DR RITESH SHIWAKOTI

MScD PROSTHODONTICS

NEUROLOGICAL DISORDER IN GERIATRIC

A branch of medicine, geriatrics is concerned with diagnosing and treating illnesses that occur in adults, generally over age 60.

A subset of this, geriatric neurology focuses on

neurologic disorders common to this age group.

Correct diagnosis of neurologic disorders in older adults can be difficult because signs of disease may mimic normal signs of aging.

Patients frequently have more than one neurologic problem at once.

It can be challenging to find the best treatment once such

a problem has been diagnosed.

Common Geriatric Neurology Problems

Dementia

Epilepsy

Headache disorders

Multiple sclerosis

Neuro infections

Neurological disorders associated with malnutrition

Pain associated with neurological disorders

Parkinson’s disease

Stroke

Traumatic brain injuries

Memory and Aging

As people get older, they complain of memory loss.

Slight memory loss from normal aging should not interfere with daily activities.

Forgetting appointments, being unable to find your way in familiar areas, having difficulty with cooking or reading--these are all possible signs of more severe memory loss which needs to be investigated.

Causes of Memory Disorders

Depression,

Vitamin B12 deficiency,

Medications and

Sleep disorders to more severe dementia.

Alzheimer's disease

The causes of memory loss and dementia should be identified early.

Medications can improve memory loss.

Patients and families also benefit from an accurate diagnosis, which allows them to get community support and plan for the future.

Dementia

Dementia is a syndrome caused by disease of the brain, usually of a chronic or progressive nature, in which there is disturbance of multiple higher cortical functions, including memory, thinking, orientation, comprehension, calculation, learning capacity, language and judgement.

Dementia mainly affects older people

Only 2% of cases start before the age of 65 years.

The prevalence doubles with every five-year increment in age.

Dementia is one of the major causes of disability in later life.

Cortical amyloid plaques and neurofibrillary tangles i.e. Alzheimer’s disease AD accounting for one half to three quarters of all cases.

Repeated disruption of the blood supply to the brain by strokes and other vascular pathology

Causes thAat may be treated effectively by timely medical or surgical intervention— these include

Hypercalcaemia

Subdural haematoma

Normal pressure hydrocephalus

Deficiencies of thyroid hormone

Vitamin B12 and folic acid deficiency

Causes

Alzheimer's disease is a neurological disorder in which the death of brain cells causes memory loss and cognitive decline. A neurodegenerative type of dementia, the disease starts mild and gets progressively worse.

It eventually affects most areas of your brain, including those important in memory, thinking, judgment, language, problem-solving, personality and movement.

In 2010, some 4.7 million people of 65 years of age and older were living with Alzheimer's disease in the US.

The 2013 statistical report just over a tenth of people in the over-65 age group have the disease in the US.

In the over-85s, the proportion goes up to about a third.

The Alzheimer's Association says it accounts for between 60% and 80% of all cases of dementia

Vascular dementia, which is caused by stroke not Alzheimer's, is the second most common type of dementia.

Alzheimer's is caused by brain cell death.

It is a neurodegenerative disease, which means there is progressive brain cell death that happens over a course of time.

The total brain size shrinks with Alzheimer's - the tissue has progressively fewer nerve cells and connections.

Tiny inclusions in the nerve tissue, called plaques and tangles.

Plaques are found between the dying cells in the brain -from the build-up of a protein called beta-amyloid.

The abnormal protein clumps, inclusions, in the brain tissue are always present with the disease.

Risk factors

Unavoidable risk factors

Age - the disorder is more likely in older people, and a greater proportion of over-85-year-olds have it than of over-65s.

Family history (inheritance of genes) - having Alzheimer's in the family is associated with higher risk

Having a certain gene (the apolipoprotein E or APOE gene) puts a person eight times more risk than a person without the gene.

Numerous other genes have been found to be associated with Alzheimer's disease, even recently (see developments below).

Being female (more women than men are affected).

Potentially avoidable or modifiable factors

Diabetes

High cholesterol

High blood pressure (These also increase the risk of stroke, which itself can lead to another type of dementia.)

Low educational and occupational attainment.

Prior head injury (trauma)

Sleep disorders

Estrogen hormone replacement therapy

Sign and symptoms

1)Worsened ability to take in and remember new information, for example:

"Repetitive questions or conversations”

Misplacing personal belongings

Forgetting events or appointments

Getting lost on a familiar route.

2)Impairments to reasoning, complex tasking, exercising judgment:

"Poor understanding of safety risks”

Inability to manage finances

Poor decision-making ability

Inability to plan complex or sequential activities.

3) Impaired visuospatial abilities (but not, for example, due to eye sight problems)

"Inability to recognize faces or common objects or to find objects in direct view”

Inability to operate simple implements, or orient clothing to the body.

4) Impaired speaking, reading and writing:

"Difficulty thinking of common words while speaking, hesitations Speech, spelling, and writing errors."

5)Changes in personality and behavior

Out-of-character mood changes, including agitation; less interest, motivation or initiative; apathy; social withdrawal

Loss of empathy

Compulsive, obsessive or socially unacceptable behavior.

Stages of Alzheimer's disease

The progression of Alzheimer's can be broken down into three basic stages-

Preclinical (no signs or symptoms yet)

Mild cognitive impairment

Dementia.

Tests and diagnosis

Inital tests includes

Interview and careful history

Physical examination

Check neurological function, e.g. by testing balance, senses and reflexes.

Sending off for tests of blood and urine samples

Arranging brain scans (possibly including CT, MRI and EEG).

Genetic test ( DNA test )

Cognitive test : "abbreviated mental test score" (AMTS):

What is your age?

What is the time, to the nearest hour?

Repeat an address at the end of the test that I will give you now (e.g. "42 West Street")

What is the year?

What is the name of the hospital or town we are in?

Can you recognize two people (e.g. the doctor, nurse, home help, etc.)?

What is your date of birth?

In what year did World War 1 begin? (Other widely known dates in the past can be used.)

Name the president/prime minister/monarch.

Count backwards from 20 down to 1.

Treatment and prevention

There is no known cure for Alzheimer's disease - the death of brain cells in the dementia cannot be halted or reversed.

There is, however, much backing for therapeutic interventions to help people live with Alzheimer's disease more ably.

The Alzheimer's Association includes the following as important elements of dementia care:

Effective management of any conditions occurring alongside the Alzheimer's

Activities and/or programs of adult day care

Support groups and services.

Parkinson’s disease

Parkinson's disease (PD also known as idiopathic or primary parkinsonism, hypokinetic rigid syndrome/HRS, or paralysis agitans) is a degenerative disorder of the central nervous system.

The motor symptoms of Parkinson's disease result from the death of dopamine-generating cells in the substantianigra, a region of the midbrain; the cause of this cell death is unknown

The disease is named after the English doctor James Parkinson, who published the first detailed description in An Essay on the Shaking Palsy

Epidemiology

PD is the second most common neurodegenerative disorder after Alzheimer's disease and affects approximately seven million people globally and one million people in the United States.

The prevalence (proportion in a population at a given time) of PD is about 0.3% of the whole population in industrialized countries.

PD is more common in the elderly and prevalence rises from 1% in those over 60 years of age to 4% of the population over 80.

The mean age of onset is around 60 years, although 5–10% of cases, classified as young onset, begin between the ages of 20 and 50.

PD may be less prevalent in those of African and Asian ancestry.

Some studies have proposed that it is more common in men than women The incidence of PD is between 8 and 18 per 100,000 person–years.

Risk factors

The most frequently replicated relationships are an increased risk of PD in those exposed to pesticides, and a reduced risk in smokers

Classification

Idiopathic Parkinson's disease

Idiopathic Parkinson's disease - or Parkinson's - is the most common type of parkinsonism. Unlike some other forms which have specific causes it is not known why idiopathic Parkinson's occurs.

The main symptoms of idiopatic Parkinson's are tremor, rigidity and slowness of movement.

Vascular parkinsonism

The most likely causes of vascular parkinsonism are hypertension and diabetes. A stroke (cerebrovascular accident), cardiac disease or carotid artery pathology (another form of stroke) may also be involved.

Symptoms of vascular parkinsonism may include difficulty speaking, making facial expressions or swallowing. Other signs can include problems with memory or confused thought, cognitive problems and incontinence.

Drug-induced parkinsonism

Drugs - known as neuroleptic drugs - used to treat schizophrenia and other psychotic disorders block dopamine.

Dopamine is a chemical in the brain which allows messages to be sent to the parts of the brain that co-ordinate movement.

The symptoms of drug-induced parkinsonism tend to be static.

Most people will recover within months, and often within hours or days, of stopping the drug that caused the dopamine block.

Dementia with Lewy bodies

People who have dementia with Lewy bodies commonly experience visual hallucinations and some Parkinson's-type symptoms, such as slowness of movement, stiffness and tremor.

Inherited Parkinson's

It is thought that although it is not directly inherited, some people may have genes that increase the possibility of developing Parkinson's.

People who have genes that are prone to Parkinson's may be more likely to develop the condition when combined with other factors, such as environmental toxins or viruses.

Juvenile Parkinson's

Juvenile Parkinson's is a term used when the condition affects people under the age of 20.

Signs and symptoms

Inherited Parkinson's

It is thought that although it is not directly inherited, some people may have genes that increase the possibility of developing Parkinson's.

People who have genes that are prone to Parkinson's may be more likely to develop the condition when combined with other factors, such as environmental toxins or viruses.

Juvenile Parkinson's

Causes

Environmental factors

Pesticide exposure

Head injuries, and

Living in the country or farming

Rural environments and the drinking of well water may be risks as they are an indirect measures of exposure to pesticides].

Heavy metals exposure has been proposed to be a risk factor.

Genetics:

Mutations in specific genes have been conclusively shown to cause PD. These genes code for alpha-synuclein (SNCA), parkin (PRKN), leucine-rich repeat kinase 2 (LRRK2 or dardarin), PTEN-induced putative kinase 1 (PINK1), DJ-1 and ATP13A2.In most cases, people with these mutations will develop PD

Pathophysiology

The primary symptoms of Parkinson's disease result from greatly reduced activity of dopamine-secreting cells caused by cell death in the pars compacta region of the substantia nigra.

There are five major pathways in the brain connecting other brain areas with the basal ganglia. These are known as the motor, oculo-motor, associative,limbicand orbitofrontal circuit.

All of them are affected in PD, and their disruption explains many of the symptoms of the disease since these circuits are involved in a wide variety of functions including movement, attention and learning.

Diagnosis

Medical history

Neurological examination

Computed tomography (CT) and magnetic resonance imaging (MRI)

Gene examination

Another type of imaging test, called PET, sometimes may detect low levels of dopamine in the brain.

Treatment

Prevention:

Caffeine consumption appears protective against Parkinson's disease

Tobacco smoke is found to reduce the risk of PD

Antioxidants, such as vitamins C and D also reduces risk.

There have been preliminary indications of a possible protective role of estrogens and anti-inflammatory drugs.

Management:

Levodopa has been the most widely used treatment for over 30 years.

L-DOPA is converted into dopamine in the dopaminergicneurons by dopa decarboxylase.

Since motor symptoms are produced by a lack of dopamine in the substantia nigra, the administration of L-DOPA temporarily diminishes the motor symptoms.

Several dopamine agonists that bind to dopaminergic post-synaptic receptors in the brain have similar effects to levodopa

MAO-B inhibitors (selegiline and rasagiline) increase the level of dopamine in the basal ganglia by blocking its metabolism.

Other drugs such as amantadine and anticholinergics may be useful as treatment of motor symptoms

Treating motor symptoms with surgery was once a common practice, but since the discovery of levodopa, the number of operations declined

Brain pacemaker implanted in the brain for specific stimilus.

Epilepsy in the Elderly

Research shows that the incidence of epilepsy higher in the elderly.

Epilepsy was believed to be predominantly a childhood disorder.

Epilepsy is the most common serious neurological disorder in the elderly after stroke and dementia

US census projections

147 percent increase in the over 65 years old population between 2000-2050

Only 49 percent in population over the same period.

Elderly people with epilepsy are a large but neglected group.

In a postal survey 25% of general practitioners were unaware that epilepsy commonly manifests for first time in elderly.

Cause

Stroke is the leading cause of new-onset epilepsy in elderly– 8% of patients will hemorrhagic stroke will develop seizures within two

weeks

– 5% of patients with ischemic stroke will develop seizures with in 2 weeks.

Post-stroke epilepsy usually develops within 3–12 months

However, can still occur many years later

Dementias and Neurodegenerative diseases

10–20% of all epilepsy in older people.

Less appreciated is the evidence suggesting that dementia may develop with greater frequency elderly with chronic and established epilepsy.

Post-traumatic epilepsy is common in elderly

Head injury, mostly from falls, causes up to 20% of epilepsy in the elderly.

Increased risk of subdural hemorrhage, especially with anticoagulants or platelet inhibitors.

Factors that increase risk of post-traumatic epilepsy

– Loss of consciousness

– Post-traumatic amnesia > 24 hrs.

– Skull fracture, brain contusion and subdural hematoma

Common causes

– acute alcohol withdrawal

– metabolic and electrolyte disturbances

Hyponatremia

Hypocalcemia

Hypomagnesemia

– Infections

systemic

CNS.

– Drugs - commonly prescribed to elderly.

Tramadol

Antipsychotics

Antidepressants (particularly tricyclics)

Antibiotics(quinolones and macrolide)

Theophylline, levodopa, thiazide diuretics and even the herbal remedy, ginkgo biloba

Clinical Presentation

Focal or complex partial seizures

– Memory lapses,

– Episodes of confusion

– Periods of inattention

– Apparent syncope

Other factors

Impairment of cognition, Behavioral change.

Psychomotor retardation

Agitation or excitation

Subtle facial or limb twitches

Aphasia, echolalia, confabulation

Head or eye deviation

Automatisms

Autonomic disturbance

Diagnosis History

Clinical Exam

Investigations:

– Blood work

full blood count, renal function testing, serum electrolytes, and random blood glucose.1

– EKG, Holter monitoring and tilt table in some cases.

– Chest X ray

– EEG

– Neuroimaging studies

Treatment

Treatment decisions have to be made Cautiously.

– Elderly are more susceptible to the adverse effects of drugs than their younger counterparts

– The pharmacokinetics and pharmacodynamicsof antiepileptic drugs differ in old age

– Drug-drug interactions

Challanges Comorbidities of in elderly patients add to the diagnostic

challenge and also complicate the treatment options

Polypharmacy make them susceptible to drug interactions.

A survey of elderly nursing home residents found that 49% of residents receiving AEDs were prescribed six or more medications.

Adherence may not be as good in elderly patients with epilepsy.

Surgery is another method