Geriatric neurology focuses on neurological disorders common in older adults aged 60 and over. Diagnosis can be difficult as signs may mimic normal aging. Common disorders include dementia, epilepsy, headaches, multiple sclerosis, and Parkinson's disease. Alzheimer's disease is the most common cause of dementia, characterized by plaques and tangles that damage the brain over time. Parkinson's disease results from the death of dopamine-producing cells in the brain and causes movement-related symptoms. Epilepsy is also more common in the elderly, with stroke being a leading cause of new-onset epilepsy in older people.

1. NEUROLOGICAL DISORDER
IN GERIATRIC
DR RITESH SHIWAKOTI
MScD PROSTHODONTICS

2.  A branch of medicine, geriatrics is concerned with
diagnosing and treating illnesses that occur in adults,
generally over age 60.
 A subset of this, geriatric neurology focuses on
neurologic disorders common to this age group.

3. Correct diagnosis of neurologic disorders in older adults can
be difficult because signs of disease may mimic normal
signs of aging.
Patients frequently have more than one neurologic
problem at once.
It can be challenging to find the best treatment once such
a problem has been diagnosed.

4. Common Geriatric Neurology Problems
 Dementia
 Epilepsy
 Headache disorders
 Multiple sclerosis
 Neuro infections
 Neurological disorders associated with malnutrition
 Pain associated with neurological disorders
 Parkinson’s disease
 Stroke
 Traumatic brain injuries

5. Memory and Aging
As people get older, they complain of memory loss.
Slight memory loss from normal aging should not interfere
with daily activities.
Forgetting appointments, being unable to find your way in
familiar areas, having difficulty with cooking or reading--
these are all possible signs of more severe memory loss
which needs to be investigated.

6. Causes of Memory Disorders
Depression,
Vitamin B12 deficiency,
Medications and
Sleep disorders to more severe dementia.
Alzheimer's disease
The causes of memory loss and dementia should be
identified early.
Medications can improve memory loss.
Patients and families also benefit from an accurate
diagnosis, which allows them to get community support
and plan for the future.

7. Dementia

8. Dementia is a syndrome caused by disease of the brain,
usually of a chronic or progressive nature, in which there
is disturbance of multiple higher cortical functions,
including memory, thinking, orientation, comprehension,
calculation, learning capacity, language and judgement.

9. Dementia mainly affects older people
Only 2% of cases start before the age of 65 years.
The prevalence doubles with every five-year increment in
age.
Dementia is one of the major causes of disability in later
life.

10. Causes
Cortical amyloid plaques and neurofibrillary tangles i.e. Alzheimer’s
disease AD accounting for one half to three quarters of all cases.
Repeated disruption of the blood supply to the brain by strokes and
other vascular pathology
Causes thAat may be treated effectively by timely medical or surgical
intervention— these include
Hypercalcaemia
Subdural haematoma
Normal pressure hydrocephalus
Deficiencies of thyroid hormone
Vitamin B12 and folic acid deficiency

11.  Alzheimer's disease is a neurological disorder in which
the death of brain cells causes memory loss and
cognitive decline. A neurodegenerative type of dementia,
the disease starts mild and gets progressively worse.
It eventually affects most areas of your brain, including
those important in memory, thinking, judgment,
language, problem-solving, personality and movement.

12. In 2010, some 4.7 million people of 65 years of age and older were
living with Alzheimer's disease in the US.
The 2013 statistical report just over a tenth of people in the over-65
age group have the disease in the US.
In the over-85s, the proportion goes up to about a third.
The Alzheimer's Association says it accounts for between 60% and
80% of all cases of dementia
Vascular dementia, which is caused by stroke not Alzheimer's, is the
second most common type of dementia.

13. Alzheimer's is caused by brain cell death.
It is a neurodegenerative disease, which means there is
progressive brain cell death that happens over a course
of time.
The total brain size shrinks with Alzheimer's - the tissue
has progressively fewer nerve cells and connections.

14. Tiny inclusions in the nerve tissue, called plaques and
tangles.
Plaques are found between the dying cells in the brain -
from the build-up of a protein called beta-amyloid.
The abnormal protein clumps, inclusions, in the brain tissue
are always present with the disease.

15. Risk factors
Unavoidable risk factors
Age - the disorder is more likely in older people, and a greater
proportion of over-85-year-olds have it than of over-65s.
Family history (inheritance of genes) - having Alzheimer's in the family
is associated with higher risk
Having a certain gene (the apolipoprotein E or APOE gene) puts a
person eight times more risk than a person without the gene.
Numerous other genes have been found to be associated with
Alzheimer's disease, even recently (see developments below).
Being female (more women than men are affected).

16. Potentially avoidable or modifiable factors
Diabetes
High cholesterol
High blood pressure (These also increase the risk of stroke, which itself
can lead to another type of dementia.)
Low educational and occupational attainment.
Prior head injury (trauma)
Sleep disorders
Estrogen hormone replacement therapy

17. Sign and symptoms
1)Worsened ability to take in and remember new information, for
example:
"Repetitive questions or conversations”
Misplacing personal belongings
Forgetting events or appointments
Getting lost on a familiar route.
2)Impairments to reasoning, complex tasking, exercising judgment:
"Poor understanding of safety risks”
Inability to manage finances
Poor decision-making ability
Inability to plan complex or sequential activities.

18. 3) Impaired visuospatial abilities (but not, for example, due
to eye sight problems)
"Inability to recognize faces or common objects or to find
objects in direct view”
Inability to operate simple implements, or orient clothing to
the body.
4) Impaired speaking, reading and writing:
"Difficulty thinking of common words while speaking,
hesitations Speech, spelling, and writing errors."

19. 5)Changes in personality and behavior
Out-of-character mood changes, including agitation; less
interest, motivation or initiative; apathy; social
withdrawal
Loss of empathy
Compulsive, obsessive or socially unacceptable behavior.

20. Stages of Alzheimer's disease
The progression of Alzheimer's can be broken down into
three basic stages-
 Preclinical (no signs or symptoms yet)
 Mild cognitive impairment
 Dementia.

21. Tests and diagnosis
Inital tests includes
 Interview and careful history
 Physical examination
 Check neurological function, e.g. by testing balance,
senses and reflexes.
 Sending off for tests of blood and urine samples
 Arranging brain scans (possibly including CT, MRI and
EEG).
 Genetic test ( DNA test )

22. Cognitive test : "abbreviated mental test score" (AMTS):
 What is your age?
 What is the time, to the nearest hour?
 Repeat an address at the end of the test that I will give you now
(e.g. "42 West Street")
 What is the year?
 What is the name of the hospital or town we are in?
 Can you recognize two people (e.g. the doctor, nurse, home help,
etc.)?
 What is your date of birth?
 In what year did World War 1 begin? (Other widely known dates in
the past can be used.)
 Name the president/prime minister/monarch.
 Count backwards from 20 down to 1.

23. Treatment and prevention
There is no known cure for Alzheimer's disease - the death
of brain cells in the dementia cannot be halted or
reversed.
There is, however, much backing for therapeutic
interventions to help people live with Alzheimer's disease
more ably.
The Alzheimer's Association includes the following as
important elements of dementia care:
 Effective management of any conditions occurring alongside the
Alzheimer's
 Activities and/or programs of adult day care
 Support groups and services.

24. Parkinson’s disease

25. Parkinson's disease (PD also known as idiopathic or
primary parkinsonism, hypokinetic rigid syndrome/HRS,
or paralysis agitans) is a degenerative disorder of
the central nervous system.
The motor symptoms of Parkinson's disease result from the
death of dopamine-generating cells in the substantia
nigra, a region of the midbrain; the cause of this cell
death is unknown
The disease is named after the English doctor James
Parkinson, who published the first detailed description
in An Essay on the Shaking Palsy

26. Epidemiology
PD is the second most common neurodegenerative
disorder after Alzheimer's disease and affects approximately seven
million people globally and one million people in the United States.
The prevalence (proportion in a population at a given time) of PD is
about 0.3% of the whole population in industrialized countries.
PD is more common in the elderly and prevalence rises from 1% in
those over 60 years of age to 4% of the population over 80.
The mean age of onset is around 60 years, although 5–10% of cases,
classified as young onset, begin between the ages of 20 and 50.
PD may be less prevalent in those of African and Asian ancestry.
Some studies have proposed that it is more common in men than
women The incidence of PD is between 8 and 18 per 100,000
person–years.

27. Risk factors
 The most frequently replicated relationships are an
increased risk of PD in those exposed to pesticides, and
a reduced risk in smokers

28. Classification
Idiopathic Parkinson's disease
 Idiopathic Parkinson's disease - or Parkinson's - is the most common
type of parkinsonism. Unlike some other forms which have specific
causes it is not known why idiopathic Parkinson's occurs.
 The main symptoms of idiopatic Parkinson's are tremor, rigidity and
slowness of movement.
Vascular parkinsonism
 The most likely causes of vascular parkinsonism are hypertension
and diabetes. A stroke (cerebrovascular accident), cardiac
disease or carotid artery pathology (another form of stroke) may
also be involved.
 Symptoms of vascular parkinsonism may include difficulty speaking,
making facial expressions or swallowing. Other signs can include
problems with memory or confused thought, cognitive problems and
incontinence.

29. Drug-induced parkinsonism
 Drugs - known as neuroleptic drugs - used to treat schizophrenia
and other psychotic disorders block dopamine.
 Dopamine is a chemical in the brain which allows messages to be
sent to the parts of the brain that co-ordinate movement.
 The symptoms of drug-induced parkinsonism tend to be static.
 Most people will recover within months, and often within hours or
days, of stopping the drug that caused the dopamine block.

30. Dementia with Lewy bodies
 People who have dementia with Lewy bodies commonly experience
visual hallucinations and some Parkinson's-type symptoms, such as
slowness of movement, stiffness and tremor.
Inherited Parkinson's
 It is thought that although it is not directly inherited, some people
may have genes that increase the possibility of developing
Parkinson's.
 People who have genes that are prone to Parkinson's may be more
likely to develop the condition when combined with other factors,
such as environmental toxins or viruses.
Juvenile Parkinson's
 Juvenile Parkinson's is a term used when the condition affects
people under the age of 20.

31. Signs and symptoms
Inherited Parkinson's
 It is thought that although it is not directly inherited, some people
may have genes that increase the possibility of developing
Parkinson's.
 People who have genes that are prone to Parkinson's may be more
likely to develop the condition when combined with other factors,
such as environmental toxins or viruses.
Juvenile Parkinson's

32. Causes
Environmental factors
 Pesticide exposure
 Head injuries, and
 Living in the country or farming
 Rural environments and the drinking of well water may be risks as
they are an indirect measures of exposure to pesticides].
 Heavy metals exposure has been proposed to be a risk factor.


33. Genetics:
 Mutations in specific genes have been conclusively
shown to cause PD. These genes code for alpha-synuclein
(SNCA), parkin (PRKN), leucine-rich repeat
kinase 2 (LRRK2 or dardarin), PTEN-induced putative
kinase 1 (PINK1), DJ-1 and ATP13A2.In most cases,
people with these mutations will develop PD

34. Pathophysiology
 The primary symptoms of Parkinson's disease result
from greatly reduced activity of dopamine-secreting cells
caused by cell death in the pars compacta region of
the substantia nigra.
 There are five major pathways in the brain connecting
other brain areas with the basal ganglia. These are
known as the motor, oculo-motor, associative,limbic
and orbitofrontal circuit.
 All of them are affected in PD, and their disruption
explains many of the symptoms of the disease since
these circuits are involved in a wide variety of functions
including movement, attention and learning.

35. Diagnosis
 Medical history
 Neurological examination
 Computed tomography (CT) and magnetic resonance
imaging (MRI)
 Gene examination
 Another type of imaging test, called PET, sometimes
may detect low levels of dopamine in the brain.

36. Treatment
Prevention:
 Caffeine consumption appears protective against
Parkinson's disease
 Tobacco smoke is found to reduce the risk of PD
 Antioxidants, such as vitamins C and D also reduces risk.
 There have been preliminary indications of a possible
protective role of estrogens and anti-inflammatory drugs.

37. Management:
Levodopa has been the most widely used treatment for
over 30 years.
L-DOPA is converted into dopamine in the dopaminergic
neurons by dopa decarboxylase.
Since motor symptoms are produced by a lack of dopamine
in the substantia nigra, the administration of L-DOPA
temporarily diminishes the motor symptoms.
Several dopamine agonists that bind to dopaminergic post-synaptic
receptors in the brain have similar effects to
levodopa

38. MAO-B inhibitors (selegiline and rasagiline) increase the
level of dopamine in the basal ganglia by blocking its
metabolism.
Other drugs such as amantadine and anticholinergics may
be useful as treatment of motor symptoms
Treating motor symptoms with surgery was once a
common practice, but since the discovery of levodopa,
the number of operations declined
Brain pacemaker implanted in the brain for specific
stimilus.

39. Epilepsy in the Elderly

40.  Research shows that the incidence of
epilepsy higher in the elderly.
 Epilepsy was believed to be predominantly
a childhood disorder.
 Epilepsy is the most common serious
neurological disorder in the elderly after
stroke and dementia

41. US census projections
 147 percent increase in the over 65 years
old population between 2000-2050
 Only 49 percent in population over the
same period.

42.  Elderly people with epilepsy are a large
but neglected group.
 In a postal survey 25% of general
practitioners were unaware that epilepsy
commonly manifests for first time in
elderly.

43. Cause

44.  Stroke is the leading cause of new-onset
epilepsy in elderly
– 8% of patients will hemorrhagic stroke will develop seizures within two
weeks
– 5% of patients with ischemic stroke will develop seizures with in 2
weeks.
 Post-stroke epilepsy usually develops
within 3–12 months
 However, can still occur many years later

45. Dementias and Neurodegenerative diseases
 10–20% of all epilepsy in older people.
 Less appreciated is the evidence
suggesting that dementia may develop
with greater frequency elderly with chronic
and established epilepsy.

46.  Post-traumatic epilepsy is common in elderly
 Head injury, mostly from falls, causes up to 20% of
epilepsy in the elderly.
 Increased risk of subdural hemorrhage, especially with
anticoagulants or platelet inhibitors.
Factors that increase risk of post-traumatic
epilepsy
– Loss of consciousness
– Post-traumatic amnesia > 24 hrs.
– Skull fracture, brain contusion and subdural hematoma

47.  Common causes
– acute alcohol withdrawal
– metabolic and electrolyte disturbances
 Hyponatremia
 Hypocalcemia
 Hypomagnesemia
– Infections
 systemic
 CNS.
– Drugs - commonly prescribed to elderly.
 Tramadol
 Antipsychotics
 Antidepressants (particularly tricyclics)
 Antibiotics(quinolones and macrolide)
 Theophylline, levodopa, thiazide diuretics and even the herbal remedy,
ginkgo biloba

48. Clinical Presentation
 Focal or complex partial seizures
– Memory lapses,
– Episodes of confusion
– Periods of inattention
– Apparent syncope

49. Other factors
 Impairment of cognition, Behavioral change.
 Psychomotor retardation
 Agitation or excitation
 Subtle facial or limb twitches
 Aphasia, echolalia, confabulation
 Head or eye deviation
 Automatisms
 Autonomic disturbance

50. Diagnosis
 History
 Clinical Exam
 Investigations:
– Blood work
 full blood count, renal function testing, serum electrolytes, and
random blood glucose.1
– EKG, Holter monitoring and tilt table in some cases.
– Chest X ray
– EEG
– Neuroimaging studies

51. Treatment

52.  Treatment decisions have to be made
Cautiously.
– Elderly are more susceptible to the adverse
effects of drugs than their younger
counterparts
– The pharmacokinetics and pharmacodynamics
of antiepileptic drugs differ in old age
– Drug-drug interactions

53. Challanges
 Comorbidities of in elderly patients add to the diagnostic
challenge and also complicate the treatment options
 Polypharmacy make them susceptible to drug
interactions.
 A survey of elderly nursing home residents found that
49% of residents receiving AEDs were prescribed six or
more medications.
 Adherence may not be as good in elderly patients with
epilepsy.

54.  Surgery is another method