneumonia
• Pulmonary embolism
Slide 8
SIGNS OF INTERNAL
CAROTID ARTERY DISEASE
• Transient monocular blindness
(amaurosis fugax)
• Hemispheric deficit
 Hemiparesis
 Hemisensory loss
 Homonomous hemianopia
 Aphasia
 Apraxia
Slide 9
EVALUATION OF SYMPTOMATIC
CAROTID ARTERY DISEASE
• Neuroimaging study (CT or MRI)
• Noninvasive imaging of carotid arteries
 B-mode ultrasonography
 Doppler ultrasonography
 Magnetic resonance angiography
Slide 10
TREATMENT FOR CAROTID STENOSIS
• Symptomatic and ≥70%: Carotid endarterectomy or
endovascular treatment
• Symptomatic and ≤70%, or asymptomatic: Carotid
endarterectomy or medical management or
endovascular treatment
• Medical management should optimize:
 Blood pressure
 Lipid status
 Antiplatelet agents
Slide 11
ATHEROSCLEROTIC STROKE
PREVENTION
• Low-dose aspirin monotherapy
• Sustained-release dipyridamole with aspirin
• Clopidogrel 75 mg once daily
• Warfarin: reserve for primary or secondary
stroke prevention in the setting of cardioembolic
disease
Slide 12
SIGNS OF VERTEBROBASILAR
ARTERIAL DISEASES
• Abnormal eye movements
• Dysarthria
• Horner’s syndrome
• Dysphagia
• Unilateral, bilateral, or
crossed motor and
sensory abnormalities in
the face, arm, or leg
• Behavioral and
visual symptoms
• Stupor or coma
• Ataxia
Slide 13
TREATMENT OF VERTEBROBASILAR
ARTERIAL DISEASES
• Supportive medical treatment
• Emerging technology with endovascular
approach may provide further treatment
options
Slide 14
TREATMENT FOLLOWING
ISCHEMIC STROKE
• Optimize hydration status
• Control BP (but avoid acute hypotension)
• Prevent deep-vein thrombosis
• Detect/treat coronary ischemia, heart failure,
and cardiac arrhythmias
• Initiate long-term antiplatelet therapy or oral
anticoagulation
Slide 15
LACUNAR STROKE
• May occur independently or concurrently with
large-vessel cerebrovascular disease
• May result in:
 Pure motor hemiplegia
 Pure hemisensory stroke
 Ataxic hemiparesis
 Dysarthria–clumsy hand syndrome
• Risk factors should be managed aggressively
Slide 16
RECOMBINANT TISSUE–PLASMINOGEN
ACTIVATOR (rt-PA) (ALTEPLASE)
• Consider when:
 Patient presents within 3 hours of neurologic defect
 CT confirms absence of intracranial hemorrhage
• Approximately doubles the chances of a
favorable outcome at 3 months
• Carries a risk of symptomatic intracerebral
hemorrhage
Slide 17
CONTRAINDICATIONS TO ALTEPLASE
• Major surgery within 2 weeks
• Previous intracranial hemorrhage
• Systolic BP >185 or diastolic BP >110
• Symptoms of subarachnoid hemorrhage
• Recent urinary or GI tract bleeding
• Coagulopathy
• Thrombocytopenia
• INR > 1.7
Slide 18
INCIDENCE OF
INTRACEREBRAL HEMORRHAGE
• Accounts for 15% to 20% of all strokes
• Approximately 80% occur between the ages
of 40 and 70
• Black Americans and Asian Americans may
be at slightly higher risk than white
Americans
Slide 19
RISK FACTORS FOR
INTRACEREBRAL HEMORRHAGE
• Hypertension (present in
75%–80% of cases)
• Other secondary
causes
• Excessive use of alcohol
 Trauma
• Cerebral amyloid angiopathy
 Atriovenous
malformations
 Commonly causes
cerebral lobar
hemorrhage in older
adults
 Aneurysms
 Intracranial bleeds tend to
be recurrent
Slide 20
TREATMENT OF
INTRACEREBRAL HEMORRHAGE
• Acute treatment is supportive
 Interim control of severe hypertension
 Discontinuation of antiplatelets and
anticoagulants
• Consider neurosurgical drainage for large
lobar or intraventricular hemorrhages
Slide 21
SUBDURAL HEMATOMA
• Defined as collection of blood between the
dura and the arachnoid
• Usually due to head trauma, although the
trauma may be mild, particularly in older adults
• Bilateral in approximately 15% of cases
• In older patients, chronic subdural hematoma
is most relevant
Slide 22
INCIDENCE OF CHRONIC SUBDURAL
HEMATOMA INCREASES WITH AGE
7.4
Incidence per 100,000
8
7
• No history of head
injury50% of cases
6
• Other risk factors:
5
4

Clotting disorders
3

Shunting procedures

Seizures
2
1
0.13
0
20-29
70-79
Age
Slide 23
SYMPTOMS OF
CHRONIC SUBDURAL HEMATOMA
• Headache
• Slight to severe cognitive impairment
• Hemiparesis
• Seizures in some patients
• Focal neurologic signs in some patients
• Neuroimaging shows extra-axial blood
collection
Slide 24
TREATMENT OF
CHRONIC SUBDURAL HEMATOMA
• Symptomatic and the patient’s condition is
worsening: Removal of the clot may be
attempted
• Incidental finding on neuroimaging or the
patient’s condition is improving: Clinical
monitoring is appropriate, as the hematoma
may shrink and disappear without surgery
Slide 25
HEADACHES
• As in younger people, classified into:
 Migraines (with or without aura)
 Tension-type headaches
• More likely to represent systemic or intracranial
lesion in older adults than in younger adults
• Prevalence appears to decrease with age
• Incidence of migraine decreases with age
Slide 26
MIGRAINES
• Moderate to severe pulsating headache
• Associated with nausea/vomiting or photophobia
• Often unilateral
• Auras, when they occur, usually precede the
headache (transient neurologic symptoms)
• Auras tend to disappear with age
• In some individuals, headaches disappear while
auras remain
Slide 27
TREATMENT OF HEADACHE
Abortive therapies
•
Over-the-counter preparations
•
Ergotamines or triptans—contraindicated in the
setting of uncontrolled hypertension, stroke, or CAD
Preventive therapies
•
β-blockers (propranolol, atenolol)
•
Valproic acid
•
Topiramate
•
Tricyclic antidepressants (off-label)
•
Calcium channel blockers (off-label)
Slide 28
GIANT CELL (TEMPORAL) ARTERITIS
• Occurs primarily in patients ≥ 50 years old
• Causes throbbing headache, especially at
temporal/occipital arteries
• Peaks in incidence between ages 70 and 80
• Women affected twice as often as men
Slide 29
OTHER SIGNS AND SYMPTOMS OF
GIANT CELL ARTERITIS
• Tenderness/nodularity of scalp arteries
• Jaw claudication
• Visual changes or hearing loss
• Low-grade fever, polymyalgia
• Elevation of peripheral markers of inflammation
 But ESR normal in about 10% of cases
 Elevation of CRP is a more sensitive sign
Slide 30
MANAGEMENT OF SUSPECTED
GIANT CELL ARTERITIS
• Promptly evaluate by temporal artery biopsy
• Prednisone (40–60 mg daily) relieves
symptoms within a few days
• Gradually taper the dose with close serologic
monitoring
Slide 31
AMYOTROPHIC LATERAL SCLEROSIS
(ALS) (1 of 2)
• Neurodegenerative condition involving both
upper and lower motor neuron cell bodies
• Progressive weakness and wasting of skeletal
muscles, often in combination with bulbar palsy
and respiratory failure
• Common symptoms: gait disturbance, falls, foot
drop, weakness in grip, dysphagia, dysarthria
Slide 32
ALS (2 of 2)
• Differential diagnosis
 Lesions of foramen magnum
 Lesions of high cervical cord
 Vitamin B12 deficiency
• Average survival 2 to 3 years—bulbar signs imply
worse prognosis
• Treatment mostly supportive—riluzole has modest
effects on survival, time to tracheostomy
Slide 33
MYELOPATHY
(SPINAL CORD DYSFUNCTION)
• Usually results from spinal cord compression
• Intrinsic lesions often result from spinal cord tumors
or vascular events (infarcts or hemorrhages)
• Extrinsic lesions are more prevalent:
 Cervical spondylosis
 Disc prolapse or herniation
 Vertebral body subluxation due to rheumatoid arthritis
 Spinal metastases
• MRI is key to diagnosis
Slide 34
TREATMENT OF MYELOPATHY
• Conservative management (especially if neck
pain present):
 Activity modification
 Cervical collar, massage, heat treatment, and/or
physical therapy
 Muscle relaxants and pain medications
• Decompressive surgery advisable for persistent
pain or a progressive neurologic deficit
Slide 35
RADICULOPATHY
• Caused by compression of spinal root as it exits spinal cord
• In older adults may result from:
 Herniated discs
 Osteophyte formation
• Pain radiates down neck, back, arm, or leg
• Neurologic examination may reveal:
 Motor and sensory defects
 Diminution of reflexes in distribution of spinal root(s)
Slide 36
PERIPHERAL NEUROPATHY (PN)
• Prevalence up to 20% in older adults; up to 60%
in patients >60 years old with diabetes mellitus
• Other common causes:
 Medications, alcohol abuse, and nutritional
deficiencies
 Renal disease (ie, uremia)
 Monoclonal gammopathy (eg, multiple myeloma)
 Neoplasm
Slide 37
OUTPATIENT EVALUATION OF PN
Vitamin
Deficiency
Systemic Disease
Diabetic
Uremic
Dialysis-associated
amyloidosis
Hypothyroidism
Differential
Diagnosis
Inflammatory
Systemic
Vasculitis
CIDP
Toxic
Heavy metals (lead,
mercury, arsenic)
Alcohol abuse
Cocaine / amphetamine
Heroin
B1 (thiamine)
B2
B6 (pyridoxine)
B12
Folate
E
Infectious
Common Medications
Amiodarone
Phenytoin
Statins
Colchicine
Hydralazine
Nitrofurantoin
Metronidazole
Chemotherapeutics (platinumbased and vinca alkaloids)
Vitamin intoxication (B6 or E)
Hepatitis B or C w/
cryoglobulinemia
HIV
CMV, EBV
Diphtheria
West Nile virus
Other
Paraneoplastic
Monoclonal
gammopathy
Hereditary
Slide 38
OUTPATIENT EVALUATION OF PN
History and Physical
Asymmetric sensory loss / weakness
Distal atrophy and hyporeflexia
Single nerve
DDx
Compressive/
entrapment
neuropathy
Traumatic
NCVs and EMG of
affected nerve
Supportive care
Avoid
exacerbating
activity
Splints or pads
Surgical release
procedures
Multiple nerves
DDx
Diabetes
Systemic disease
B12 deficiency
Multiple compression
neuropathies
Mononeuritis
Multiplex
Vasculitis
Sarcoidosis
NCVs and EMG of 3 or 4
limbs including affected
nerves
Consider nerve biopsy
and neuromuscular
referral
Symmetric length-dependent sensory loss/ weakness
Hyporeflexia and distal atrophy
Polyneuropathy — See DDx on slide 38
First-Line Evaluation
3-limb NCVs and EMG
Chemistry and CBC panel
Fasting glucose and HbA1c
B12 and methylmalonic acid
Folate
TSH
ESR, CRP
Second-Line Evaluation
HIV, Hepatitis B and C studies
SPEP / UPEP
ANA, rheumatoid factor, ANCA
EBV and CMV titers
Nerve biopsy
Referral to neurologist
Symptomatic Treatment
Tricyclic antidepressants — amitriptyline,
nortriptyline, desipramine
Anticonvulsants — carbamazepine, gabapentin,
pregabalin
Other — duloxetine
TREATMENT OF PN
• Optimizing glucose control may lessen the
severity of diabetic neuropathy
• Treatment of neuropathic pain:
 Tricyclic antidepressants
 Anticonvulsants (off-label except for specific
neuropathies)
 Duloxetine
 Capsaicin cream and other topical anesthetics
Slide 40
MYOPATHY
• Characterized by proximal muscle weakness, wasting,
and diminished or absent reflexes
• May be accompanied by elevations in serum enzymes
and by myopathic pattern on electromyogram and
muscle biopsy
• Common myopathies in older adults:




Polymyositis
Endocrine myopathies
Toxic myopathies
Myopathies associated with carcinoma
Slide 41
SUMMARY (1 of 2)
• Cerebrovascular disease is the leading cause of
disability and death among older people
• Control of systolic hypertension is the most
important factor in preventing stroke
• Age alone is not a contraindication to rt-PA
therapy
• Chronic subdural hematoma is not always due to
head trauma, and incidence increases with age
Slide 42
SUMMARY (2 of 2)
• Giant cell arteritis, which occurs primarily in
older patients, commonly causes throbbing
head pain, tenderness of scalp arteries, and
jaw claudication
• Peripheral neuropathy is prevalent in older
adults, especially those with diabetes
Slide 43
CASE 1 (1 of 3)
• A 70-year-old male smoker has a history of
hypertension, dyslipidemia, diabetes mellitus,
and nonvalvular atrial fibrillation.
Slide 44
CASE 1 (2 of 3)
Which of the following most increases this
patient’s risk of stroke?
A. Cigarette smoking
B. Hypertension
C. Dyslipidemia
D. Atrial fibrillation
Slide 45
CASE 1 (3 of 3)
Which of the following most increases this
patient’s risk of stroke?
A. Cigarette smoking
B. Hypertension
C. Dyslipidemia
D. Atrial fibrillation
Slide 46
CASE 2 (1 of 3)
• An 80-year-old man comes to the office because he has
had a left frontal headache and blurry vision for 2 weeks.
• He has been feeling more tired than usual, and his jaw
aches when he eats. He denies nausea, vomiting, neck
stiffness, or visual loss.
• On examination, there is no nuchal rigidity or temporal
tenderness. His pupils are round, equal in size, and
reactive to light. Visual acuity, visual fields, funduscopic
examination, and extraocular movements are normal.
Slide 47
CASE 2 (2 of 3)
Which of the following is most likely to confirm
the diagnosis?
A. CT of the head
B. Temporal artery biopsy
C. Slit-lamp examination
D. Tonometry
E. Cerebral angiography
Slide 48
CASE 2 (3 of 3)
Which of the following is most likely to confirm
the diagnosis?
A. CT of the head
B. Temporal artery biopsy
C. Slit-lamp examination
D. Tonometry
E. Cerebral angiography
Slide 49
CASE 3 (1 of 3)
• A 72-year-old woman is brought in to the office by her
daughter because of worsening lethargy and
personality change over the last 2 months, with no
other symptoms.
• She has had to retire from teaching because of
episodes of confusion and irritability.
• About 2 months ago, she was involved in a minor car
accident but had no apparent injuries.
• Physical examination, including the neurologic
examination, is normal.
Slide 50
CASE 3 (2 of 3)
Which test is most likely to confirm the
diagnosis?
A. Thyrotropin concentration
B. Vitamin B12 concentration
C. Electroencephalography
D. Geriatric Depression Scale
E. CT of the head
Slide 51
CASE 3 (3 of 3)
Which test is most likely to confirm the
diagnosis?
A. Thyrotropin concentration
B. Vitamin B12 concentration
C. Electroencephalography
D. Geriatric Depression Scale
E. CT of the head
Slide 52
ACKNOWLEDGMENTS
Editor:
Annette Medina-Walpole, MD
GRS7 Chapter Authors:
R. Charles Callison, Jr., MD
Harold P. Adams, Jr., MD
GRS7 Question Writer:
Helen Fernandez, MD
Pharmacotherapy Editor:
Judith L. Beizer, PharmD
Medical Writers:
Beverly A. Caley
Faith Reidenbach
Managing Editor:
Andrea N. Sherman, MS
Copyright © 2010 American Geriatrics Society
Slide 53