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Peripheral Neuropathies in Older Adults. Annabel K. Wang, MD University of California, Irvine Department of Neurology. Peripheral Neuropathies. Common disorder Prevalence of non-traumatic peripheral neuropathies 2.4% in general population 15% over the age of 40. Peripheral Neuropathies.

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peripheral neuropathies in older adults

Peripheral Neuropathiesin Older Adults

Annabel K. Wang, MD

University of California, Irvine

Department of Neurology

peripheral neuropathies
Peripheral Neuropathies
  • Common disorder
  • Prevalence of non-traumatic peripheral neuropathies
    • 2.4% in general population
    • 15% over the age of 40
peripheral neuropathies1
Peripheral Neuropathies
  • Terms are confusing
    • polyneuropathy
    • neuropathy
slide4

Peripheral Neuropathies

  • Motor neuron disorders
  • Radiculopathies
  • Plexopathies
  • Single and Multiple Mononeuropathies
  • Symmetric Polyneuropathies
  • Motor Neuropathies
  • Sensory Ganglionopathies
goals
Goals
  • Early Recognition
  • Early Treatment
  • Prevention of Complications
objectives
Objectives
  • Review symptoms and signs
  • Identify common causes
  • Discuss treatment options
  • Address co-morbidities
symptoms
Symptoms
  • Positive or negative phenomena
  • Sensory symptoms early
  • Typically symmetric in onset
  • Weakness later
  • Distal symptoms predominant
  • Worse at night
positive phenomena
Positive Phenomena
  • Tingling
  • Coldness
  • Burning
  • Electrical shocks
  • Stabbing sensations
  • Deep aching
negative phenomena
Negative phenomena
  • Lack of sensation
  • Hypersensitivity
associated symptoms
Associated Symptoms
  • Imbalance
  • Fatigue
  • Falls
slide11

Early Signs

  • Distal sensory loss:
    • Large Fibers
      • loss of vibration before proprioception
      • decreased ankle reflexes
    • Small fibers
      • Loss of pinprick and temperature
  • Stocking-glove distribution
early signs
Early Signs
  • Distal weakness
    • Toe extensors
    • Foot dorsiflexors
    • Finger extensors
common causes
Common Causes
  • Diabetes
  • Leprosy
  • Vitamin B12 deficiency
diabetes
Diabetes
  • Prevalence of Diabetes (2011): 8.3% of population
  • 25.8 million children and adults in the US
  • Age 65 years or older
    • 10.9 million, or 26.9% of this age group have diabetes
diabetes1
Diabetes
  • 60-70% will develop neuropathy
    • polyneuropathy, autonomic neuropathy, CTS
  • Association with amputation
    • major contributor of amputations
    • 60% of non-traumatic amputations
    • 65,700 amputations from 2006
diabetic polyneuropathy
Diabetic Polyneuropathy
  • Defined as the presence of symptoms and/or signs of peripheral nerve dysfunction in people with diabetes after the exclusion of other causes
  • An absence of symptoms should never be assumed to indicate an absence of signs
diabetic polyneuropathy1
Diabetic Polyneuropathy
  • Treatment
    • Glucose control
    • Pain management
    • Management of autonomic symptoms
leprosy
Leprosy
  • Rare in United States
  • Endemic areas
  • Often sensory (ulnar and peroneal nerves)
  • Associated skin lesions
  • Hypertrophic nerves
  • Nerve biopsy
  • Treat underlying infection
vitamin b12 deficiency
Vitamin B12 Deficiency
  • Prevalence: 5-20%
  • Malabsorption, insufficient intake, pernicious anemia, gastric bypass surgery, medications
  • Distal sensory and motor loss
  • Combined subacute degeneration
  • Vitamin B12 (<260 pmol/L) and methylmalonic acid (271 nmol/L) levels
  • Supplementation: intramuscular or oral
approach
Approach
  • Acute vs. chronic onset
    • Acute fulminant and live threatening
  • Axonal vs. demyelinating
    • Demyelinating forms respond well to immunotherapy
acute polyneuropathies
Acute Polyneuropathies
  • Guillain-Barre Syndrome or Acute Inflammatory Demyelinating Polyradiculoneuropathy
  • Porphyria
  • Toxic (arsenic and thallium)
chronic polyneuropathies
Chronic Polyneuropathies
  • Inherited (CMT, HMSN, HNPP)
    • Family History
    • Foot Deformities
    • Foot Ulcers
  • Acquired
    • “MINI”
acquired polyneuropathy
Acquired Polyneuropathy

“MINI”

  • Metabolic
  • Immune
  • Neoplastic
  • Infectious
metabolic causes
Metabolic Causes
  • Diabetes
  • Uremia
  • Alcohol abuse
  • Hypothyroid
  • Vitamin B1 or B12 deficiency
  • Vitamin B6 toxicity
  • Medications/chemotherapy
immune causes
Immune Causes
  • Vasculitis
  • Non-vasculitic
    • CIDP
    • MMN
    • Sarcoid
    • Sjogren’s
neoplastic causes
Neoplastic Causes
  • Paraneoplastic
  • Paraproteinemic
slide27
MGUS
  • Monoclonal gammopathy of unclear significance
  • Prevalence:
    • 3% of persons >50 years
    • 5% >70 years
  • 1% per year risk of progression to multiple myeloma (MM) or a related disorder
infectious causes
Infectious Causes
  • Leprosy
  • Hepatitis C
  • Lyme
  • HIV
  • West Nile
  • Syphilis
  • Diptheria
slide29

Autonomic Symptoms

  • Lightheadedness or “dizziness”
  • Blurred vision
  • Dry eyes, dry mouth
  • Cold feet
  • Early satiety, constipation, diarrhea
  • Urinary retention, incontinence
  • Erectile Dysfunction
  • Hypohidrosis
slide30

Dysautonomias

  • Diabetes
  • Amyloidosis (acquired and inherited)
  • Paraneoplastic
  • Inherited (HSAN)
  • Sjogren’s Neuropathy
  • Porphyria
differential diagnosis
Differential Diagnosis
  • Small fiber neuropathy
  • Plantar fasciitis
  • Osteoarthritis
  • Vascular insufficiency
  • Cervical myelopathy
  • Lumbosacral radiculopathy
slide32

Neurophysiology

  • Electromyography
  • Autonomic Testing
  • Quantitative Sensory Studies
slide33

Electromyography (EMG)

  • Two part test:
    • Nerve conduction studies
    • Needle electromyography
  • Establish diagnosis of polyneuropathy
  • Distinguish demyelinating from axonal
  • Differentiate radiculopathy, plexopathy
  • Normal in small fiber and autonomic neuropathy
slide34

Autonomic Testing

  • Heart rate response to deep breathing
  • Valsalva Maneuver
  • Tilt Table
  • Quantitative Sudomotor Axon Reflex Test
basic laboratory investigation
Basic Laboratory Investigation
  • Hematology:
    • complete blood count
    • erythrocyte sedimentation rate
    • C-reactive protein
    • vitamin B12, folate,
    • Methylmalonic acid, homocysteine
basic laboratory investigation1
Basic Laboratory Investigation
  • Biochemical and endocrine:
    • comprehensive metabolic panel (fasting glucose)
    • thyroid function tests
    • serum immunofixation.
    • glucose tolerance test if indicated
basic laboratory investigation2
Basic Laboratory Investigation
  • Urine:
    • urinalysis
    • urine immunofixation.
  • Drugs and toxins
specialized laboratory investigation
Specialized Laboratory Investigation
  • Malignancies:
    • skeletal radiographic survey
    • mammography
    • computed tomography or magnetic resonance imaging of chest, abdomen, and pelvis
    • ultrasound of abdomen and pelvis
    • positron emission tomography
    • cerebrospinal fluid analysis including cytology
    • serum paraneoplastic antibody profile
specialized laboratory investigation1
Specialized Laboratory Investigation
  • Connective tissue diseases and vasculitis:
    • antinuclear antigen profile
    • rheumatoid factor
    • anti-Ro/SSA, anti-La/SSB,
    • antineutrophil cytoplasmic antigen antibody (ANCA) profile
    • cryoglobulins.
specialized laboratory investigation2
Specialized Laboratory Investigation
  • Infectious agents:
    • Campylobacter jejuni
    • Cytomegalovirus
    • hepatitis panel (B and C)
    • HIV
    • Lyme disease
    • herpes viruses
    • West Nile virus
    • cerebrospinal fluid analysis.
slide41

Biopsy

  • Nerve biopsy
    • Sural
    • Superficial peroneal
  • Epidermal skin biopsy
nerve biopsy
Nerve Biopsy
  • Vasculitis
  • Lymphoma
  • Amyloid
  • Sarcoid
  • Leprosy
  • Inflammation
slide43

Management

  • Care of feet
    • Inspect feet daily (mirror)
    • Keep feet clean and moisturized
    • Foot care with podiatrist
    • Molded shoes
    • Avoid walking barefoot
    • Checking temperatures of water/sand
slide44

Treatment

  • Foot care
  • Physical Therapy
    • Gait and balance exercises
  • Ankle supports (orthotics)
  • Occupational Therapy (ADLs)
therapeutic treatment
Therapeutic Treatment
  • Importance of diagnosis
  • Recognition of the underlying cause
  • Glucose control
  • Thyroid medication
  • Vitamin supplementation or reduction
  • Antibiotics or antiviral medications
  • Immunotherapy
symptomatic treatment
Symptomatic Treatment
  • Only 2 medications are FDA approved for diabetic polyneuropathy
    • Duloxetine
    • pregabalin
symptomatic treatment1
Symptomatic Treatment
  • Pain management limited by side effects
    • Analgesics
    • Anti-inflammatories
    • Antiepileptics
    • Antidepressants
    • Narcotics
co morbidities
Co-morbidities
  • Depression
  • Decreased mobility
  • Falls
  • Fear of falls
  • Social isolation
  • Osteoporosis
slide49

Complications

  • Risk of injury due to lack of sensation
  • Charcot joints
  • Foot ulcers
  • Amputations
  • Falls
summary
Summary
  • Common disorder
    • >40 years of age: 15%
  • Routine screening for diabetes, vitamin B12 deficiency, serum immunofixation.
summary1
Summary
  • Neurophysiological tests distinguish axonal /demyelinating/autonomic/small fiber
  • Demyelinating neuropathies are commonly inflammatory and treatable.
  • Axonal neuropathies have multiple causes
summary2
Summary
  • Treatment
    • Therapeutic
    • Symptomatic
    • Comorbidities
references
References
  • Diabetes Statistics. http://www.diabetes.org/diabetes-basics/diabetes-statistics/
  • Bril V et al. Evidence-based guideline: Treatment of painful diabetic neuropathy. Neurology; Published online before print April 11, 2011; DOI 10.1212/WNL.0b013e3182166ebe
  • Bril V. Treatments for diabetic neuropathy. JPNS 2012:17(s2);22–27.
  • Leishear K et al. Relationship Between Vitamin B12 and Sensory and Motor Peripheral Nerve Function in Older Adults. JAGS 2012:60(6); 1057–1063.
  • England JD et al. Evaluation of distal symmetric polyneuropathy: the role of autonomic testing, nerve biopsy, and skin biopsy (an evidence-based review). Muscle Nerve 2009 ;39: 106–115.
  • England JD et al. Evaluation of distal symmetric polyneuropathy: the role of laboratory and genetic testing (an evidence-based review). Muscle Nerve 2009 ;39: 116–125.
references1
References
  • Kyle RA, Rajkumar SV. Monoclonal gammopathy of undetermined significance and smouldering multiple myeloma: emphasis on risk factors for progression. BJH 2007:139(5);730–743.
  • Mauermann ML, Burns TM. The evaluation of chronic axonal polyneuropathies. Semin Neurol. 2008:28(2):133-51.
  • Ramaratnam S. Neurologic Manifestations of Leprosy.   http://emedicine.medscape.com/article/1165419-overview#aw2aab6b6
  • Rutkove SB. Overview of polyneuropathy.http://www.uptodate.com/contents/overview-of-polyneuropathyUpto date
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