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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 injury50% 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