Changes With Aging

Aging may affect all aspects of the nervous system, from mental status to motor and sensory function and reflexes. Age-related losses may take their toll on the mental function of an elderly person. These include the deaths of loved ones and friends, retirement from valued employment, diminution in income, decreased physical capacities including impairments in vision and hearing, and perhaps decreased stimulation or growing isolation. In addition, biologic changes affect the aging brain. Brain volume and the number of cortical brain cells decrease, and both microanatomic and biochemical changes have been identified. Nevertheless, most men and women adapt well to getting older. They maintain their self-esteem, they alter their activities in ways that are appropriate to their changing capacities and circumstances, and eventually they ready themselves for death.

In assessing the nervous system of an older person, it is sometimes difficult to distinguish the changes of normal aging from those of age-related or other diseases. Some findings that you would consider abnormal in younger people, however, occur often enough in the elderly that you may attribute them to aging alone. Alterations in hearing, vision, extraocular movements, and pupillary size, shape, and reactivity have been described in Chapter 5 (see pp. 134-136).

Changes in the motor system are common. Older persons move and react with less speed and agility than younger ones, and skeletal muscles decrease in bulk. The hands of an aged person often look thin and bony because their small muscles have atrophied. Look for such muscular wasting in the backs of the hands, where atrophy of the dorsal interosseous muscles may leave concavities or grooves. As illustrated on page 572, this change is often most evident between the thumb and the hand (1st and 2nd metacarpals) but may also be seen between the other metacarpals. Atrophy of small muscles may also flatten the thenar and hypothenar eminences of the palms. Muscle strength, though diminished, is relatively well maintained. Arm and leg muscles may also show atrophy. This sometimes exaggerates the apparent size of adjacent joints.

Occasionally, an older person develops a benign essential tremor in the head, jaw, lips, or hands that may be confused with parkinsonism (p. 608). Unlike parkinsonian tremors, however, benign tremors are slightly faster and disappear at rest, and there is no associated muscle rigidity.

Vibration sense is frequently decreased or lost in the feet and ankles (but not in the fingers or over the shins). Less commonly, position sense may diminish or disappear.

Aging may also alter some of the reflexes. The gag reflex may be diminished or absent. Ankle reflexes may be symmetrically decreased or absent, even when reinforced. Less commonly, knee reflexes are similarly affected. Abdominal reflexes may diminish or disappear and, partly because of musculo-skeletal changes in the feet, the plantar responses become less obvious and more difficult to interpret.

If changes such as those described are accompanied by other neurologic abnormalities, or if atrophy and reflex changes are asymmetric, you should search for an explanation other than age alone.

Most elderly people do well on a mental status examination, but functional impairments may become evident, especially at advanced ages. Many older people complain about their memories. "Benign forgetfulness" is the usual explanation and may occur at any age. This term refers to a difficulty in recalling the names of people or objects or certain details of specific events. Naming this common phenomenon, when appropriate, may help to reassure a person who is worried that it signifies Alzheimer's disease. In addition to this circumscribed forgetfulness, elderly people retrieve and process data more slowly, and they take more time to learn new material. Their motor responses may slow, and their ability to perform complex tasks may become impaired.

The clinician must often try to distinguish these age-related changes from the manifestations of specific mental disorders, some of which are more prevalent with aging, such as depression and dementia. Sorting out these ailments from medical complaints may be difficult, particularly since both mood disturbances and cognitive changes may impair the patient's ability to recognize or report symptoms. Older patients are also more susceptible to delirium, a temporary confusional state that may be the first clue to infection or problems with medications. The clinician must learn to recognize these conditions promptly and to protect the patient from harm. (Information on detection of these conditions can be found on pp. 549-551, the Health History, on pp. 551-553, Health Promotion and Counseling, and in Table 16-1, Disorders of Mood, p. 599, and Table 16-5, Delirium and Dementia, p. 603.)

Common or Concerning Symptoms

■ Changes in mood, attention, or speech

■ Changes in orientation, memory, insight, or judgment

■ Delirium or dementia

■ Dizziness or vertigo

■ Generalized, proximal, or distal weakness

■ Numbness, abnormal or loss of sensations

■ Loss of consciousness, syncope, or near-syncope

■ Tremors or involuntary movements

Much of the information about the patient's mental status becomes evident during the interview. As you talk to the patient and listen to the patient's story, you should assess level of consciousness, general appearance and mood, and ability to pay attention, remember, understand, and speak. By placing the patient's vocabulary and general fund of information in the context of the patient's cultural and educational background, you can often make a rough estimate of intelligence. Likewise, the patient's responses to illness and life circumstances often tell you about his or her degree of insight and judgment. If the patient has unusual thoughts, preoccupations, beliefs, or perceptions, you should explore them as they arise during the interview. If you suspect a problem in orientation and memory, you can ask, "Let's see, your last clinic appointment was when . . . ?" . . . "And the date today?" The more you can integrate your exploration of mental status into a sensitive patient history, the less it will seem like an interrogation.

See Table 16-1, Disorders of Mood, p. 599, and Table 16-2, Disorders of Speech, p. 600.

See Table 16-3, Anxiety Disorders, p. 601, and Table 16-4, Psychotic Disorders, p. 602.

For some patients, you will need to supplement your interview with questions in specific areas. You may determine the need to go further and pursue a formal mental status examination. The components of the mental status examination are described in the section on Techniques of Examination, pp. 556-557.

All patients with documented or suspected brain lesions, psychiatric symptoms, or reports of vague or changed behavioral symptoms by family members need further systematic assessment. Patients may have subtle behavioral changes, difficulty taking medications properly, problems attending to household chores or paying bills, or loss of interest in their usual activities. Other patients may behave strangely after surgery or during an acute illness. Each problem should be identified as expeditiously as possible. Mental function influences the ability to hold a job and is often important in evaluating disability.

Possible signs of depression or dementia

See Table 16-5, Delirium and Dementia, p. 603.

Two of the most common symptoms in neurologic disorders are headache and dizziness. Turn to p. 136 and p. 139 to review the health history pertinent to these symptoms.

For headache, be sure to ask about location, severity, how long it lasts, and any associated symptoms, such as visual changes, weakness, or loss of sensation. Ask if the headache is affected by coughing, sneezing, or sudden movements of the head.

See Table 5-1, Headaches, pp. 170-173.

Subarachnoid hemorrhage may evoke "the worst headache of my life." Dull headache affected by such maneuvers, especially on awakening and recurring in the same location, is seen with mass lesions such as a brain tumor.

The complaint of dizziness can have many meanings. You will need to elicit exactly what the patient has experienced. Is the patient light-headed or feeling faint? Or is there vertigo, a perception that the room is spinning or rotating?

Light-headedness in palpitations, near syncope from vasovagal stimulation, low blood pressure, febrile illness, and others. Vertigo in middle-ear conditions, brainstem tumor. See Table 5-2, p. 174.

Especially in older patients, are any medications contributing to the dizziness? Are there any associated symptoms such as double vision, or diplopia, difficulty forming words, or dysarthria, or difficulty with gait or balance, or ataxia?

Diplopia, dysarthria, ataxia in posterior circulation transient ischemic attack (TIA) or stroke

What about any associated weakness, either generalized or in the face or a part of the body? Weakness is another common symptom and requires careful attention to detail. Probe for exactly what it means to the patient. Explore whether there is any paralysis, or inability to move a part or side of the body. Did the weakness start slowly or suddenly? Has it progressed? How? What areas of the body are involved? Does the weakness affect one or both sides? What movements are affected?

Weakness or paralysis in transient ischemic attack or stroke

Focal weakness may arise from ischemic, vascular, or mass lesions in the central nervous system; also from peripheral nervous system disorders, neuromuscular disorders, or the muscles themselves.

For weakness without light-headedness, try to distinguish between proximal and distal weakness. For proximal weakness, ask about combing hair, trying to reach something on a high shelf, or difficulty getting up out of a chair or taking a high step up. Does the weakness increase with repeated effort and improve after rest? Are there associated sensory or other symptoms? For distal weakness in the arms, inquire about hand movements such as opening a jar or can, or using hand tools such as scissors, pliers, or a screwdriver. For distal weakness in the legs, ask about frequent tripping.

Bilateral proximal weakness in myopathy. Bilateral, predominantly distal weakness in polyneuropathy. Weakness made worse with repeated effort and improved with rest suggests myasthenia gravis.

Find out if the patient has had any loss of sensation. Ask if there has been any numbness, but clarify its meaning and location. Has there been loss of sensation, difficulty moving a limb, or altered sensations such as tingling or pins and needles? There may be peculiar sensations without an obvious stimulus, called paresthesias. These occur commonly when an arm or leg "goes to sleep" following compression of a nerve, and may be described as tingling, prickling, or feelings of warmth, coldness, or pressure. Dysesthe-sias are distorted sensations in response to a stimulus and may last longer than the stimulus itself. For example, a person may perceive a light touch or pinprick as a burning or tingling sensation that is irritating or unpleasant. Pain may arise from neurologic causes but is usually reported with symptoms of other body systems, such as the head and neck or the mus-culoskeletal system.

Loss of sensation, paresthesias, and dysesthesias in central lesions in the brain and spinal cord, as well as disorders of peripheral sensory roots and nerves; paresthesias in the hands and around the mouth in hyperventilation.

See Table 5-1, Headaches, pp. 170-173, Table 15-2, Pains in the Neck, p. 523, and Table 15-1, Low Back Pain, p. 522.

"Have you ever fainted or passed out?" leads the discussion to any loss ofcon-sciousness. It is important to begin by exploring what the patient means by loss of consciousness. Did the patient black out completely, or could voices be heard throughout the episode, indicating some consciousness? Be sure to use descriptive terms carefully and precisely. Syncope is the sudden but temporary loss of consciousness that occurs with decreased blood flow to the brain, commonly described as fainting. Symptoms of feeling faint, lightheaded, or weak, but without actual loss of consciousness, are called near syncope or presyncope.

See Table 16-6, Syncope and Similar Disorders, pp. 604-605.

Get as complete and unbiased a description of the event as you can. What brought on the episode? Were there any warning symptoms? Was the patient standing, sitting, or lying down when the episode began? How long did it last? Could voices be heard while passing out and coming to? How rapidly did the patient recover? In retrospect, were onset and offset slow or fast?

Young people with emotional stress and warning symptoms of flushing, warmth, or nausea may have vasodepressor (or vasovagal) syncope of slow onset, slow offset. Cardiac syncope from arrhythmias, more common in older patients, often with sudden onset, sudden offset.

Also ask if anyone observed the episode. If so, what did the patient look like before losing consciousness, during the episode, and afterward? Was there any seizure-like movement of the arms or legs? Any incontinence of the bladder or bowel? Any drowsiness or impaired memory after the episode ended?

Tonic-clonic motor activity, bladder or bowel incontinence, and postictal state suggest a generalized seizure. Unlike syncope, injury such as tongue biting or bruising of limbs may occur.

A seizure is a paroxysmal disorder caused by sudden excessive electrical dis- See Table 16-7, Seizure Disorders, charge in the cerebral cortex or its underlying structures. Seizures can be of pp. 606-607. several types. Depending on the type, there may or may not be loss of consciousness. With some types of seizures, there may be abnormal feelings, thought processes, and sensations, including smells, as well as abnormal movements. Asking "Have you ever had any seizures or 'spells'?" . . . "Any fits or convulsions?" can open the discussion. As with syncope, aim for a full and complete description, including precipitating circumstances, warnings, and behavior and feelings both during the attack and afterward. Ask about age at onset, frequency, any change in frequency or symptom pattern, and use of medications. Is there any history of prior head injury or other conditions that may be causally related?

Tremors and other involuntary movements occur with or without additional neurologic manifestations. Ask about any trembling, shakiness, or body movements that the patient seems unable to control.

See Table 16-8, Involuntary Movements, pp. 608-609.

Distinct from these symptoms is an almost indescribable restlessness ofthe legs that typically develops at rest and is accompanied by an urge to move about. Walking gives relief.

The common but often overlooked restless legs syndrome, usually benign

Important Topics for Health Promotion and Counseling

■ Screening for depression and suicidality

■ Screening for dementia

■ Prevention of TIAs or stroke

Up to a third of all primary care visits involve mental health—depressed mood, anxiety, somatic concerns, and more serious disorders of mood and mental function. The burden of suffering imposed by these disorders is great. For the general population, focus health promotion and counseling on depression, suicidality, and dementia, three important conditions often overlooked. You should also screen for use of drugs or alcohol (see pp. 43-45).

The lifetime prevalence of major depression meeting formal diagnostic criteria is 5% to 10% in men and 10% to 20% in women. Primary-care providers fail to diagnose major depression in up to 50% of affected patients, often missing early clues such as low self-esteem, anhedonia (failure to find pleasure in daily activities), sleep disorders, and difficulty in concentrating or making decisions. Routine general screening has not been shown to improve outcomes; rather, target diagnosis and treatment to patients who are symptomatic. Watch carefully for depressive symptoms, especially in patients who are young, female, single, divorced, separated, seriously or chronically ill, or bereaved. Patients with a prior history of depression or positive family history are also at risk. Failure to diagnose depression can have consequences that are fatal—suicide rates in patients with major depression are eight times higher than in the general population.*

Clinicians must be adept at eliciting suicidal ideation or intent (see Chap 2, p. 47). Suicide rates are highest among men over age 65, but have been increasing in teenagers and young adults. Risk factors include any history of psychiatric illness (especially if linked to a hospital admission), substance abuse, personality disorder, prior suicide attempt, or family history of suicide. Clinicians should ask about domestic firearms and screen for alcohol dependence: guns are present in the home of more than half of all suicide victims, and alcohol intoxication is associated with nearly 25% of suicide deaths. Any evidence of suicidal ideation must be further assessed. Has a weapon been obtained? Is there a plan or a note? Such patients should be promptly referred for mental health and psychiatric care and for treatment of any related problems of alcohol or drug abuse.

Dementia, a "global impairment of cognitive function that interferes with normal activities,"* affects 16% of Americans over 65. Prominent features include short- and long-term memory deficits and impaired judgment. Thought processes are impoverished and speech may be hesitant due to difficulty in finding words. Loss of orientation to place may make navigating by foot or car problematic or even dangerous. Most dementias represent Alzheimer's disease (~50%-85%) or vascular multi-infarct dementia (~10%-20%). Be watchful for Alzheimer's disease in individuals with a pos

*U.S. Preventive Services Task Force: Ch. 49: "Screening for Depression." In Guide to Clinical Preventive Services. Baltimore, Williams and Wilkins, pp. 541-546, 1996.

tU.S. Preventive Services Task Force: Ch. 48: "Screening for Dementia." In Guide to Clinical Preventive Services. Baltimore, Williams and Wilkins, pp. 531-541, 1996.

itive family history, since their risk is three times higher than in the general population.

Dementia often has a slow, insidious onset and may escape detection by both families and clinicians, especially in its initial stages. Currently there are no reliable screening tests to help you detect dementia early in its course. Clinicians should be alert to evidence of change in cognitive function or activities of daily living, and to family complaints about new or unusual patient behaviors. Use of the Mini-Mental State Examination is helpful for assessing cognitive impairment (although scores may be affected by level of education and cultural variables such as language). Once cognitive change is identified, be sure to address the possible role of medications, depression, or metabolic abnormalities. Couple cognitive and behavioral assessment with a careful neurologic examination during your evaluation of the patient. Be sure to look for other medical and psychiatric conditions that could be contributing to changes in behavior or level of daily activity. For demented patients and affected families, counseling about the potential for disruptive behavior, accidents and falls, and termination of driving privileges is warranted. Clinicians can foster discussion of legal matters such as power of attorney and advanced directives while the patient is still able to contribute to decision-making.

Finally, direct clinical attention to averting cerebrovascular accidents (CVAs). Strokes, or CVAs, are the third leading cause of death in the United States and contribute to extensive disability in the workforce and general population. The incidence of stroke increases with age and is 60% higher in African Americans compared to Caucasians. The clinician's first task in stroke prevention is to control hypertension. Hypertension accelerates atherosclerotic changes in the carotid, vertebral, and cerebral arteries and disturbs autoregulation of cerebral blood pressure. It is the leading risk factor for both ischemic and hemorrhagic stroke, which account for approximately 85% and approximately 10% of all CVAs, respectively. In addition, clinicians should counsel patients to modify conditions contributing to atherosclerosis: smoking, hyperlipidemia, and diabetes. Drug users should be warned of the link between stroke and cocaine.

Clinicians should be alert to symptoms of transient ischemic attacks (TIAs), generally defined as neurologic events that resolve within 24 hours. TIAs can be viewed as CVA warning signals, the anginal equivalent of the brain. In the first year after a TIA, risk of CVA is 6%-7%, and the CVA usually occurs in the same vascular distribution as the TIA. Common symptoms of TIAs include visual loss (especially transient monocular blindness from emboli), aphasia, dysarthria, and changes in facial movement or sensation. For TIAs affecting motor or sensory pathways, watch for clumsiness, weakness, paralysis, or tingling or paresthesias of the arm, leg, or hemibody.

Preview: Recording the Examination—The Nervous System

Note that initially you may use sentences to describe your findings; later you will use phrases. The style below contains phrases appropriate for most write-ups. Unfamiliar terms are explained in the next section, Techniques of Examination. Note that there are five components to the examination and write-up of the nervous system.

"Mental Status: Alert, relaxed, and cooperative. Thought process coherent. Oriented to person, place, and time. Detailed cognitive testing deferred. Cranial Nerves: I—not tested; II through XII intact. Motor: Good muscle bulk and tone. Strength 5/5 throughout. Cerebellar: Rapid alternating movements (RAMs), finger-to-nose (F^N), heel-to-shin (H^S) intact. Gait with normal base. Romberg—maintains balance with eyes closed. No pronator drift. Sensory: Pinprick, light touch, position, and vibration intact. Reflexes: 2+ and symmetric with plantar reflexes downgoing."

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