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Peripheral Neuropathy in Older People Peripheral Neuropathies Are Common in Older People

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Peripheral Neuropathy in Older People Peripheral Neuropathies Are Common in Older People Pain 47 Peripheral neuropathy in older people Peripheral neuropathies are common in older people. Although the ageing process itself may play a part, there are multiple other causes. Peripheral neuropathy interferes with normal daily activities and leads to increased risk of falls, injury and poor quality of life. Management of peripheral neuropathy ofen needs a multidisciplinary team approach. Siyum Strait, Specialist Registrar Acute Medicine, Great Western Hospital, Swindon Pippa Medcalf, Consultant Physician, Gloucester Royal Hospital, Great Western Road, Gloucestershire Email [email protected] Peripheral neuropathy is one involvement, time course, type of (eg. diabetic distal symmetrical pattern of damage to the peripheral defcit or nature of the underlying polyneuropathy), purely nervous system.1 Physical signs of pathology.8 (Box 1) motor (eg. acute motor axonal peripheral neuropathy are common The patterns of nerve neuropathy), mixed motor and in older people.2 Recognition involvement that occur include sensory (eg. Charcot-Marie-Tooth of these deficits is particularly mononeuropathy, multiple disease) and autonomic. important because peripheral mononeuropathy (mononeuritis Te responsible pathology may neuropathy may contribute to the multiplex), symmetrical be axonal, demyelinating or mixed vulnerability to falls that is common polyneuropathy, radiculopathy and axonal and demyelinating. in this age group.3,4 More than 30% polyradiculoneuropathy. Peripheral neuropathies of all of patients aged over 65 years will Mononeuropathy refers to groups may involve large nerve fall at least once per year.5 involvement of major nerve trunks, fbres, small nerve fbre or both. Peripheral neuropathy singly or multiply. Radiculopathy Large nerve fibres are long, commonly causes impairment refers to involvement of nerve myelinated and enable fast of proprioception and balance, roots, again singly or multiply. conduction of impulses. They which can be identified from an Polyneuropathy affects terminal can afect motor function and the inability to maintain unipedal branches of multiple nerves, sensory modalities of vibration, stance for 10 seconds, impaired often involving both legs and position sense and temperature. position sense at the great toe and arms and occurring bilaterally Small fbres may or may not decreased vibratory sense that (symmetrical polyneuropathy).9 be myelinated. Each type involves improves proximally.6 Distal symmetrical polyneuropathy different sensations. Involvement Recognition of the cohort of is the most common variety of of small fbres commonly produces patients with these deficits may polyneuropathy.10 pain and paresthesiae (often identify treatable causes and Te time course can be acute described as burning, lancinating or provide a better management plan (reaching maximal deficit in less “ice pick in the bone”). for patients prone to falling.6,7 than four weeks eg. Guillain-Barré Small fibre neuropathy syndrome), subacute (reaching is the most common type of maximal defcit in 4–8 weeks) or neuropathy in people over the Classifcation chronic (taking more than eight age of 50 years and typically weeks to develop). affects the lower limbs. It often Peripheral neuropathy can be Te resulting defcits may be precedes the development of large classifed by the pattern of nerve purely or predominantly sensory fibre neuropathy. This type of www.gmjournal.co.uk November 2012 | Midlife and Beyond | GM 48 Pain Multiple mononeuropathy Box 1: Classifcation of Multiple mononeuropathy Box 2: Classifcation of peripheral neuropathy (mononeuritis multiplex) is mononeuropathy caused by vascular, infammatory, Facial palsy infltration, immune reactions and Vascular Bell’s palsy trauma. (Box 3) Diabetes Sarcoidosis Polyarteritis nodosa Polyneuropathy Lyme disease Rheumatoid arthritis Causes of symmetrical Guillain-Barré syndrome polyneuropathy are more extensive Non-systemic vasculitis Chronic infammatory and complicated than those Infammatory demyelinating polyneuropathy of mononeuropathy, although Sarcoidosis Herpes zoster relatively few diagnoses account for Lyme disease Carpal tunnel syndrome a large number of cases (eg. diabetes Infltrations mellitus, alcohol over use). Ulnar nerve palsy Malignancy Radial nerve palsy Amyloidosis Meralgia paraesthetica Clinical evaluation Immune reactions Common peroneal nerve palsy Immunisation, foreign serum An accurate history and clinical and proteins examination remains vital in the Trauma neuropathy is ofen unrecognised clinical evaluation of a patient with Multiple nerve injuries by physicians and responds poorly peripheral neuropathy. or slowly to medication.9 Although large and small nerve History Patients may also have cramps fibres may be affected together, The history should address and spasms. only large fibre involvement symptoms, possible causes and Autonomic symptoms depend can be detected by conventional time course. It is important to note upon the system involved. Cardiac nerve conduction studies. Nerve the time period that has taken for involvement may give rise to heart damage due to inflammation or symptoms to evolve and progress. rate irregularities, orthostatic compression tends to sustain a Sensory nerve involvement hypotension and dizziness on more or less complete recovery commonly causes a sensation standing. Gastro-intestinal because of the ability of Schwann of wearing an invisible glove or involvement can commonly cause cells to proliferate and remyelinate sock, burning or freezing pain nausea, vomiting, constipation demyelinated axons. in the extremities, numbness, and diarrhoea. Genito-urinary tingling, pins and needles, band- involvement results in poor bladder like sensation around the wrist control and sexual dysfunction. Causes or ankles and unsteadiness Autonomic symptoms can be and stumbling. very disabling. Among adult patients referred Motor symptoms are usually In searching for probable for assessment of peripheral those of wasting and weakness. causative factors, enquiry should neuropathy, a specifc cause can be Te symptoms will depend upon routinely address recent infections, identifed in about 72% cases.2 the muscle groups affected and alcohol and drug intake, diet, whether those involved are distal or family history and symptoms of Mononeuropathy proximal, but include difculty in systemic disease. Mononeuropathy is usually due to turning keys in locks, unfastening direct compression or entrapment buttons and removing the tops of Clinical examination of the nerves but may be the bottles and jars, foot drop, difculty Motor signs include muscle wasting first manifestation of diabetic or climbing stairs, getting out of chairs and weakness, which in symmetrical vasculitic neuropathy. (Box 2) and standing from crouching. polyneuropathy is usually distal GM | Midlife and Beyond | November 2012 www.gmjournal.co.uk Pain 49 stocking distribution. Sensory serum proteins, vitamin B12, Box 3: Classifcation of testing should include light touch, TSH, auto antibodies, serum mononeuritis multiplex pinprick, vibration and joint protein electrophoresis and position. Distal tendon refexes are immunoelectrophoresis, serum Diabetes commonly absent. creatinine, liver function Idiopathic neuropathy The patient should be tests, chest radiographs and Connective tissue disease observed standing and walking, electrophysiological studies. rising onto their heels and If these investigations do not Systemic lupus erythematosus toes, the Romberg’s test and provide information that leads to Polyarteritis nodosa walking heel to toe. The skin a diagnosis, special investigations Rheumatoid arthritis should be examined for trophic may be required, such as Non-systemic vasculitis skin changes and ulcers in the cryoglobulins, HIV, anti Myelin- Inherited neuropathies extremities. Bony deformities Associated Glycoprotein (MAG) such as pes cavus and clawtoes antibodies, urinary heavy metals Infections may be present. Nerves should be and Lyme serology. HIV palpated for thickening. Malignancies Examination of the optic Nerve conduction studies Multiple myeloma fundus may reveal papilloedema Nerve conduction studies play Waldenstrom’s in chronic inflammatory a vital role in confirming the macroglobulinaemia demyelinating polyneuropathy presence of peripheral neuropathy and the retinal abnormalities of and establishing its cause. Tey Cryoglobulinaemia diabetes mellitus. help to determine whether a Monoclonal gammopathy of patient has a mononeuropathy, uncertain signifcance mononeuritis multiplex or a Paraneoplastic syndrome Investigations generalised neuropathy; whether Chemotherapy & drugs the neuropathy is symmetrical Metronidazole, nitrofurantoin, Te clinical features ofen suggest or asymmetrical; whether phenytoin, thalidomide, a likely underlying cause and both sensory and motor fibres vincristine point to the most appropriate are affected; and whether the investigations.11 General laboratory underlying pathology is of axonal Metabolic disorders tests and nerve conduction studies degeneration or demyelination. Tyroid disease should be performed as the first Motor conduction velocities Multiple nerve injuries stage of investigation in all patients. below 40m/s in the upper limb Uraemia Subsequent investigations will and 30m/s in the lower limb depend on the results of these indicate possible demyelination. Cirrhosis initial studies.11 Lesser degrees of slowing of Acromegaly nerve conduction velocity Defciencies indicate peripheral nerve damage, Tiamine+ General which could
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