Tag: falls

Parkinson’s disease: a quick one on one

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Parkinson’s disease (PD) is a common neurological disease. This disorder of the brain is seen in people of all races and both sexes. PD is caused by the deficiency of a neurochemical called DOPAMINE in the brain. In this blog post I shall discuss the clinical presentation and diagnosis of PD.

Parkinson’s disease is included under the category of neurodegenerative brain disorders. What that means is that the disease is progressive. Once the disease starts, it slowly progresses. The rate of progression though varies from patient to patient. The disease onset is usually insidious. Most people first exhibit signs of the disease after age 60 (in some people the disease may start in the late 40’s or in their 50’s-this is then referred to as Early Onset Parkinson’s).

Disease onset-onset of PD is usually insidious and at times may not be noticed by the patient or the family. Typical first symptom may be a slight tremor (shaking) in the thumb of one hand/finger of one hand, the hand itself or the chin. The tremor is not disabling at onset and hence ignored by the patient/family. It is important to emphasize here that NOT ALL TREMORS ARE PD. There are numerous causes of tremor, many which are benign (do not signify any serious disease). PD tremor has some special characteristics (features) which helps to distinguish it from other types of tremors.

CHARACTERISTICS (FEATURES) OF PD TREMOR

  1. The tremor is usually insidious in onset and of low amplitude.
  2. The tremor is usually asymmetrical at onset (one thumb/one hand). As the disease progresses the tremor becomes more prominent and may involve both the sides of the body.
  3. PD tremor is typically what is referred to as a RESTING TREMOR. What this means is that the tremor is most prominent when the hands are completely at rest (example-the tremor is noted when the patient’s hands are resting on his/her lap, resting on the driving wheel). This is an IMPORTANT distinguishing feature of PD tremor. Tremors which are more prominent when the hands are extended in front (POSTURAL TREMOR) or while in motion are usually not due to PD.

CLINICAL PRESENTATION OF PD (SIGNS AND SYMPTOMS)

PD initially presents with motor symptoms. Patients do not have sensory symptoms such as pain, numbness, tingling. The common motor symptoms of PD are the following:

  1. Tremor: tremor of PD is a resting tremor (see above).
  2. Bradykinesia: the word bradykinesia means “slowness of movement” and is one of the main symptoms of PD. The patient is slow to walk, slow to initiate movement. As PD progresses, the patient becomes more and more bradykinetic (slow). There is loss of spontaneous movements such as facial expressions, gesturing, eye blinks.
  3. Rigidity: rigidity is another cardinal symptom of PD and refers to the stiffness which PD patients feel in their muscles. Rigidity can be detected by the neurologist on clinical examination.
  4. Disturbance of gait and posture: patients with PD experience a disturbance in their gait (how a person walks) and posture. A patient with PD is usually stooped (bent) forwards and walks with short quick steps. This is referred to as the SHUFFLING GAIT OF PD. This disturbance of gait and posture makes PD patients more prone to falls. It is important to emphasize here that FALLS ARE AN INPORTANT CAUSE OF MORBIDITY IN PD PATIENTS.

Photo source: *photo: https://www.labiotech.eu/medical/axovant-parkinsons-disease-gene/ (the above image has been edited)

DIAGNOSIS OF PD

The diagnosis of PD is predominantly clinical and has not changed much since the disease was first described by James Parkinson, an English surgeon in his now famous 1817 work AN ESSAY ON THE SHAKING PALSY.

PD is diagnosed in the following way:

  1. Clinical examination by a neurologist: neurologists are able to diagnose PD after taking a history and doing a neurological examination in which they assess for tremor, bradykinesia, rigidity and gait/posture.
  2. Neuroimaging: it is important to emphasize that neuroimaging studies such as CT scan head and MRI brain are usually reported normal in patients with PD.
  3. New imaging modalities: DaT scan is a new imaging test which uses a small amount of a radioactive tracer drug to determine how much dopamine is available in a patient’s brain. It is important to emphasize that DaT scan is neither needed nor a definitive test for PD diagnosis. It is primarily helpful in differentiating Parkinson like diseases (Parkinsonian syndromes) from a more benign condition called essential tremor (ET).

DISCLAIMER: The information in this blog is for educational and informational purposes only. It does not constitute medical advice. Use of the site content does not establish any patient-doctor relationship. If you choose to write to me or post a comment on this blog, please do not divulge any personal medical information.

Nitin K Sethi, MD, MBBS, FAAN

Falls in neurodegenerative conditions: what can be done?

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               Nitin K Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY 10065

FALLS ARE COMMON IN THE ELDERLY!!!

Falls are common in neurodegenerative conditions so that is what I shall discuss in this post. Patients with diseases like Alzheimer’s dementia, fronto-temporal dementia (Pick’s disease), multi-infarct dementia (vascular dementia), Parkinson’s disease, multiple sclerosis, Progressive Supranuclear Palsy and some post stroke patients are all prone to falls either early or sometime in their disease course.

FALLS CAUSE MORBIDITY AND MORTALITY!!!

Falls are an important cause of morbidity and mortality in this vulnerable population. Imagine a-85-year old man with Alzheimer’s dementia. Even though he has cognitive deficits (decreased memory and problems with other cognitive skills like calculation, abstract thinking and language) he is still relatively mobile. Every day he takes a 30 min walk in his immediate neighbourhood. One day while walking, he trips over and falls when his foot gets caught in a crack in the side-walk. He is unable to get up by himself . Help only reaches him after an hour when his family comes looking for him. He is rushed to the nearest hospital where an X-ray reveals fracture of the hip and the pelvis. Surgical management is indicated for fracture stabilization.  He is admitted to the hospital and the hospital course gets complicated by development of pressure sores (bed sores), deep venous thrombosis (blood clots in the veins of the legs) and pulmonary embolism (blood clot in the lung vasculature).  All these are directly related to his forced immobilization due to hip and pelvic fractures. He gets progressively more disoriented during his prolonged hospital stay though survives and makes a slow recovery and is discharged to a sub-acute facility.

FALLS HURT AND CAUSE INJURIES!!!

Falls may lead to various injuries:

1) Fractures of the hips, long bones: tibia, fibula, femur, neck of femur, radius, ulna

2) Neurotrauma: head injuries: subdural and epidural hematomas, sub arachnoid hemorrhage, intracranial hemorrhage (bleeding into the brain)

3) Craniofacial injuries: injuries to the face, eyes, the orbit

4) Fractures of the ribs

5) Back injuries

THE STATISTICS ARE SCARY!!!!

The incidence of hip fracture increases as the population ages. One in five persons dies in the first year after sustaining a hip fracture, and of those who survive past one year many have significant functional limitation. Of those who survive one year after hip fracture, only 40 percent can perform all routine activities of daily living and only 54 percent can walk without an aid.

WHY DO THE ELDERLY FALL???

Why are falls common in the elderly and more so in the elderly population with a neurodegenerative condition? The causes are many:

1) Poor eye-sight (as we age cataracts and other retinal degenerative conditions become common contributing to poor eye-sight). They have poor depth perception and visual contrast sensitivity.

2) decreased acuity of hearing

3) concomitant neuropathy (many of the elderly population may have a condition like diabetes giving rise to a concomitant peripheral neuropathy. Persons with a sensory motor polyneuropathy are not able to sense the ground and thus their righting reflex is off). RIGHTING REFLEX: various reflexes that tend to bring the body into normal position in space and resist forces acting to displace it out of normal position.

4) Neurological conditions like Parkinson’s disease and Alzheimer’s dementia impair these postural reflexes/ righting reflexes making patients even more prone to falls and resultant injuries.

5) The elderly are on multiple medications like  benzodiazepines, anticonvulsants, sedatives and  antihypertensives which may contribute to the falls. 

6) Risk of osteoporosis and osteopenia increases as we age: when the elderly fall they are more likely to hurt themselves or fracture their bones.

7) Other concomitant medical conditions like diabetes, kidney problems, thyroid problems, blood pressure problems and cardiac problems may contribute to the falls.

WHAT CAN BE DONE?

The big question is how to prevent falls in the elderly. A number of interventions may help.

1) Treat the neurodegenerative/ underlying condition contributing to the falls. Gait and postural reflexes of patients with Parkinson’s disease improve when they are treated with medications like Levodopa-carbidopa and dopamine agonist. The response though varies, their tremor may improve though their gait may still remain off.

Good control of blood sugar in a diabetic patient helps and may halt the progression of the neuropathy.

Alzheimer’s disease patients also gain some benefit in their gait and mobility when they are treated with medications like Aricept.

2) Correct visual/ eye problems: timely cataract surgery, corrective lenses and glasses all help in improving stability and confidence of the elderly patient.

3) Hearing aids may be of help in those who have hearing loss.

4) Restriction of outdoor activities may be advisable in a patient who is at high risk of falls. If that is not acceptable, these activities should be carried out under direct supervision. Keep a walking partner etc.

5) Correct mechanical/ musculoskeletal gait problems such as ingrown toe nail, back and hip pain, foot drop etc.

6) Regular exercise is helpful. By keeping muscles supple and maintaining their tone it ensures that righting reflexes are not lost.

7) Physical therapy may be immensely helpful in some patients (laying emphasis on gait retraining).

8) Use of assist devices like canes (single point, four point), walker is helpful.

9) Fall proof the home and immediate patient surroundings: remove anything which may cause injury if the patient falls-this includes sharp objects, tables with sharp edges, loose carpets.

have fall prevention devices at the top of stairs.

have a bed whose sides can be put at night (just like in the hospital).

have an alarm or some other call device set-up at home so that help can be summoned.

Last but not least” MOST FALLS OCCUR TO AND FROM THE BED TO THE BATHROOM AT NIGHT, SO LEAVE THE BATHROOM LIGHT ON AT NIGHT!!!”

 

Falls in the elderly: making sense of the numerous causes

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Today I consulted on a 90-year-old lady who had been admitted to the hospital for evaluation of frequent falls. Even though she was 90, she was a young 90. Very alert and interactive and with normal strength in bed and mentation.

Since falls in elderly is a common problem, I thought why not discuss about this here. Falls are an important cause of morbidity and mortality especially in the elderly. This is a complicated topic and I shall tackle it by first discussing about how we maintain our balance.

Balance in humans is maintained due to a complex interaction of various neurological and muscular systems. There are added inputs from the visual and auditory systems which help in maintaining stability.

Hence problems with balance and stability may arise from primary neurological conditions, either problems involving the central nervous system such as the cerebellum or the peripheral nerves as in neuropathies. The peripheral nerves carry the sensation of joint sense (where the joints are with respect to space, vibration sense and position sense (suppose you are standing on a cold floor. Even with your eyes closed you are able to make out that the floor is cold, is it even or uneven, is it soft or hard. Now if you had a severe neuropathy and had no joint sense or position sense, then if your eyes were closed you shall be unstable and liable to fall).

We also need visual and auditory cues to maintain balance  (imagine trying to walk to the bathroom at night in a pitch dark room. You shall be unsteady and liable to fall and hurt yourself).

Then there can be mechanical, neuromuscular and othopedic causes of gait instability.Example you have had a stroke in the past and hence you are weak in one leg, have had a fracture of one of the long bones of the leg or you have a myopathy, all these conditions make you prone to falls.

So how does one make sense of the numerous causes of falls in the elderly? Diagnosing the etiology of falls can be one of the toughest tasks in clincal medicine. At times in a given patient the etiology is multifactorial (combination of old age and general deconditioning, poor eyesight as we age, poor hearing as we age, superimposed neuropathy etc).

You need to see an astute physician who is willing to spend time to pinpoint the problem. The workup starts with a good history and a thorough neurological examination. Is the problem confined to the central nervous system or is it coming from the peripheral nervous system? Are there any orthopedic causes contributing to the problem? Does the patient have poor eye sight?

Your doctor shall make you walk to see your balance, test your reflexes, test your coordination with the eyes open and then closed. Further workup may include an imaging study of the brain or spinal cord and nerve conduction studies.

So if falls are your problem or that of a loved one, please do see a doctor. You can be helped!!!

Personal Regards,

Nitin Sethi, MD