Peripheral neuropathies in older adults
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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


Peripheral neuropathies in older adults

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


Peripheral neuropathies in older adults

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


Peripheral neuropathies in older adults

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


Peripheral neuropathies in older adults

Autonomic Symptoms

  • Lightheadedness or “dizziness”

  • Blurred vision

  • Dry eyes, dry mouth

  • Cold feet

  • Early satiety, constipation, diarrhea

  • Urinary retention, incontinence

  • Erectile Dysfunction

  • Hypohidrosis


Peripheral neuropathies in older adults

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


Peripheral neuropathies in older adults

Neurophysiology

  • Electromyography

  • Autonomic Testing

  • Quantitative Sensory Studies


Peripheral neuropathies in older adults

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


Peripheral neuropathies in older adults

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.


Peripheral neuropathies in older adults

Biopsy

  • Nerve biopsy

    • Sural

    • Superficial peroneal

  • Epidermal skin biopsy


Nerve biopsy

Nerve Biopsy

  • Vasculitis

  • Lymphoma

  • Amyloid

  • Sarcoid

  • Leprosy

  • Inflammation


Peripheral neuropathies in older adults

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


Peripheral neuropathies in older adults

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


Peripheral neuropathies in older adults

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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