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Peripheral Neuropathies in Older Adults

Explore the prevalence, symptoms, and treatment of peripheral neuropathies, including diabetic polyneuropathy, leprosy, and vitamin B12 deficiency. Learn about common causes, differential diagnoses, and neurophysiology tests.

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Peripheral Neuropathies in Older Adults

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  1. Peripheral Neuropathiesin Older Adults Annabel K. Wang, MD University of California, Irvine Department of Neurology

  2. Peripheral Neuropathies • Common disorder • Prevalence of non-traumatic peripheral neuropathies • 2.4% in general population • 15% over the age of 40

  3. Peripheral Neuropathies • Terms are confusing • polyneuropathy • neuropathy

  4. Peripheral Neuropathies • Motor neuron disorders • Radiculopathies • Plexopathies • Single and Multiple Mononeuropathies • Symmetric Polyneuropathies • Motor Neuropathies • Sensory Ganglionopathies

  5. Goals • Early Recognition • Early Treatment • Prevention of Complications

  6. Objectives • Review symptoms and signs • Identify common causes • Discuss treatment options • Address co-morbidities

  7. Symptoms • Positive or negative phenomena • Sensory symptoms early • Typically symmetric in onset • Weakness later • Distal symptoms predominant • Worse at night

  8. Positive Phenomena • Tingling • Coldness • Burning • Electrical shocks • Stabbing sensations • Deep aching

  9. Negative phenomena • Lack of sensation • Hypersensitivity

  10. Associated Symptoms • Imbalance • Fatigue • Falls

  11. 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

  12. Early Signs • Distal weakness • Toe extensors • Foot dorsiflexors • Finger extensors

  13. Common Causes • Diabetes • Leprosy • Vitamin B12 deficiency

  14. 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

  15. 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

  16. 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

  17. Diabetic Polyneuropathy • Treatment • Glucose control • Pain management • Management of autonomic symptoms

  18. Leprosy • Rare in United States • Endemic areas • Often sensory (ulnar and peroneal nerves) • Associated skin lesions • Hypertrophic nerves • Nerve biopsy • Treat underlying infection

  19. 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

  20. Approach • Acute vs. chronic onset • Acute fulminant and live threatening • Axonal vs. demyelinating • Demyelinating forms respond well to immunotherapy

  21. Acute Polyneuropathies • Guillain-Barre Syndrome or Acute Inflammatory Demyelinating Polyradiculoneuropathy • Porphyria • Toxic (arsenic and thallium)

  22. Chronic Polyneuropathies • Inherited (CMT, HMSN, HNPP) • Family History • Foot Deformities • Foot Ulcers • Acquired • “MINI”

  23. Acquired Polyneuropathy “MINI” • Metabolic • Immune • Neoplastic • Infectious

  24. Metabolic Causes • Diabetes • Uremia • Alcohol abuse • Hypothyroid • Vitamin B1 or B12 deficiency • Vitamin B6 toxicity • Medications/chemotherapy

  25. Immune Causes • Vasculitis • Non-vasculitic • CIDP • MMN • Sarcoid • Sjogren’s

  26. Neoplastic Causes • Paraneoplastic • Paraproteinemic

  27. 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

  28. Infectious Causes • Leprosy • Hepatitis C • Lyme • HIV • West Nile • Syphilis • Diptheria

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

  30. Dysautonomias • Diabetes • Amyloidosis (acquired and inherited) • Paraneoplastic • Inherited (HSAN) • Sjogren’s Neuropathy • Porphyria

  31. Differential Diagnosis • Small fiber neuropathy • Plantar fasciitis • Osteoarthritis • Vascular insufficiency • Cervical myelopathy • Lumbosacral radiculopathy

  32. Neurophysiology • Electromyography • Autonomic Testing • Quantitative Sensory Studies

  33. 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

  34. Autonomic Testing • Heart rate response to deep breathing • Valsalva Maneuver • Tilt Table • Quantitative Sudomotor Axon Reflex Test

  35. Basic Laboratory Investigation • Hematology: • complete blood count • erythrocyte sedimentation rate • C-reactive protein • vitamin B12, folate, • Methylmalonic acid, homocysteine

  36. Basic Laboratory Investigation • Biochemical and endocrine: • comprehensive metabolic panel (fasting glucose) • thyroid function tests • serum immunofixation. • glucose tolerance test if indicated

  37. Basic Laboratory Investigation • Urine: • urinalysis • urine immunofixation. • Drugs and toxins

  38. 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

  39. 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.

  40. Specialized Laboratory Investigation • Infectious agents: • Campylobacter jejuni • Cytomegalovirus • hepatitis panel (B and C) • HIV • Lyme disease • herpes viruses • West Nile virus • cerebrospinal fluid analysis.

  41. Biopsy • Nerve biopsy • Sural • Superficial peroneal • Epidermal skin biopsy

  42. Nerve Biopsy • Vasculitis • Lymphoma • Amyloid • Sarcoid • Leprosy • Inflammation

  43. 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

  44. Treatment • Foot care • Physical Therapy • Gait and balance exercises • Ankle supports (orthotics) • Occupational Therapy (ADLs)

  45. Therapeutic Treatment • Importance of diagnosis • Recognition of the underlying cause • Glucose control • Thyroid medication • Vitamin supplementation or reduction • Antibiotics or antiviral medications • Immunotherapy

  46. Symptomatic Treatment • Only 2 medications are FDA approved for diabetic polyneuropathy • Duloxetine • pregabalin

  47. Symptomatic Treatment • Pain management limited by side effects • Analgesics • Anti-inflammatories • Antiepileptics • Antidepressants • Narcotics

  48. Co-morbidities • Depression • Decreased mobility • Falls • Fear of falls • Social isolation • Osteoporosis

  49. Complications • Risk of injury due to lack of sensation • Charcot joints • Foot ulcers • Amputations • Falls

  50. Summary • Common disorder • >40 years of age: 15% • Routine screening for diabetes, vitamin B12 deficiency, serum immunofixation.

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