Volume 91 No. 5 May 2008 Geriatric Neurology Medicine Health UNDER THE JOINT VOLUME 91 N O. 5 May 2008 EDITORIAL SPONSORSHIP OF: The Warren Alpert Medical School of Brown University Eli Y. Adashi, MD, Dean of Medicine & Biological Science RHODE ISLAND PUBLICATION OF THE RHODE ISLAND M EDICAL SOCIETY Rhode Island Department of Health David R. Gifford, MD, MPH, Director Quality Partners of Rhode Island Richard W. Besdine, MD, Chief COMMENTARIES Medical Officer 126 Introduction to Geriatric Neurology Issue Rhode Island Medical Society Joseph H. Friedman, MD Nick Tsiongas, MD, MPH, President 126 Some Thoughts On Ethical Guidelines for the Neurology-Impaired Elderly EDITORIAL STAFF Stanley M. Aronson, MD Joseph H. Friedman, MD Editor-in-Chief Joan M. Retsinas, PhD CONTRIBUTIONS Managing Editor SPECIAL ISSUE: Geriatric Neurology Stanley M. Aronson, MD, MPH Editor Emeritus 129 Aging of the Human Nervous System: What Do We Know? EDITORIAL BOARD Richard W. Besdine, MD, FACP, AGSF, and Difu Wu Stanley M. Aronson, MD, MPH 132 Mild Cognitive Impairment, Healthy Aging and Alzheimer’s Disease Jay S. Buechner, PhD Chuang-Kuo Wu, MD, PhD John J. Cronan, MD James P. Crowley, MD 134 Gait In the Elderly Edward R. Feller, MD Joseph H. Friedman, MD John P. Fulton, PhD 136 Parkinson’s Disease In the Elderly Peter A. Hollmann, MD Sharon L. Marable, MD, MPH Marie-Hélène Saint-Hilaire, MD, FRCPC Anthony E. Mega, MD 138 Epilepsy In the Elderly Marguerite A. Neill, MD Amanda M. Diamond, MD, and Andrew S. Blum, MD, PhD Frank J. Schaberg, Jr., MD Lawrence W. Vernaglia, JD, MPH 142 Peripheral Neurology: Speech Concerns In the Elderly Newell E. Warde, PhD George M. Sachs, MD, PhD OFFICERS 144 Sleep Disorders In the Elderly Nick Tsiongas, MD, MPH Jean K. Matheson, MD President 146 Driving Safety Among Older Adults Diane R. Siedlecki, MD President-Elect Melissa M. Amick, PhD, and Brian R. Ott, MS Vera A. DePalo, MD 148 Geriatric Neurorehabilitation In the New Millenium Vice President Stephen T. Mernoff, MD Margaret A. Sun, MD Secretary Mark S. Ridlen, MD COLUMNS Treasurer 151 HEALTH BY NUMBERS – The Value Equation: Costs and Quality of Rhode Barry Wall, MD Island’s Health Plans Immediate Past President Bruce Cryan, MBA, MS DISTRICT & COUNTY PRESIDENTS 153 PUBLIC HEALTH BRIEFING – Rhode Island Leads In Regulating Office-Based Geoffrey R. Hamilton, MD Bristol County Medical Society Cosmetic Surgery Herbert J. Brennan, DO Shaun Najarian Kent County Medical Society 154 POINT OF VIEW – Creative and Sensory Therapies Enhance the Lives of Rafael E. Padilla, MD People With Alzheimers Pawtucket Medical Association Patrick J. Sweeney, MD, MPH, PhD John Stoukides, MD Providence Medical Association 155 PHYSICIAN’S L EXICON – The Prefixes of the Past Nitin S. Damle, MD Stanley M. Aronson, MD Washington County Medical Society Jacques L. Bonnet-Eymard, MD 155 Vital Statistics Woonsocket District Medical Society 156 May Heritage Cover: “Red Blooms in Spring,” watercolor, by Theresa Aiello. Ms. Aiello, age 91, painted Red Blooms in Spring as part of the art program at the Hope Alzheimer’s Center. She has been par- ticipating at the Center since 2004 and lives in Medicine and Health/Rhode Island (USPS 464-820), a monthly publication, is owned and published by the Rhode Island Medical Society, 235 North Providence. Promenade St., Suite 500, Providence, RI 02908, Phone: (401) 331-3207. Single copies $5.00, individual subscriptions $50.00 per year, and $100 The Hope Alzheimer’s Center specializes in caring per year for institutional subscriptions. Published articles represent opinions of the authors and do not necessarily reflect the official policy of the Rhode Island Medical Society, unless clearly specified. Advertisements do not imply sponsorship or endorsement by the Rhode Island Medical Society. Periodicals postage for people with memory loss and helping families paid at Providence, Rhode Island. ISSN 1086-5462. POSTMASTER: Send address changes to Medicine and Health/Rhode Island, 235 Promenade St., keep their loved ones living at home. For more Suite 500, Providence, RI 02908. Classified Information: RI Medical Journal Marketing Department, P.O. Box 91055, Johnston, RI 02919, information on the center, contact Cyndi Forcier, phone: (401) 383-4711, fax: (401) 383-4477, e-mail: firstname.lastname@example.org. Production/Layout Design: John T eehan, e-mail: email@example.com. phone 946-9220. www.hopealzheimerscenter.org 157 VOLUME 91 NO. 5 MAY 2008 Commentaries Introduction To Geriatric Neurology Issue Age takes a toll. Mathematicians’ best normal. Essential tremor in an elderly In this issue we grapple with the neu- work is behind them by their late twen- person, for example, can be indistinguish- rology of aging. Excepting pediatricians, ties, if not earlier. Chess champions are able from Parkinson’s disease, but the we all deal with the elderly, and neuro- never elderly. No athletic records are held prognosis and treatments are quite dif- logical problems become, like all other by the elderly. Yet some people get wiser. ferent. Gait disorders in an elderly per- problems, increasingly common. Many The great novels are products of skills son with widespread arthritis, multiple non-neurologists are neurology-phobic honed with time, wisdom and experience, joint replacements and diabetic neuropa- and, because neurology used not to be a and, clearly a different sort of creativity thy, are often impossible to accurately clas- treatment oriented discipline, often tend than required in mathematics and chess. sify, other than with the highly accurate to overlook neurologic problems, or else Our brains start to lose neurons in our designation, “multifactorial,” which may, consider them part of the process of nor- twenties. As an elderly Houston Merritt, or may not be helpful to all concerned. mal aging (“once you’re 80 everyone has MD, the author of one of the standard In the course of my 25 years of prac- tremors or falls down once in a while”). American neurology texts, and a giant of tice I have personally witnessed the as- In this issue we hopefully are “user twentieth century neurology, once com- tounding increase in the number of eld- friendly,” and help you in your day to mented, “when it’s very quiet, I can some- erly and very elderly patients I treat. In a day care of the elderly. times hear the splash a dying neuron recent review I learned that I have cared These articles are summaries of a day makes as it falls into the lacunar lakes in for 43 patients with Parkinson’s disease long course on geriatric neurology given my brain.” over the age of 90! Twenty years ago I in Providence on Nov 3, 2007. In the 1930’s the great British neu- probably hadn’t ever seen a PD patient rologist, MacDonald Critchley, pub- of that advanced age. As we all know, this – JOSEPH H. FRIEDMAN, MD lished a series of papers pointing out that is a mixed blessing. In Gulliver’s Travels, aging produced, as a normal conse- one of the lands Gulliver visits has a small Disclosure of Financial Interests quence, many of the features we identify group of people who are immortal. He Joseph Friedman, MD, Consultant: Acarta as pathological in Parkinson’s disease. Yet thinks this a great miracle but is informed Pharmacy, Ovation, Transoral; Grant Research these changes are not considered patho- that it is considered a curse because the Support: Cephalon, Teva, Novartis, Boehringer- logical. Perhaps they will be sometime people are not free of the diseases of ag- Ingelheim, Sepracor, Glaxo; Speakers’ Bureau: soon. These “normal” changes often pro- ing, thus becoming crippled and de- AstraZeneca,Teva,Novartis,Boehringer-Ingelheim, duce clinical challenges for physicians mented, and never granted the freedom GlaxoAcadia, Sepracor, Glaxo Smith Kline trying to distinguish pathological from of death. Some Thoughts On Ethical Guidelines for the Neurologically-impaired Elderly There is a widely accepted Inuit tale [denied as factual by many There is little debate that a patient who is both elderly and anthropologists] that when their frail elders reach a point of neurologically impaired is effectively marginalized, certainly by senility requiring active nursing care, or when the food supply contemporary society – and sometimes even by members of the of their community becomes perilously low, the demented el- healing community. Many patients with organic disabilities have ders are reverently placed upon an ice-flow to drift away into a way of rehabilitating themselves; less so, though, for those with the Eskimo equivalent of oblivion. the loss of neural or cognitive function, thus making the elderly Two current social and geophysical realities have altered who are paralyzed or the elderly who are demented vulnerable this aboriginal scenario: first, the intrusion of earnest ethical to a more stringent standard of appraisal – outliers, perhaps – in debate regarding the extent and merit of care for the elderly the calculus of care for the elderly American citizen. who are neurologically impaired [such care ranging from the In an appraisal of moral norms and moral hopes in the very best technologically to utter abandonment]; and second, field of geriatric neurology, there are substantially more ques- with the indisputable acceleration of global warming, there is tions than there are confident answers or even flexible guide- the diminution in the number and survivability of arctic ice- lines. Geriatric neurology, particularly as it pertains to the de- flows. mented elderly, presents an array of incorrigible problems 158 MEDICINE & HEALTH /RHODE ISLAND readily distinguishable from the other sub-disciplines of medi- formally sensitized and educated in distinguishing between a cine by the frequent use of such alien words as triage, eco- demented elderly wandering the streets and an inebriated per- nomic utilitarianism, equity, social justice, palliation, hospice son wandering the same thoroughfares. care and the right to die; and the use of such needlessly inflam- Years later the report was reviewed and our recommenda- matory words as euthanasia and “pulling-the-plug.”. tions [regarding the assignment of state hospital beds for those An ethical consideration - with any medical dilemma in- with advanced dementia] were accepted. volving the elderly - certainly demands that a few basic ques- There is little debate now that organic dementia is more tions be confronted: than a medical problem; more than a public health problem draining much of this nation’s health-care budget; and certain 1. Does the patient’s age, per se, play any conscious role in deter- a compelling nightmare for those responsible for planning for mining the employment [or abandonment] of any therapeu- this nation’s future medical needs. tic intervention ? Should it ? Is there such a thing as age-related In 1950, 4% of this nation’s GNP was invested in health rationing of institutional care or medical interventions? care. By 1994, this had risen to 14%; it is now verging upon 2. Rewording the question, does age-conscious triage be- 20% - and rising. A decade ago this government was spending, come operative in elderly, neurologically impaired patients on average, $14,000 per year on each elderly American under more so than in orthopedically-impaired elderly ? the Medicare program; it is now approaching $20,000. And as 3. Are stroke victims, beyond the age of 80, viewed differently the nation – particularly its old-old segment – grows in number, than dementia victims of similar age ? Rewording this ques- and as the number of Americans burdened with dementia of tion: Does future prognosis play a role in determining present the Alzheimer type increases exponentially, the cost of protect- medical intervention ? Does the projected lifespan for the ing and caring for these encumbered patients will grow at an patient influence the type and intensity of the therapy? alarming rate. Finally these staggering costs will overweigh the 4. Concerning diagnostic or clinical interventions of doubt- humanitarian beliefs in this country and—barring a medical ful merit, whose vision [or will] prevails ? The patient ? The miracle in discovering ways to prevent or cure the organic patient’s assigned surrogate ? The family ? Clergy ? Physi- dementias—the rationing of care will become inevitable. cian ? And when differences arise, whose decision prevails? What may we expect in an elderly person with long-stand- 5. Are there occasions when palliation replaces active inter- ing dementia? At best a stabilization of the sense of personal vention ? And what are the thresholds when active inter- identity and cognitive awareness. Visitors, whose visits tend to vention gets replaced? be brief and cursory, may comment that they experience no 6. When is the patient’s plea to die listened to and acted upon? communication with their sick relatives, that they are no longer recognized by the demented patients and view them as one Before confronting these questions, let us consider a bit of step removed from a persistent vegetative state. Nursing aides local history as well as certain demographic verities. In 1984, however, may attest to a measurable degree of communication Rhode Island’s General Assembly convened a task force as- as well as preservation of some “selfness.” To exploit a com- signed with the problem of determining the extent to which mon cliché, is the cognitive cerebrum half-full or half-empty? patients with enduring dementia imperiled the health care sys- Despite the notable advances in biotechnology in recent tem of the state. Our first task was to define the clinical state of years, and despite some unsubstantiated claims that the progress dementia [using standard criteria of duration of dementia, type of Alzheimer’s disease may be slowed by certain medications, and extent of memory loss, degree of disorientation, loss of so- the professional care of such patients remains largely in the cial judgment, insight and the capacity to fulfill the minimal domain of care-takers such as nurses. Physicians continue to tasks of daily living]; then to survey each of the 107 registered play an identifiable role in initiating more aggressive therapies nursing homes in the state to determine how many of their for such complications as decubitus ulcers, opportunistic in- residents could be identified as organically demented; and fi- fections and renal or cardiopulmonic failure. What guidelines nally, to extrapolate from these data to estimate the total num- may then be established for a disease that is both progressive— ber of the demented within the state [in hospitals, nursing homes often relentlessly so—and without effective therapy? and private homes]. We did not distinguish between dementia Certainly, comfort measures, good nursing, pain-control of the Alzheimer’s type, multi-infarct dementia, Lewy body if needed and scrupulous attention to hygienic needs. But dementia or other dementias such as the heritable ones as those beyond these interventions, what then? Specifically, when in associated with Huntington’s disease. the course of this ailment might discussions be begun about a We concluded, conservatively, that in 1985 there were about regime confined to palliative care? Daniel Callahan has sug- 10,000 persons with dementia in a state population of about gested three standards to observe in such trying situations: one million souls [about 1% of Rhode Island.] We presented our data to the State legislature. The first response to our oral 1. No one should, in the modern world, have to live longer presentation was: “Never heard of Alzheimer’s disease. What is it in the advanced stages of dementia than he or she would ? Something new like AIDS?” Our demographic data—and have in a pre-technologic era. our projections into the 21st Century—were treated with a com- 2. The likely deterioration in individuals with advanced de- bination of wry amusement and skepticism. And, accordingly, mentia should lead to a shift in the usual standard of treat- our recommendations were largely ignored—although the State ment: that of stopping rather than continuing or extend- police did take to heart our recommendation that the police be ing treatment. 159 VOLUME 91 NO. 5 MAY 2008 3. For the medical profession, there is as great an obligation We, as a society, must confront the realities of a near-fu- to avoid a lingering, painful or degrading death as there ture in which an avalanche of impaired elderly with dementia is to promote health and life. will inundate the health care industry and its inpatient institu- tions, places ranging from nursing homes to tertiary care hos- Which avoids the crucial question: What clinical features pitals. forewarn the attending physician that the time has arrived to Our health-care professions are about to be overwhelmed by a warrant cessation of interventions beyond those designed for tragedy of human aging called dementia. We assemble earnest pa- comfort, cleanliness, adequate hydration and freedom from pers such as this, make honorable declarations, admonish ourselves pain ? The single criterion continues to be whether there is for alleged insensitivities, atone for our past negligences, pay obei- any residual sense of conscious selfness in the patient, any aware- sance to the ethical standards of our vocations, recall oaths to do no ness—even if only episodic—of himself or herself. Just as fam- wrong, identify the physical needs of the demented, decry the in- ily members, visiting briefly, may observe nothing beyond a sensitive insurance industry for wanting to set explicit thresholds for vegetative existence, so too with the physician visiting for a few triage – but rarely do we listen to the secular voices of the demented. moments. The insight into the patient’s sense of social identity Let me end with a poem by Maya Angelou, a poem that says so may come, more commonly, from the nurse or aide who feeds, much more than any powerpoint presentation might convey: bathes and interacts regularly with the patient. The thoughts, wishes and religious observances of the fam- The print is too small, distressing me. ily, the views of the concerned clergy must be listened to, but Wavering black things on the page. not heeded blindly. The wishes of the patient remains para- Wiggling polliwogs all about. mount, whether expressed in an advance directive, in a will or I know its my age. in any reliable document; or, expressed orally during his or her I’ll have to give up reading. current institutionalization. The food is too rich, revolting me. • • • I swallow it hot or force it down cold, And wait all day as it sits in my throat. Tired as I am, I know I’ve grown old. I’ll have to give up eating. My children’s concerns are tiring me. They stand at my bed and move their lips, And I can’t hear one single word. I’d rather give up listening. Life is too busy, wearying me. Questions and answers and heavy thought. I’ve subtracted and added and multiplied. And all of my figuring has come to naught. Today I’ll give up living. – STANLEY M. ARONSON, MD Disclosure of Financial Interests Stanley M. Aronson, MD, has no financial interests to disclose. CORRESPONDENCE e-mail: SMAMD@cox.net 160 MEDICINE & HEALTH /RHODE ISLAND Aging of the Human Nervous System: What Do We Know? Richard W. Besdine, MD, FACP, AGSF, and Difu Wu LEARNING OBJECTIVES quence of the pure aging syndrome. The resulting reduced ca- Demonstrate the ability to identify and use in clinical care: pacity to maintain homeostasis during stress often leads to early and unexpected decompensation under a variety of mild homeo- 1. Nervous system changes with age static perturbations. It is the superimposition of acute illness or 2. Differences between pure aging in the NS and the ef- drug toxicity upon the pure aging syndrome that results in fects of common diseases “homeostenotic” organ crises. There is no better example than the 3. Age-related changes in key domains: extraordinary vulnerability of elders to delirium when they are a. Cognition/Memory stricken with many illnesses or adverse drug effects. b. Special senses Once the changes of pure aging are understood, the im- c. Strength pact, evaluation and management of superimposed disease in d. Balance older adults can be appreciated. The complexity of these in- e. Somatic sensation teractions of disease and aging defines the field of geriatrics. Nowhere are these interactions more complex and potentially OVERVIEW: AGING IN 21ST CENTURY AMERICA confusing for the clinician than in the nervous system. Americans have gained >25 years of average life expectancy during the 20th century, and there is no evidence of slowing in the I. COGNITION 21st. Although clinical and public health interventions have al- A. Attention – There is a mild decline in overall accu- lowed gains in healthy life expectancy (average age of disability racy, beginning in the 60s that progresses slowly, but sustained onset) to keep pace with the striking gains in longevity, the sheer attention very good in healthy older adults. Older adults are numerical increases of older persons portend a burden of disease more easily distracted, especially if irrelevant information is and disability that will overwhelm the social and financial capacity presented concurrent with important material. of our technologically advanced society to manage older persons’ Clinical point: When giving crucial information to older health and health care. And Congress dabbles by trying to trim 1- patients, stick to core data, repeat it and write it down. 2% from the current Medicare growth rate. The tools to meet these care needs are biomedical science coupled with strategic B. Learning and memory changes in health care delivery for the very old and vulnerable; 1. Sensory memory is the earliest stage (visual, auditory, neurological problems of aging are a major contributor to the tactile); it is inherently unstable and decays rapidly. morbidity and healthcare costs for older adults. There is no age-related change. 2. Primary (short-term) memory is the stage after trans- NEUROLOGY OF AGING fer of sensory memory. There is no loss with age. There is no greater fear among most Americans than loss of 3. Secondary (long-term) memory persists for hours, days brain function – whether the loss of the very persona from demen- and years. There is a decline with age, mostly in free tia (usually Alzheimer’s disease), the multiple other neurodegenerative recall; recognition is well preserved. The universal tem- conditions that are increasingly common with age (e.g., Parkinson’s porary decline in the ability to retrieve names generally disease, ALS) or the sudden devastation of stroke. begins early in middle age, and worsens over time. The lost name is almost always retrieved soon after the epi- WHAT IS OBLIGATORY WITH AGING? sode. This phenomenon is not predictive of any As we age, many neurological disorders become common. What neurodegenerative disorder (e.g., Alzheimer’s disease). are the changes occurring in the nervous system that are inevitable 4. Encoding strategies help retrieval - mnemonics, men- with age in the healthiest adults, even those who exhibit all known tal hierarchies, clusters—but they are used less by older risk-reducing behaviors? Using the term Pure Aging Syndrome persons. Training gives long-lasting improvements. makes clear that no disease, environmental, life style or behavioral 5. Distraction interferes with learning more in older risk factor plays a role in the change. These are brain function persons than in young. changes that are inevitable, irreversible with current technology, and 6. Clinical point: Give instructions directly and simply, while mostly decremental, do not cause symptoms on their own. encourage encoding strategies, refer to reputable Although there is much in the literature about decrease in brain size memory training. and weight with age, secular trends of increasing size of humans make such conclusions from cross-sectional data hazardous. In ad- C. Language – Vocabulary increases well into the 50s dition, only in the past 50 years have large numbers of healthy adults and 60s, and shows no decline with age in those who continue survived into old age. Accordingly, great caution should be taken to be engaged in complex language use. Similarly, syntactic when concluding that brain shrinkage is due to age alone. skills – the ability to combine words in meaningful sequences – A useful concept is “homeostenosis,” the progressive restric- show no decline with pure aging. tion of physiologic reserve capacity in organ systems as a conse- 161 VOLUME 91 NO. 5 MAY 2008 D. Intelligence, as measured by the Wechsler Adult In- II. STRENGTH telligence Scale, declines with age, but the biggest, earliest losses A. Muscle – Disuse and disease, as in many systems, are were reported in flawed studies. Cohort differences under- major confounders of age effect. mined these cross sectional studies, causing selection bias re- 1. Age-related changes include loss of muscle mass, garding education, gender, race, occupation and income. Sum- though strength loss can be relatively preserved by mary scores of “intelligence” per se are less useful in adults. exercise. Reduction in muscle fiber size occurs pri- Measuring specific intellectual functions has become usual. marily in Type II (‘fast’) fibers, which are highly anaerobic; Type I (‘slow’) fibers, which are aerobic, 1. Crystallized intelligence (learning and experience) re- tend to retain their size during aging. mains stable or improves with age until the late 70s 2. Muscle wasting in frail older persons, a disorder or beyond, especially in those who remain healthy known as sarcopenia, leads to higher incidence of and engaged in cognitively demanding activities. falls and fractures and functional decline. 2. Fluid intelligence (problem-solving with novel ma- terial requiring complex relations) declines rapidly B. Spinal reflex changes include decline in amplitude after adolescence. of the spinal stretch reflex with normal aging, due in part to 3. Perceptual motor skills (timed tasks) decline with age. stiffness of tendons. Special Senses D. Motor cortex changes with age include decrease in E. Vision the number of neurons and synapses; one hypothesis is that 1. Pure aging includes decline in accommodation (pres- disuse atrophy occurs, arguing for a “use it or lose it” construct. byopia), low-contrast acuity, glare tolerance, adapta- tion, color discrimination and attentional visual field. E. Basal Ganglia – Age-related changes in the striatum Changes occur in components of the eye itself and include decline in dopamine D1 receptor density in the cau- in central processing. These numerous changes af- date and putamen. Age-related loss of dopamine neurotrans- fect reading, balance and driving, but compensatory mission may play a role in vulnerability of older adults to ex- glasses and behavior can maintain safety. trapyramidal disorders. In the substantia nigra, pigmented 2. The common eye diseases in old age (glaucoma, macu- neurons drop out; their loss is associated with motor dysfunc- lar degeneration, cataracts, diabetic retinopathy) are tion, including bradykinesia, stooped posture and gait distur- superimposed upon these pure aging changes. bance. These aging changes mimic parkinsonian features, and may account for the increase in prevalence of PD with age. F. Hearing 1. Conductive and sensory hearing losses (presbycusis) III. BALANCE occur with age; losses are primarily high tones, mak- Balance function declines with increasing age, but is rarely ing consonants in speech difficult to discriminate. the sole cause of falls in older persons. Strength, cerebellar integ- 2. Although impairment is defined as an auditory threshold rity, vestibulo-cochlear function, hearing and vision all play a role greater than 25 decibels, the nearly half of Americans > in maintaining balance. Degeneration of the otoconia (granules 80 who don’t reach the clinical threshold of 25 decibels of the otolith) is a mechanism for vestibule-cochlear decline with still have diminution in acuity – pure aging effects. aging. Many diseases affect the vestibular portion of the 8th N, 3. Consequences include difficulty in localizing sound and it is also sensitive to drugs. Finally, proprioception also con- and understanding speech, usually accompanied by tributes to maintenance of balance. Muscle spindle and mechano- hypersensitivity to loudness. receptor functions decline with pure aging, further interfering 4. Common diseases in old age are superimposed upon with balance. Clinical position sense does not decline with age. these changes, often resulting in worsening hearing impairment (e.g., cerumen impaction, otosclerosis, IV. SENSATION 8th N drug toxicity). A. Pain – Typically painful disorders are often less or not at all painful in elders. G. Taste buds don’t diminish, but salt detection declines; perception of sweet is unchanged, and bitter is exaggerated. The 1. Some cortical processing capacity for pain sensation ap- volume and quality of saliva diminish. All changes combine to pears to decline with age. When functional magnetic make eating less interesting. These aging changes are com- resonance imaging (fMRI) was used to compare cortical pounded by common diseases (periodontal) and medications. nociceptive responses to painful contact heat in healthy young and older subjects, older subjects had significantly H. Smell acuity declines with aging. There is atrophy smaller pain-related fMRI responses in anterior insula of olfactory bulb neurons, and central processing is altered. (aINS), primary somatosensory cortex (S1), and supple- The result is decreased perception and less interest in food. mentary motor area. Gray matter volumes in S1 and aINS Again, these age-related changes are compounded by disease were significantly smaller in the elders, suggesting reduced (e.g., AD and PD have diminution and alteration of smell). processing capacity in these regions, perhaps accounting for smaller pain-related fMRI responses. 162 MEDICINE & HEALTH /RHODE ISLAND The Mini-Cog assessment instrument combines an uncued 3-item recall test with a clock-drawing test (CDT) that serves as a recall distractor. The Mini-Cog can be administered in about 3 min, requires no special equipment, and is relatively uninfluenced by level of education or language differences. ADMINISTRATION – The test is administered as follows: 1. Make sure you have the patient’s attention. Instruct the patient to listen carefully to and remember 3 unrelated words and then to repeat the words back to you (to be sure the patient heard them). 2. Instruct the patient to draw the face of a clock, either on a blank sheet of paper, or on a sheet with the clock circle already drawn on the page. After the patient puts the numbers on the clock face, ask him or her to draw the hands of the clock to read a specific time (11:10 and 8:20 are most commonly used and more sensitive than some others). These instructions can be repeated, but no additional instructions should be given. If the patient cannot complete the CDT in =3 min, move on to the next step. 3. Ask the patient to repeat the 3 previously presented words. SCORING – Give 1 point for each recalled word after the CDT distractor. Score 0–3 for recall. Give 2 points for a normal CDT, and 0 points for an abnormal CDT. The CDT is considered normal if all numbers are depicted, once each, in the correct sequence and position, and the hands readably display the requested time. Add the recall and CDT scores together to get the Mini-Cog Score: • 0–2 indicates positive screen for dementia. • 3–5 indicates negative screen for dementia. 2. Endogenous pain inhibition is reduced with aging. Opioid- 18. Resnick SM, Pham DL, et al. J Neurosci 2003;23:3295–301. 19. Rodríguez-Aranda C. Clin Neuropsychol 2003;17:203-15. mediated endogenous analgesic systems are particularly 20. Shaffer SW, Harrison AL. Phys Ther 2007;87:193-207. Epub 2007 Jan 23. Review. susceptible to functional decline with aging. Additionally, 21. Smith CD, Chebrolu H, et al. Neurobiol Aging 2007;28:1075-87. Epub older age is associated with reduced beta-endorphin levels. 2006 Jun 13. 22. Smith DE, Rapp PR, et al. J Neurosci 2004;24:4373–41. 3. Some pain thresholds show age-related changes. Al- 23. Tumeh PC, Alavi A, et al.. Semin Nucl Med 2007;37:69-87. Review. though sensitivity to heat pain is decreased with age 24. Ward NS. Ageing Res Rev 2006;5:239-54. Epub 2006 Aug 14. Review. (above), sensitivity to pressure pain is enhanced. 4. Both Substance P and calcitonin gene-related pep- , , Richard W. Besdine, MD, FACP AGSF is Professor of Medicine,Greer tide (CGRP), major neuro-transmitters of primary af- Professor of Geriatric Medicine, Director, Division of Geriatrics (Medi- ferent nociceptive fibers, are decreased with aging, cine), and Director, Center for Gerontology and Healthcare Research, at likely reflecting reduction in density or function of The Warren Alpert Medical School of Brown University. nociceptive nerves. The rate of CGRP axonal trans- Difu Wu is a student at The Warren Alpert Medical School port also decreases with advancing age. of Brown University. B. Sensory nerves lose myelin selectively, perhaps pre- Disclosure of Financial Interest disposing to neuropathy. Vibration sensation perception di- Richard W. Besdine, MD, FACp, AGSF. Grant Research minishes with aging, especially in the legs. Since position sense Support: Donald W. Reynolds Foundation is carried in the same tracts as vibration, diminished vibratory Difu Wu has no financial interests to disclose. sense should be followed up by position sense testing. CORRESPONDENCE REFERENCES Richard W. Besdine, MD, FACP, AGSF 1. Beers MH (Ed). The Merck Manual of Geriatrics. 3th Ed. NJ: Merck & Co., Inc, 2006. Center for Gerontology and Healthcare Research 2. Boeve B, McCormick J, et al. Neurol 2003;60:477-80. 3. Borson S, Scanlan J, et al. Int J Geriatr Psychiatry 2000;15:1021-7 The Warren Alpert Medical School of Brown University 4. Burke SN, Barnes CA.. Nat Rev Neurosci 2006;7:30–40 2 Stimson Avenue 5. Craft S, Cholerton B, Reger M. Aging and Cognition: What is Normal? In: Box G-ST Hazzard WR, Blass JP, , et al, eds., Principles of Geriatric Medicine & Gerontol- ogy, 5th Ed. NY: McGraw-Hill, 2003:1370-1. Providence, Rhode Island 02912 6. Galban CJ, Maderwald S, et al. J Gerontol A Biol Sci Med Sci 2007;62:453-8. e-mail: Richard_Besdine@brown.edu 7. Gibson SJ, Farrell M. Clin J Pain 2004 ;20:227-39. 8. Keuker JI, Luiten PG, Fuchs E. Neurobiol Aging 2003;24:157–65. 9. Kirkwood TB. Cell 2005;120:437–47. 8SOW-RI-GERIATRICS-053008 10. Lindeboom J, Weinstein H. Eur J Pharmacol. 2004;490:83-6. 11. Mattay VS, Fera F, et al. Neurol 2002;58:630-5. THE ANALYSES UPON WHICH THIS PUBLICATION IS BASED were 12. Mrak RE, Griffin ST, Graham DI. J Neuropathol Exp Neurol 1997;56:1269–75. performed under Contract Number 500-02-RI02, funded by 13. Nanda A, Besdine RW. Dizziness. In. Halter JB et al, editors. Principles of the Centers for Medicare & Medicaid Services, an agency of Geriatric Medicine and Gerontology. 6th Ed. New York. McGraw-Hill; 2003. the U.S. Department of Health and Human Services. The con- 14. Nusbaum AO, Tang CY, et al.. AJNR Am J Neuroradiol 2001;22:136-42. tent of this publication does not necessarily reflect the views 15. Peters R. Postgrad Med J 2006;82:84–8. or policies of the Department of Health and Human Services, 16. Quiton RL, Roys SR, et al. Ann N Y Acad Sci 2007;1097:175-8. nor does mention of trade names, commercial products, or 17. Raz N. The ageing brain: structural changes and their implications for cogni- organizations imply endorsement by the U.S. Government. tive ageing. In New Frontiers in Cognitive Ageing, Dixon R, Backman L, Nilsson The author assumes full responsibility for the accuracy and L (eds). Oxford University Press: Oxford, 2004; 115–34. completeness of the ideas presented. 163 VOLUME 91 NO. 5 MAY 2008 Mild Cognitive Impairment, Healthy Aging and Alzheimer’s Disease Chuang-Kuo Wu, MD, PhD As predicted in 1976, the growth of tation of dementia.7 In a five-year, pro- and other neuropsychological batteries, the elderly population has resulted in a spective, longitudinal study of healthy eld- to be used as screening tests. tremendous increase in Alzheimer’s dis- erly adults (above 75 years of age), Clinicians encounter several pitfalls ease (AD).1 In 2007, there were prob- Verghese et al. reported that the elderly when diagnosing MCI. It is caused by a ably more than 5 million Americans suf- (n=345; age 78.9) who participated in variety of pathologies other than just AD. fering from AD.2 The major advances in- three kinds of cognitive activities and one To predict that a MCI patient is in the pro- clude more clinical tools to diagnose AD physical activity had a reduced risk of de- dromal stage of AD, we have to consider and several medications approved by the mentia. 8 Reading, playing board games other differential diagnoses. In the elderly, FDA for treatment. and playing musical instruments are the two most common conditions which deemed beneficial cognitive activities; can mimic MCI are depression and stroke. Our goals are: dancing is the only physical activity iden- Patients with late-life depression commonly - Recognizing healthy, successful tified that is associated with a lower risk of complain of memory and cognitive prob- aging of cognition and devel- dementia. They also observed that subjects lems. By sophisticated neuropsychological oping strategies for primary (n=124; age 79.7) who eventually devel- testing, their cognitive functions are usu- prevention oped dementia (the majority of them had ally within normal limits and subjective - Developing new disease modi- AD) were older individuals with lower lev- memory problem can be restored by ad- fying agents to alter the course els of education (less than 12 grades) and equate treatment. Older adults who had a of AD. relatively lower test scores (on two memory sudden onset of cognitive impairment of- - Defining mild cognitive im- tests) at baseline. This landmark study pro- ten had a cerebrovascular event. Recent pairment (MCI) as a diagnos- vides evidence of risk-reducing activities studies have reported that patients with the tic entity for early intervention. to delay the onset of AD. amnesic-type of MCI often do have under- lying AD pathology. For example, Morris Currently the FDA has proposed that since so many amnesic HEALTHY AND SUCCESSFUL AGING MCI patients have AD pathology the di- Healthy aging is defined by the lack approves no agnostic criteria need to be revised.12 In con- of a significant decline in physical and mental abilities.3 These people are socially treatment for MCI trast, the Mayo clinic reported that 71% of amnesic MCI brains displayed the AD active and emotionally satisfied. One defi- because all the data pathology but that 29% of them showed nition of “successful aging” is that the eld- indicate a clear lack non-AD pathologies, which particularly erly who perform in the upper end of a affected the mesial temporal regions.13 distribution of test scores are deemed suc- of benefit. Neurochemical studies of MCI brains cessful.4 The effect of aging on cognition have demonstrated upregulation of the syn- is a hot topic. People older than 65 con- MILD COGNITIVE IMPAIRMENT thetic cholinergic enzyme, suggesting no tinue to change through the rest of their (MCI) decline of acetylcholine in MCI brains. This lives in different ways. A wide variety of The term, mild cognitive impair- fits with the observation that all published age-related phenomena have been de- ment (MCI), was initially used as stage 3 clinical trials to date of cholinesterase in- scribed.5 Many studies have documented of Reisberg’s Global Deterioration Scale hibitors show no significant efficacy.14 Cur- various life styles leading to healthy or suc- (GDS) in the staging of AD.9 Petersen, rently the FDA approves no treatment for cessful aging.3,4,5 Learning from these stud- et al then proposed MCI as a diagnostic MCI because all the data indicate a clear ies, preventive strategies are postulated to entity for the transition between normal lack of benefit. delay the onset of dementia. Among them, aging and AD.10 In 2001, the American education and participation in certain lei- Academy of Neurology published its ALZHEIMER’S DISEASE sure activities are two areas which have guideline for the diagnosis of MCI.11 The In the near future, we will witness demonstrated benefit.6,7 criteria include 1) memory complaint 2) major advances in the treatment of AD, From epidemiological data, Katzman objective memory impairment 3) normal such as the introduction of disease-modify- pointed out that elder people with poor general cognitive function 4) intact ing agents. None are yet available, however. or no education have an increased risk of ADLs 5) not demented by DSM IV cri- The first crucial step in treating AD patients developing dementia6 compared to those teria. The clinical tools recommended is to classify the clinical stage. (Figure 1). better educated. It is postulated that edu- according to the guideline are the Mini- Today only symptomatic treatments are cation might generate brain “reserve”, Mental State Examination (MMSE), the available for AD, including cholinesterase which can compensate the initial presen- Clinical Dementia Rating (CDR) scale inhibitors (CEIs) and a NMDA receptor 164 MEDICINE & HEALTH /RHODE ISLAND 5. Baltes PB, Baltes MM. Psychological perspectives on successful aging. In: Baltes PB, Baltes MM. Editors. Successful aging. Cambridge University Press; 1990:1-34. 6. Katzman R. Neurol 1993;43:13-20. 7. Zhang M, Katzman R, Dalmon D Ann Neurol 1990;27:428-37. 8. Verghese J, Lipton RB, et al. NEJM 2003;348:2508-16. 9. Flicker C, Ferris SH, Reisberg B. Neurol 1991;41:1006-9. 10. Petersen RG, Smith GE, et al. Arch Neurol 1999; 56:303-8. 11. Petersen RG, Stevens JC, et al. Neurol 2001; 56:1133-42. 12. Morris JC. Arch Neurol 2006; 63:15-6. 13. Jicha GA, Parisi JE, et al. Arch Neurol 2006; 63:674-81. 14. DeKosky ST, Ikonomovic MD, et al. Ann Neurol Figure 1. 2002; 51:145-55. 15. Jelio V, Kivipelto M, Winblad B. JNNP 2006; 77:429-38. antagonist. Since 1992,the FDA has ap- with a significant decline in ADLs from the proved five medications to treat Alzheimer’s mild to moderate stage; likewise, a score be- Chuang-Kuo Wu, MD, PhD, is Associate disease. We no longer prescribe tacrine be- low 15 indicates a further decline toward Director, Clinical core of NIA-Funded ADC Cog- cause of significant side effects. Donepezil, the moderate to severe stage. nitive Neurology and Alzheimer’s Disease Center, rivastigmine and galantamine are approved Treating the cognitive problems of AD and Assistant Professor, Department of Neurology, for treating mild to moderate stage of AD. patients is limited to those approved by the Northwestern University Feinberg School of Medi- In 2004, memantine was approved for the FDA. When AD patients receive treat- cine. Until July 31, 2007, Dr.Wu was an assistant moderate to severe stage of AD. In 2007, ment, we should monitor progress of dis- professor of clinical neurosciences, The Warren donepezil won approval for the severe stage ease with the MMSE. A 4-point decline Alpert Medical School of Brown University, and of AD; rivastigmine has a skin patch ap- within a short period (6 months) deserves associate director of the Alzheimer’s disease and proved to treat the mild to moderate AD. repeated clinical evaluation for other medi- memory disorders center of Rhode Island Hospital. In the clinic, patients can be evaluated cal conditions which can worsen cognition. simply by the MMSE as the first assessment The combination of CEIs and memantine Disclosure of Financial Interests tool. Many clinical scales have been devel- is recommended for treating the moderate The author has no financial inter- oped to replace the MMSE. However, the to severe AD patient if side effects are toler- ests to disclose. MMSE yields a significant amount of data able. Memantine is not approved for mild for interpretation. The first step in establish- AD or MCI diagnosis. CORRESPONDENCE ing the diagnosis of AD is to rule out other Chuang-Kuo Wu, MD, PhD mimicking conditions, both treatable and REFERENCES 1. Katzman R. Arch Neurol 1976; 33:217-8. Northwestern Memorial Hospital untreatable. For example, a typical, high 2. Hebert LE, Scherr PA, et al. Arch Neurol 675 North St. Clair Street school-educated, 70 year-old patient comes 2003;60:1119-22. Galter 20-100 in with a caregiver complaining of a memory 3. Reichstadt J, Depp CA, et al. Am J Geriatr Psy- Chicago, IL 60611 problem, and scores 24/30. Based on the chiatry 2007;15:194-201. 4. Fritsch T, McKee MJ, et al. t Gerontologist phone: 312-695-9627 education level and age, the score suggests a 2007;47:307-22. e-mail: firstname.lastname@example.org high probability of dementia. Using a set of laboratory tests and a brain scan (CT or MRI), a clinician can confidently rule out other causes and establish AD as the cause of dementia (two-step approach). Scores of 12 to 23 are usually considered the mild to moderate stage of AD, as defined in the cho- linesterase inhibitor clinical trials. A score be- low 15 indicates the moderate to severe range. However, there is no consensus about the defined score for the moderate stage of AD. The Alzheimer’s Disease Cooperative Study (ADCS) group reported that the abil- ity to perform a wide range of instrumental and basic ADLs correlates well with the MMSE scores of AD patients. A significant drop on the MMSE to below 20 correlates 165 VOLUME 91 NO. 5 MAY 2008 Gait In the Elderly Joseph H. Friedman, MD A number of impressive statistics on Gait disorders may occur for a num- of the base, with scissoring, the crossing of falls in the elderly are routinely cited in ber of reasons, and most are non-neuro- feet, being an extreme example, most of- review articles.1,2 Interestingly, none of logical in origin. Joint pain, muscle weak- ten seen in people who were born with a them are recent. 1,2 My guess is that as the ness, deformities, blindness, vestibular form of cerebral palsy. population ages, these numbers will dysfunction, psychological factors, poorly worsen. In addition, abandonment of the fitting shoes (especially in those with 4. Stride and foot strike “chemical straitjacket” routinely used for edema and bunions) and deconditioning The stride length depends on the speed the demented twenty years ago which all may play a role. Pain, shoes, feet and of gait as well as the height of the subject. Ex- rendered poor walkers into non-walkers blindness should be asked about. cessively long strides are rare, and produce a may have increased fall frequency. Weakness and numbness may be pe- “loping” quality, whereas short steps are com- For example, data from 1988, still ripheral nervous system contributions to gait mon, especially in the elderly, seen in parkin- cited in recent articles, 1,2 state that one third disorders or may result from central ner- sonian disorders as well as “fear of falling” in of people over age 65 fall each year, and vous disorders. Increased tone, ataxia, weak- which people walk as if they are on ice. In for half of them this is an ongoing prob- ness and abnormal “motor programs” are asymmetric disorders, such as Parkinson’s dis- lem.3,4 Ten percent of these falls results in central nervous system abnormalities. ease, one stride length may be shorter than significant morbidity (data from early the other, producing a limping gait. 1990s).5 Presumably these numbers in- COMPONENTS OF GAIT In normal gait the heel strikes the crease with age. Falls are the fifth most com- 1. Ability to stand ground first, but in Parkinsonian disor- mon cause of death in the elderly. Only The patient should be asked to stand ders there is a flat foot strike. In spastic 25% of patients who suffer hip fractures without using her arms. They may be kept disorders the ball of the foot hits first. regain their former level of function. And folded across the chest or put into a pray- These different foot strike patterns may falls frequently induce a fear of falling, ing position. If the patient cannot do this, be reflected in wear on the shoes. which itself contributes to the problem. she should try to stand pushing off from Impairment in mobility affects 14% the armrests on her chair. A note should 5. Armswing of those between 65 and 74 but half of those be made of how easily the patient was able This is not important in the biophysics over 85.6 This impairment occurs for a to do this or whether the doctor needed of walking but is extremely important in mak- number of reasons, including brain to help. ing diagnoses. The armswing is reduced in changes, both normal and pathological, as Parkinsonism, for example, generally more well as changes in muscles and the sensory 2. Posture reduced on the worse side, possibly absent on organs (eyes, vestibular apparatus, periph- Patients with an abnormal posture will one side and normal on the other. Armswing eral nerves). Normal aging produces physi- generally have kyphosis, scoliosis or some is absent after a stroke. In patients with ataxic cal changes that overlap with the signs of degree of both. Rare patients will have a syndromes the arms are often abducted, as if Parkinson’s disease, except for tremor.7 hyperlordotic posture from lower spinal supplying extra balance. T remor may be seen The clinical importance of gait can- muscle weakness or dystonia. Kyphosis is only during walking in Parkinson’s disease, not be overestimated. In a nursing home usually idiopathic, but may be due to com- whereas tremor is not seen during walking in evaluation, every single patient seen by pression fractures, Parkinson’s disease, patients with essential tremor. In choreiform this author had a significant gait abnor- spondylitis. The curvature may occur any- disorders, such as generalized tardive dyski- mality. Of course, in many cases, that was where from the lumbar spine up. In PD, nesia or Huntington’s disease, the armswing is why they were not living at home. for example, patients may have highly vari- often excessive. It may also be excessive in some It is my hypothesis that gait abnormali- able degrees of flexion in the thorax or the disorders in which there is a short stride, as if ties are often not identified by doctors because neck or both. to compensate. it has not been part of their training. In the outpatient setting, doctors, for efficiency, tend 3. Base 6. Turning to see patients in examining rooms, partially The normal width of foot placement A normal turn requires a pivot. One undressed, seated on the examining table. In is considered the width of the shoulders. foot is kept on the ground and rotation the hospital, it is difficult to get patients out of The base should be noted both when occurs on the ball of that foot. In Parkin- bed or off their stretchers, and a lot more dif- standing and when walking. Ataxic gaits, sonism the patient turns “en bloc,” in one ficult to get them back on them, especially in due to sensory problems, cerebellar or ves- piece, using two or more steps. Some- the emergency department where the stretch- tibular dysfunction will cause the base to times the patient turns in a large circle, ers are quite high. increase or to vary. Spastic problems, due as if making a U-turn. Turning fre- The basic problem is the lack of a to corticospinal tract dysfunction, as seen quently causes loss of balance, in all gait language for describing and classifying in spastic forms of cerebral palsy, stroke or disorders. gait problems. cervical myelopathies, cause a narrowing 166 MEDICINE & HEALTH /RHODE ISLAND 7. Pull test Armswing is normal, but sometimes re- 4. Nevitt MC, Cummings SR, et al. Risk factors for recurrent nonsyncopal falls. JAMA This test, like the Romberg, tests bal- duced when the arms are abducted, act- 1989;261:2663-8 ance. The pull test is performed by in- ing like a balancing rod used for tight- 5. Nevitt MC, Cummings SR, Hudes ES. Risk factors forming the patient that you are going rope walkers. Alcohol intoxication pro- for injurious fall. J Gerontol 1991;46:M164-M170. to pull him off balance and that he duces an ataxic gait. 6. Odenheimer G, Funkenstein H, et al. Compari- son of neurologic changes in “successful aging” should try to keep from falling, taking as 5. Post stroke: armswing is lost on the persons vs the total aging population. Arch Neurol few steps as possible. It is important to affected side, and the arm is often flexed 1994;41:573-80. pull hard enough to make the patient at the elbow, and wrist, while adducted at 7. Critchley M. Neurolocial changes in the aged. Res take a step or two. Taking more than three the shoulder. The affected leg is typically Publ Assoc Res Nerv Mental Dis 1956;35:198-223. steps is considered abnormal, indicative kept in extension, as if acting like a crutch. of a balance problem. The leg is moved in a circular fashion as the knee is not bent. The ball of the foot http://medlib.med.utah.edu/ INTERPRETATIONS usually hits the ground first. neurologicexam/html/ As in most aspects of the neurologi- 6. Spastic: this is seen in children or gait_abnormal.html contains infor- cal examination, the cardinal feature is adults with cereral palsy, but also with mation on gait including video ex- symmetry. When the stride length is dif- other bilateral corticospinal dysfunction, amples of a doctor simulating and ferent on the two sides, we usually see a typically after bilateral strokes, multiple explaining common gait disorders as limp or scuffing of one foot. Asymmetric sclerosis or cervical myelopathy, as occurs well as including examples. Other armswing is obvious, once you look for with cervical spondylosis. The posture is websites cited include information it. When the gait looks abnormal, try to normal. The legs are stif and do not bend about gait, both for health profes- break it down into the component parts normally at the knees. The base narrows. sional and patient. listed above to see if the abnormality can Because the legs are kept extended, the be localized. When the patient shifts ball of the foot usually hits the ground weight suddenly, it is often an indication first. Stride length is reduced. Armswing Joseph H. Friedman, MD, is execu- of joint pain, and this should be inquired changes are determined by the level of tive editor of Medicine & Health/Rhode about. the lesions so that in brain diseases, the Island. armswing is reduced. When the spastic Examples: gait arises from a cervical process, it may Disclosure of Financial Interests 1. Foot drop: the affected foot is or may not be reduced. Joseph Friedman, MD, Consultant: lifted higher than normal and then the 7. Cautious gait. This is the gait of Acarta Pharmacy, Ovation, Transoral; ball of the foot is dropped onto the someone fearful of falling, which, para- Grant Research Support: Cephalon, Teva, ground or is thrown forward and doxically, may increase the risk. The pa- Novartis, Boehringer-Ingelheim, Sepracor, slapped. tient walks as if on ice, with slow, deliber- Glaxo; Speakers’ Bureau: Astra Zeneca, 2. Hip weakness produces a wad- ate steps, placing each foot flatly and sol- Teva,Novartis, Boehringer-Ingelheim, dling gait. To lift the swing leg and move idly on the ground before advancing. GlaxoAcadia, Sepracor, Glaxo Smith Kline it forward, weight is shifted to the sup- 8. Astasia abasia. This is an old term, porting leg by tilting the pelvis up on the meaning “can’t sit, can’t stand,” used for CORRESPONDENCE swing side. This is usually a symmetric conversion disorder, or psychogenic gait Joseph H. Friedman, MD problem so that the hip swivels up and disorders. Although these are considered Neurohealth down. rare in the elderly, they do occur. Gener- 227 Centreville Rd. 3. Parkinsonism is one of the most ally the gait is extremely bizarre, and, Warwick, RI 02886 common gait in the elderly, and not al- unlike other gait disorders where the e-mail: Joseph_Friedman@brown.edu ways pathological.7 The posture is stooped, body tries to minimize risk and effort, the stride length is reduced and there is a these generally maximize effort and pro- tendency for a flat foot strike. Armswing duce convoluted postures, standing on Professional or is reduced. Turning is without a pivot and one leg and other unusual stresses to the Medical Office balance is impaired on the pull test. As the balance systems. Contrary to popular Space to Lease gait deteriorates, the patient will often be belief, these disorders are not generally Two office suites on bottom flexed at the knees, which causes a major associated with “belle indifference” or Floor of medical building. increase in weightbearing problem for the with the absence of falls or injuries. One @ 600 SF & one thigh muscles. @ 900 SF. Can be combined into a single unit. Park Ave., 4. Ataxic: this may be from cerebel- REFERENCES Cranston, minutes from RT lar dysfunction, vestibular impairment or 1. Moylan CK, Binder EF. Fall in older adults. Am J 95 & RT 10. Ample Parking. Med 2007;120:493-7. Perfect for a specialist or sensory denervation. The stance may be 2. Tinetti ME. Preventing falls in elderly persons. allied health professional- normal or wide, but the gait is irregular NEJM 2003;348:42-9. internist on the 2nd floor. and often lurching, with a tendency to 3. Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the com- Contact Sharli at veer to one side, or to either side, with 401-275-0700 munity. NEJM 1988;319:1701-7. increased problems on turning. 167 VOLUME 91 NO. 5 MAY 2008 Parkinson’s Disease In the Elderly Marie-Hélène Saint-Hilaire, MD, FRCPC An 82 year old woman was ad- gidity. Asymmetry of physical findings is ability.5 They are however under recog- mitted to a rehabilitation hospi- important to support the diagnosis, as is nized because their symptoms can over- tal after sustaining a pelvic frac- a good response to levodopa. lap with the symptoms of PD. ture. She had a past history of os- Several clinical features help to dis- Non-motor symptoms affect several do- teoporosis and chronic lower back tinguish idiopathic PD from other causes mains: neuropsychiatric, autonomic, sensory, pain treated with epidural ste- of parkinsonism. The presence of early sleep, and dermatologic. Dementia, depres- roids. For the past two years she falls, a poor response to levodopa, sym- sion and autonomic symptoms are often the had had several falls associated metry of signs at onset, or significant au- most problematic in elderly PD patients. with fractures. She also reported tonomic dysfunction should raise the sus- drooling, difficulties swallowing, picion that the patient may not have id- DEMENTIA gait shuffling and freezing, and iopathic PD. The prevalence of dementia in PD var- tremor in the left hand, more at In addition, significant cognitive de- ies between 10 and 44% depending on the rest than with action. She had no cline and hallucinations, within one year diagnostic criteria used and the nature of the cognitive impairment. She was of onset of the parkinsonian signs is sug- population studied. The risk increases with started on a small dose of levodopa/ gestive of a diagnosis of dementia with age, with one study finding that 65% of PD carbidopa 25/100, a half three Lewy Bodies. Concomitant PD and patients over the age of 85 were demented.6 times a day. She responded very Alzheimer Disease (AD) are also possible Risk factors include older age at onset, and well, stopped drooling, and had in this age group. The diagnosis can be dif- initial manifestations of hypokinesia and ri- improvement in swallowing, gait, ficult, because some patients with AD have gidity.7 The dementia in PD usually does not and tremor. However, her balance parkinsonian features. The presence of an appear at the onset of the disease. It is char- remained impaired and she con- asymmetric rest tremor, and improvement acterized by impaired executive function, tinued to need a walker. of the motor signs with levodopa lend sup- visuospatial abnormalities, impaired port to a diagnosis of PD. memory, and language deficits.8 In elderly This case exemplifies some of the chal- It is always necessary to review all the patients, superimposed cerebrovascular dis- lenges in diagnosing and treating elderly medications taken by the patient, because ease can contribute to cognitive problems. patients with Parkinson’s Disease (PD): many have extrapyramidal side effects. Po- Dementia is a major factor in the manage- 1) concurrent medical conditions, such as tential culprits include atypical neuroleptics, ment of PD, limiting the drug therapy that arthritis, can affect mobility, and symptoms (i.e. risperidone), antiemetics (i.e. can be used, and leading to earlier nursing can overlap with the symptoms of PD, thus metoclopramide), some antidepressants (i.e. home placement and decreased survival.2 delaying the diagnosis; 2) although treat- fluoxetine) and some antiepileptics (i.e. ment with levodopa is beneficial, it does valproic acid). Other conditions to exclude, DEPRESSION not eliminate gait and balance problems, especially in the elderly, are cerebrovascular Around 40% of subjects will have which are major causes of morbidity. disease and normal pressure hydrocephalus depression. 9 Although there may be a psy- Age remains the single most impor- which usually present as a gait disorder or chological response to living with a pro- tant risk factor in PD. Although the av- “lower body parkinsonism.” gressive neurological disease, there is evi- erage age of onset of PD is around 60, Patients with late onset PD progress at dence that depression in PD is related to the incidence rates consistently increase a greater rate and are more cognitively im- the underlying pathology of the disease. through age 85.1 Aging does appear to paired than those with early onset disease. There is overlap between the symptoms directly influence the clinical expression They also have more bradykinesia and pos- of depression and those of PD which can of PD, and late onset PD patients offer tural instability3. Lack of tremor, male sex, make the diagnosis challenging. The nature special challenges because of polyphar- and associated comorbidities are also associ- of the depression in PD is more character- macy, multiple pathology, and coexisting ated with a more rapid rate of progression2. ized by pessimism, hopelessness and poor cognitive problems. This article will re- motivation, with less feeling of guilt and self view the specific aspects of the clinical NON-MOTOR SYMPTOMS blame than in depressed elderly subjects with- presentation, differential diagnosis and Non-motor symptoms are increas- out PD. Psychotic features are rare.10 treatment of PD and its complications in ingly recognized as an intrinsic feature of the elderly population. PD. Their prevalence is high: A survey AUTONOMIC DYSFUNCTION found that 88% of PD patients had at least Symptoms of autonomic dysfunction CLINICAL PRESENTATION one non-motor symptom, and 11% had become more prominent as PD progresses. The diagnosis of PD is based on the five.4 With improvement in the treatment They also increase with age and medica- history and the clinical examination. It of PD motor symptoms, non-motor symp- tion use.11 They include bladder dysfunc- requires the presence of two of the fol- toms, such as dementia and depression, tion, constipation, orthostatic hypotension, lowing: rest tremor, bradykinesia or ri- have become an important cause of dis- abnormal sweating and sexual dysfunction. 168 MEDICINE & HEALTH /RHODE ISLAND In addition, age itself affects autonomic The treatment of the non-motor symp- REFERENCES function, as do concurrent diseases such as toms of PD must be addressed specifically 1. Mayeux R, Marder K, et al. The frequency of idiopathic Parkinson’s disease by age, ethnic group, diabetes and hypertension, and medica- and separately from the treatment of the and sex in northern Manhattan, 1988-1993. Am tions, including some used to treat PD. motor symptoms. The only medication ap- J Epidemiol 1995; 142:820-7. proved for the treatment of PD dementia 2. Suchowersky O, Reich S, et al. Practice Parameter. Orthostatic hypotension is Rivastigmine.14 There is no medication Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurol Falls in blood pressure (BP) occur specifically approved for the treatment of 2006; 66: 968-75. particularly when getting up in the morn- depression, bladder or sexual dysfunction, 3. Diederich NJ, Moore CG, et al. Parkinson disease ing, or after meals. They manifest as dizzi- constipation, or orthostatic hypotension in with old-age onset. Arch Neurol 2003; 60:529-33. ness when the patient stands, but can also PD. For any treatment being considered, 4. Shulman LM, Taback RL, et al. Comorbidity of the nonmotor symptoms of Parkinson’s disease. present as fatigue or episodes of confusion. the clinician must weigh the potential ben- Mov Disord 2001; 16: 507-10. Critical review of all prescribed medica- efit versus the risk of side effects. 5. Weintraub D, Moberg PJ, et al. Effect of psychiatric tions is necessary but sometimes specific and other nonmotor symptoms on disability in treatment such as fludrocortisone or Parkinson’s disease. J Am Geriatr Soc 2004; 52:784-8. proamatine must be instituted. Patients with late 6. Mayeux R, Chen J, et al. An estimate of the inci- dence of dementia in idiopathic Parkinson’s dis- onset PD progress ease. Neurol 1990; 40:1513-6. Bladder symptoms 7. Miyasaki JM, Shannon K, et al. Practice Symptoms of urgency, frequency, noc- at a greater rate Parameter.Report of the Quality Standards Sub- turia, and incontinence are common in ad- and are more committee of the American Academy of Neurol- ogy. Neurol 2006; 66: 996-1002. vanced PD. They result from detrusor hyper- reflexia with or without detrusor/sphincter cognitively impaired 8. Aarsland D, Andersen K, et al. Prevalence and characteristics of dementia in Parkinson disease. dyssynergia. In addition, they can be compli- than those with Arch Neurol 2003; 60:387-92. 9. Cummings JL. Depression and Parkinson’s dis- cated by prostatic hypertrophy in males. Un- fortunately medications for detrusor hyper- early onset disease. ease. Am J Psychiatry 1992; 149, 4: 443-54. 10. Brown RG, MacCarthy B. Psychiatric morbidity reflexia are anticholinergic and can exacer- in patients with Parkinson’s disease. Psycholog Med bate confusion in elderly PD patients. Their CONCLUSION 1990; 20: 77-87. 11. Verbaan D, Marinus J, et al. Patient-reported au- risks and benefits must be carefully weighed. Elderly PD patients have more gait tonomic symptoms in Parkinson disease. Neurol and balance difficulties, more depression, 2007; 69: 333-41. Constipation cognitive problems, and autonomic dys- 12. de Goede CJ, Keus SH, et al. The effects of physi- cal therapy in Parkinson’s disease. Arch Phys Med Constipation is very common in PD, function, in addition to concurrent diseases Rehabil 2001; 82: 509-15. because of a combination of autonomic such as cardiac and cerebrovascular disease. 13. Ramig LO, Sapir S, et al. Changes in vocal loud- dysfunction with delayed transit time, Drug therapy can be limited by neuropsy- ness following intensive voice treatment (LSVT) and immobility, drug therapy, poor diet chiatric side effects, and has marginal ben- in individuals with Parkinson’s disease. Mov Disord 2001; 16: 79-83. and lack of appropriate hydration. An ag- efit for gait, balance, and swallowing diffi- 14. Emre M, Aarsland D, , et al. Rivastigmine for gressive bowel regimen may be necessary culties. In this situation a non-medical ap- dementia associated with Parkinson’s Disease. to avoid impaction. proach involving physical and speech thera- NEJM 2004, 351: 2509-18. pies becomes an important part of the man- TREATMENT agement. A dietitian can also be involved Marie-Hélène Saint-Hilaire, MD, Treatment must be individualized to to recommend strategies to maintain FRCPC, is Medical Director of the each patient’s needs, and the functional and weight, and an occupational therapist can Parkinson’s Disease and Movement Disor- cognitive status. Symptomatic therapy is in- evaluate the home environment to improve ders Center, Boston University School of troduced when the patient is functionally safety. As the disease progresses, it may be- Medicine. disabled. Levodopa/carbidopa is still the most come increasingly difficult for patients to effective medication for the motor symptoms go to a specialty clinic. The primary care Disclosure of Financial Interests of PD, and is better tolerated than Dopam- provider then becomes more involved in Grant Research Support: Eisai, ine Agonists, amantadine or anticholinergics the management of the patient but must Bayer, Novartis; Speaker’s Bureau: Teva, in elderly patients. It is initiated at a low dose, have access to consultation with the patient’s Boeringher Ingelheim, Valeant and increased slowly to minimize side effects. specialist if necessary. The care of patients The optimal dose is the lowest one that will with advanced PD is complicated by the CORRESPONDENCE maintain adequate function. As the symp- fact that the caregiver, usually a spouse, is Marie-Hélène Saint-Hilaire, MD, FRCPC toms of PD progress, the dosage of the medi- also likely to be elderly and to suffer from a Boston University School of Medicine cation will need to be adjusted. However chronic illness. Department of Neurology certain symptoms such as gait freezing, falls, 715 Albany Street, C-329 hypophonia, and dysphagia do not respond Boston, MA 02118 well to drug treatment, and in these cases Phone: (617) 638-8640 physical therapy and speech therapy may be e-mail: email@example.com helpful.12, 13 169 VOLUME 91 NO. 5 MAY 2008 Epilepsy In the Elderly Amanda M. Diamond, MD, and Andrew S. Blum, MD, PhD People over age 65 are the most rap- global amnesia and dementia. Multiple level relationships.8 Decreased protein idly increasing segment of the population. metabolic etiologies can also be consid- binding is more common in the aged; this The incidence of epilepsy rises signifi- ered, including hypo- or hyperglycemia, may lead to higher AED free fractions, cantly with age, starting with 25.8/ thyroid dysfunction, hypercapnia, ure- which can lead to earlier toxicity with more 100,000 person-years for the ages of 60- mia and hyponatremia.7 highly protein bound AEDs such as pheny- 74 and increasing to 101.1/100,000 for Electroencephalography can be toin and valproate. Also, the elderly may the ages of 75-89.1 The prevalence of pivotal, but one must be aware of po- have a lower volume of distribution. De- epilepsy is 1.5% in the elderly, twice that tential false positive findings. Rhythmic creased clearance due to hepatic or renal of young adults.2 Also, the prevalence of runs of temporal theta activity may be insufficiency may also promote higher than epilepsy in nursing home residents is even seen in drowsiness as a normal or benign expected serum AED levels.9 The CNS higher than that in the general popula- finding. Focal slowing may be present threshold for AED toxicity may also be tion. Review of elderly nursing home with underlying cerebrovascular insults. lower in the elderly. Delayed esophageal residents reveals that up to 10.5% are Wicket spikes and subclinical rhythmic and gastric emptying, altered postprandial receiving anticonvulsants, along with an electrographic discharges in adults gastric pH, and delayed intestinal transit average of 5.6 other medications.3,4 (SREDA) are two other benign variant all affect absorption in the elderly.10 patterns that can be misinterpreted. Several medications more common in ETIOLOGY AND SEMIOLOGY Long-term video-EEG monitoring the elderly can pose significant interactions In the elderly, cerebrovascular dis- (LTM) may prove invaluable in evalu- with some AEDs. For example, highly ease accounts for 30-40% of cases.2 The ating recurrent spells. Brain imaging protein bound AEDs (e.g. phenytoin and risk of seizures within the first year after should be performed, preferably MRI. valproate) may interact with warfarin and stroke has been estimated to be 23 times Other testing considerations include ba- other highly protein bound concomitant that of the general population.5 Other sic metabolic screens, sleep studies, medications, leading to complex untoward causes include Alzheimer’s disease, Holter monitoring, echocardiogram, interactions. Cytochrome P450-inducing trauma, brain tumors and infection. tilt-table and/or vestibular testing, AEDs (phenytoin, carbamazepine, phe- About half of cases are cryptogenic, and where appropriate, to rule out compet- nobarbital) accelerate the clearance of it is presumed that vascular etiologies ac- ing diagnoses. some hepatically cleared drugs, including count for much of this group too.2 some chemotherapeutics.9 Further complicating the diagnosis is the sometimes vague history. The Several medications Several AEDs are known to contrib- ute to accelerated bone demineralization. events are often unwitnessed and may more common in The older generation of AEDs seems to involve confusional symptoms. Elderly patients do not always have classical sei- the elderly can pose be worse in this regard. The elderly are at a higher risk of osteoporosis and related zure semiologies or auras as in younger significant fractures, so this may be relevant. Balance patients. Symptoms that may suggest al- ternate diagnoses can further confound; interactions with and cognitive concerns are also enriched in the elderly. Some AEDs appear to pose these may include tremor, headache and some AEDs. greater balance risks (e.g. phenytoin, dizziness, among others.6 In a recent carbamazepine)11 or cognitive risks (e.g. VA study, 27% of patients ultimately di- MANAGEMENT phenobarbital, topiramate). Hyponatre- agnosed with epilepsy were initially mis- The assistance of family members and mia, a problem occasionally provoked by diagnosed as having syncope, altered caregivers may be needed to ensure pa- carbamazepine and oxcarbazepine, is mental status and confusion.6 Postictal tient safety. In some, help with medica- more frequent in the aged, particularly periods tend to be more prolonged in this tions may be critical and the importance with concomitant diuretic use. age group, at times lasting for several of compliance should be emphasized. The elderly are likely to have more days.7 Patients may need a home safety evalua- medical diagnoses and take more medica- tion. Medication lists should be reviewed tions than a younger population and thus DIFFERENTIAL DIAGNOSIS AND for potentially pro-convulsive medications. are far more susceptible to drug-drug in- WORK-UP Medical management of epilepsy in teractions.3 AEDs that act as hepatic en- The differential diagnosis in this the elderly poses several distinct challenges. zyme inducers or inhibitors will greatly population is extensive and includes tran- Pharmacokinetic and pharmacodynamic augment this problem of drug-drug in- sient cerebrovascular symptoms (TIA), parameters change significantly with age, teraction burden in this age group. This syncope (including convulsive syncope), making the potential for side effects of anti- is more often the case for the older AEDs. confusional migraine, drug intoxication, epileptic drugs (AEDs) greater and de- The newer (2nd generation) AEDs exhibit infection, psychiatric disorders, transient creasing the predictability of dose – blood less hepatic affects and are more often 170 MEDICINE & HEALTH /RHODE ISLAND renally cleared, have lower protein bind- zures in the elderly. After careful diagnosis, 14. Saetre E, Perucca E, et al. An international multicenter randomized double-blind controlled ing, and hence have fewer drug interac- AED choices should take into account me- trial of lamotrigine and sustained-release tions as a group. Additionally, the elderly tabolism, drug-drug in interactions, co-mor- carbamazepine in the treatment of newly diag- may have more difficulty paying for AEDs, bidities, and side effect profiles while striv- nosed epilepsy in the elderly. Epilepsia contributing to potentially poor compli- ing to achieve seizure freedom. 2007;48:1292-302. 15. Leppik IE. Epilepsy in the elderly. Epilepsia ance or restricted choice of agent. 2006;47(Suppl 1):65-70. REFERENCES ANTIEPILEPTIC CHOICES IN THE 1. Hussain SA, Haut SR, et.al. Incidence of epilepsy Amanda M. Diamond, MD, is a Fel- in a racially diverse, community-dwelling, elderly ELDERLY low in Clinical Neurophysiology, Rhode cohort. Epilepsy Res 2006;71:195-205. Little comparative efficacy data exist 2. Hauser WA. Epidemiology of Seizures in the eld- Island Hospital and The Warren Alpert to help guide the use of AEDs in the eld- erly. In: Seizures and Epilepsy in the Elderly. Rowan Medical School of Brown University. erly. Most clinical trials of AEDs have been AK, Ramsay RE, Eds. Boston, Butterworth- Heinemann, 1997:7-18. Andrew S. Blum, MD, PhD, is Direc- conducted in younger and healthier adult 3. Lackner TE, Cloyd JC, et al. Antiepileptic drug tor, Comprehensive Epilepsy Program, Rhode populations. In the UK, Brodie et al12 com- use in nursing home residents, Epilepsia Island Hospital, and Assistant Professor of pared the efficacy and tolerability of 1998;39:1083-7. Clinical Neurosciences, The Warren Alpert lamotrigine vs. carbamazepine in elderly 4. Garrard J, Cloyd JC, et.al. Factors associated with antiepileptic drug use among nursing home eld- Medical School of Brown University. patients with new onset epilepsy. They erly. J Gerontol Med Sci 2000 ;55:384-92. found similar efficacy but better tolerabil- 5. So EL, Annegers JF, et.al. Population-based study Disclosure of Financial Interests ity in the lamotrigine arm.12 A similar US of seizures disorders after cerebral infarction. Amanda M. Diamond, MD. Con- study compared gabapentin vs. lamotrigine Neurol 1996;46:350-355. 6. Ramsay RE, Rowan AJ, Pryor FM. Special con- sultant: Guidant, TEVA, Berlex (Bayer), vs. carbamazepine in the elderly and found siderations in treating the elderly patient with epi- Genentech. better tolerability in the gabapentin and lepsy. Neurol 2004;62(Suppl 2):S24-S29. Andrew S. Blum, MD. Grant Re- lamotrigine arms vs. carbamazepine with 7. Ramsay RE, Macias FM, Rowan AJ. Diagnosing search Support: Abbott Laboratories. no significant efficacy distinctions.13 How- epilepsy in the elderly. In “The Neurobiology of Epilepsy and Aging” (RE Ramsay, ed.) Int Rev Speaker’s Bureau: Glaxo SmithKline, ever, a later international study that com- Neurobiol 2007;81:1-14. ICB Pharmos, Ortho-McNeil. pared lamotrigine and carbamazepine us- 8. Perucca E, Berlowitz D, et.al. Pharmacological and Discussion of off-label usage of any ing a more flexible dosing schedule and slow clinical aspects of antiepileptic drug use in the elderly. Epilepsy Res 2006;68S:S49-S63. product: gabapentin and lamotrigine. release carbamazepine did not observe as Reference is made to studies performed 9. Boggs JG. Elderly patients with systemic disease. marked a tolerability difference.14 Epilepsia 2001;42:18-23. on the use of these medications in eld- It is helpful when treating the eld- 10. Gidal BE. Drug absorption in the elderly. Epi- erly patients with epilepsy. erly with epilepsy to keep the regimen as lepsy Res 2006;68S:S65-S69. 11. Fife TD, Blum D, Fisher RS. Measuring the ef- simple as possible. Medication choices fects of antiepileptic medications on balance in CORRESPONDENCE should be tailored to seizure type, with older people. Epilepsy Res 2006;70:103-9. Andrew S. Blum, MD, PhD most being partial onset rather than gen- 12. Brodie MJ, StephenLJ. Outcomes inelderly pa- 110 Lockwood St., Ste. 342 eralized in this population. Tolerability tients with newly diagnosed and treated epilepsy. Int Rev Neurobiolo 2007;81:253-63. Providence, RI 02903 concerns should be considered carefully 13. Rowan AJ, Ramsey MD, et al. New onset geriat- Phone: (401) 444-4364 in AED selection and individualized ac- ric epilepsy, Neurol 2005;64:1868-73. E-mail: firstname.lastname@example.org cordingly. Doses should generally begin quite low and titration should be as slow as possible .15 Levels may be helpful. Cost may be a deciding factor for some. Fortunately, the majority of elderly cases are very responsive to treatment. Refractory epilepsy may be infrequently encountered in this group. Non-phar- macologic treatment options may be lim- ited. Surgical resection is not as com- monly used in this age group. Vagal nerve stimulation may prove an option for some when AEDs prove inadequate and sur- gery is not a viable option. SUMMARY The incidence of epilepsy is higher in the elderly than in younger adults. This com- munity presents a challenging set of consid- erations in diagnosis and management. Numerous other processes may mimic sei- 171 VOLUME 91 NO. 5 MAY 2008 Peripheral Neurology: Special Concerns In the Elderly George M. Sachs, MD, PhD Changes in the peripheral nervous system role of estrogen is less well established, nervate muscle fibers with slow contrac- produce a major impact on safety and though its sharp perimenopausal fall may tion times. Type 2 motor units contain quality of life in the elderly. The chal- help explain the relatively early onset of larger motor neurons and muscle fibers lenges of aging reflect alteration of both muscle loss in women.1,2 that contract more quickly. Aging muscles neuromuscular and sensory function. Of The interaction of nerve and muscle may show a shift toward the slower con- particular concern are motor and prop- can be described in terms of “ motor units”. tractions of Type 1 units for a few rea- rioceptive deficits increasing the risk of One motor unit consists of a single spinal sons. First, aging leads to selective Type 2 falls. In addition, changes in sensory path- motor neuron and the muscle fibers it sup- fiber atrophy. Whether this simply re- ways may predispose the elderly to neu- plies through the branches of its axon. A flects decreased physical activity or some ropathic pain. This review will focus on motor unit in hand muscles typically in- other more specific feature of aging aspects of aging in muscle and nerve rel- cludes about 100 muscle fibers, where calf muscles is not clear. Secondly, muscle fi- evant to these issues. and thigh muscle motor units include bers may actually transform from Type 2 1000-2000.4 In addition to transmitting to Type 1 as a result of the denervation SARCOPENIA electrical excitation, each motor neuron and reinnervation that follows loss of Saracopenia refers to the degenera- provides trophic support to the muscle fi- motor neurons.6 tive loss of muscle mass and strength with bers in its motor unit. Once a muscle fi- The predominance of Type 1 fiber increasing age. It begins in mid-life and ber loses its nerve input, it undergoes at- contraction in aging muscles inhibits the accelerates significantly in the seventh rophy unless connection with another ability to make quick, forceful move- and eighth decades. Both active and sed- nerve terminal can be restored. ments. This poses particular problems for entary individuals suffer sarcopenia, rapid postural reflexes important in main- though it is worsened by inactivity. Growth hormone taining balance. In addition to overall Muscle mass decreases earlier in women muscle weakening and proprioceptive but men experience greater overall loss, supplementation deficits (described below), slowing of averaging 30-40% of their muscle mass by age 80.1 has not postural adjustments presents a major risk for falls in the elderly. The causes of sarcopenia are mul- demonstrated tiple. They include loss of muscle cells as improvement in THERAPEUTIC CONSIDERATIONS FOR well as hormonal changes that influence THE AGING NEUROMUSCULAR SYSTEM the growth and regeneration of differ- muscle mass or The literature regarding testosterone ent cells within muscles. In addition, de- generation of spinal motor neurons has a strength in elderly replacement for sarcopenia presents a mixed picture. Meta-analyses have sug- profound effect on the muscles they in- men or women. gested that injected testosterone can pro- nervate.1,2 duce a moderate increase in muscle mass Satellite cells are essentially stem cells Anatomical and physiolgical studies and strength in older men.7 Concerns residing in muscle. In response to physi- have shown that the number of motor over adverse effects temper any current cal trauma or even vigorous exercise, sat- units (i.e. the number of spinal motor neu- enthusiasm. In particular, no large, pro- ellite cells proliferate to form new muscle rons) supplying limb muscles remains fairly spective studies have looked at rates of fibers or fuse with damaged fibers to re- constant up to age 60. Beyond that, prostate cancer in older men receiving pair them. Most studies have shown re- healthy individuals typically lose about half testosterone supplementation. 8 duction in the number of satellite cells of their motor units between ages 60 and Growth hormone supplementation with aging. This, along with changes in 80.5 Sprouting of terminal axons from has not demonstrated improvement in growth factor and hormone levels, de- remaining motor neurons initially com- muscle mass or strength in elderly men creases the regenerative capacity of pensates for those that are lost, however as or women. Furthermore, the addition of muscle over time.3 this process continues, muscle fibers are growth hormone to a resistance exercise Testosterone (T), growth hormone inevitably left to atrophy without nerve program does not appear to confer addi- (GH) and insulin-like growth factor (IGF) supply. This neurogenic atrophy is likely tional benefit. Adverse effects including all regulate protein synthesis within muscle.. the major cause of sarcopenia.1,2 carpal tunnel syndrome, hyperglycemia, IGF appears to increase synthesis of actin edema and orthostatic hypotension led and myosin (the principal contractile pro- CHANGES IN MUSCLE DYNAMICS to high drop-out rates in treatment teins in muscle), while GH and T promote Two major types of motor units can groups of some studies.2 protein stability. Decreasing levels for all be distinguished by their morphologic Relatively few clinical trials have three of these hormones in mid to late life and physiologic characteristics. In Type evaluated the muscular effects IGF-1 presumably contribute to sarcopenia. The 1 motor units, small motor neurons in- administration. A study assessing a two 174 MEDICINE & HEALTH /RHODE ISLAND month course of IGF-1 complexed to a seen in the elderly. Though neuropathy 7. Ottenbacher KJ, Ottenbacher ME, et al. Andro- gen treatment and muscle strength in elderly men. bindng protein, found that grip strength in older individuals is not frequently re- J Am Geriatr Soc 2006;54:1666-73. improved by 11%. 9 The effect of estro- versible, simple preventive measures in- 8. Brand TC, Canby-Hagino E, Thompson IM. Tes- gen replacement on sarcopenia has also cluding use of a cane, nightlights and tosterone replacement therapy and prostate can- received little study to date. Reported shower chairs should not be neglected. cer. Curr Urol Rep 2007;8:185-9. 9. Boonen S, Rosen C, et al. Musculoskeletal effects effects of estrogen on lean body mass of the recombinant human IGF-1/IGF binding have been mixed and changes in strength NEUROPATHIC PAIN protein 3 complex in osteoporotic patients with or contraction speed have yet to be in- The age-related changes discussed proximal femoral fracture. J Clin Endocrinol Metab vestigated.10 above concern the largest sensory fibers. 2002;67:1593-9. 10. Thorneycroft JH , Lindsay R, Pickar JH. Body Exercise, in the form of resistance Evaluation of small caliber sensory fibers composition during treatment with conjugated training, appears to be the most effective is more challenging but crucial to under- estrogens with and without medroxyprogesterone treatment to counteract muscular decline standing neuropathic pain. This is an acetate. Am J Obstet Gynecol 2007;197:e1-7. in the elderly. Resistance training pro- important issue for aging populations 11. Resnick HF, Vinik AI, et al. Age 85+ years acceler- ates large-fiber peripheral nerve dysfunction J grams can achieve the same percentage given the striking predominance of cer- Gerontol Med Sci 2001;56:M25-M31. gain in muscle mass and strength at age tain neuropathic pain conditions in the 12. Richardson JK, Hurvitz EA. Peripheral neuropa- 80 as they do in young adults.2 Although elderly. 13 thy. J Gerontol Med Sci 1995; 50:M211- M215. the mechanism is not understood, resis- In contrast to the clear age-related loss 13. Hall GC, Carroll D, et al. Epidemiology and treat- ment of neuropathic pain. Pain 2006;122:156-62. tance training also increases whole muscle of large sensory fibers, anatomic studies 14. Lauria G, Holland N, et al. Epidermal innerva- contraction speed with an associated im- have demonstrated relative preservation of tion. J Neurol Sci 1999;164:172-8. provement in balance. small-caliber, pain sensing fibers in the eld- 15. Baron R, Haendler G, Schulte H. Afferent large fiber neuropathy predicts the development of This likely reflects adaptive coordi- erly.14 This raises an interesting possibility postherpetic neuralgia. Pain 1997; 73:231-8. nation among different motor units since regarding the development of post-her- the contraction speed of individual petic neuralgia, a condition which is rare George M. Sachs, MD, PhD, is Asso- muscle fibers may actually decrease with below the age of 50 but complicates 20- ciate Professor (Clinical) of Neurology, The resistance training. 40 % of zoster cases past the age of 60. Warren Alpert Medical School of Brown Studies testing sensory function in patients University. AGING IN PERIPHERAL SENSORY with post herpetic neuralgia have indicated NERVES that vibratory sensory loss (presumably Disclosure of Financial Interests Signs of peripheral sensory loss be- due to large-fiber failure) is more promi- The author has no financial inter- come increasingly prevalent with advanc- nent than small-fiber (pain and tempera- ests to disclose. ing age. Loss of ankle reflexes and decreas- ture) deficit.15 This suggests that prefer- Discussion of off-label usage of any ing distal vibration sense are particularly ential large fiber loss with aging may be products or services common. One study revealed that at least an important risk factor for the develop- *use of supplemental testosterone, one of these deficits occurred in 26% of ment of neuralgias and neuropathic pain. growth hormones and IGF-1 to reduce individuals aged 74-84 and in 54% of If small sensory fibers are relatively pre- sacropenia is investigational those older than 85.11 Correspondingly, served, they may present an important tar- anatomic studies have documented lower get for treatments. The use of local or topi- CORRESPONDENCE numbers of sural nerve fibers and physi- cal agents aimed at small fibers could George M. Sachs, MD, PhD ologic studies have shown lower ampli- supplement or replace systemic medica- 593 Eddy St., APC 689 tudes of sural nerve response in “normal” tions that are limited by adverse reactions Providence, RI 02903 older individuals. in elderly patients. e-mail: GSachs@lifespan.org Since these findings are so common, they are often considered part of “nor- REFERENCES mal aging.” This notion overlooks the 1. Thomas DR. Loss of muscle mass in aging. Clin Nutrition 2007;26:389-99. impact of peripheral sensory deficits on 2. Borst SE. Interventions for sarcopenia and muscle balance and gait in the elderly. A num- weakness in older people. Age Ageing 2004; ber of studies have documented that pe- 33:548–55. ripheral sensory loss is an important risk 3. Shefer G,Van de Mark DP, et al. Satellite-cell pool size does matter. Development Biol 2006;294:50-66. factor for falls. In some studies, the exist- 4. Feinstein B,Lindegard E, Nyman E. Morpho- ence of lower extremity neuropathy in- logical studies of human motor units in normal creased the frequency of falls about 20- human muscles. Acta Anat 1955; 2:127-39. fold.12 Even modest loss of propriocep- 5. Doherty TJ, Vandervoort AA, Brown WF. Ef- fects of aging on the motor unit. Can J Appl Physiol tion can pose significant risk when com- 1993;18:331-58. bined with slowed muscular response and 6, Doherty TJ. Aging and sarcopenia. J Appl Physiol visual or vestibular disturbances so often 2003;95:1717-27. 175 VOLUME 91 NO. 5 MAY 2008 Sleep Disorders In the Elderly Jean K. Matheson, MD Older patients frequently complain of as sleep apnea and periodic leg move- ity of sleep disordered breathing difficulty initiating sleep, sleep mainte- ments as described below. Respiratory Effort Related Arousal: When nance or excessive daytime sleepiness, airway resistance increases, oxygen while bed partners or caretakers are dis- SLEEP- RELATED BREATHING saturation and airflow may stay the traught by episodes of nocturnal confu- DISORDERS (SRBDS) same as respiratory effort increases to sion or belligerence. The most important cause of sleep dis- overcome obstruction. This increased Sleep disorders may represent a pri- ruption is sleep-disordered breathing. The respiratory effort may induce an mary disorder of mechanisms regulating term “sleep-disordered breathing” prima- arousal that disturbs sleep termed, sleep or failure of a specific organ system rily refers to the sleep apnea syndromes, but RERA, respiratory effort- related manifesting in a unique way during sleep. also includes disorders that result in noc- arousal. This event is NOT recognized Sleep complaints should not be ignored turnal hypoventilation and hypoxemia such by CMS and is sometimes called a or treated empirically with pharmaco- as restrictive and parenchymal pulmonary “hypopnea without desaturation”.1 logic agents without analysis of the etiol- diseases. While well known to cause exces- ogy. sive daytime sleepiness, the sleep apnea syn- The presence of 5 apneas/hour of dromes, both central and obstructive, are sleep was previously deemed necessary to POLYSOMNOGRAPHY also important contributors to difficulty establish the presence of either “obstruc- Polysomnography is the term ap- initiating and maintaining sleep because of tive sleep apnea” or “central sleep apnea”. plied to the simultaneous and continu- frequent nocturnal arousals. Current defi- It is now clear, however, that either in- ous measurement of multiple physiologic nitions that have the most widespread clini- complete obstructions or central parameters during sleep. In practice, the cal use are based on guidelines provided hyoventilatory episodes without apnea polysomnogram (PSG) has come to by the Center for Medicare and Medic- induce physiologic changes of the same mean a specific type of polysomnographic aid Services (CMS);2 magnitude as apneas. CMS currently study in which measurements allow for accepts a minimum AHI of 5 as evidence 1) the identification of sleep stage, 2) Apnea: An apnea is defined as the ab- of sleep apnea that justifies treatment. monitoring of cardio-pulmonary func- sence airflow for at least 10 seconds. However, RERAs, often occult contribu- tion and 3) monitoring of body move- There are three types: tors to sleep disruption, are not included ments during sleep. Obstructive apnea: Absence of airflow in the CMS definition of sleep apnea, but for at least 10 seconds with evidence are accepted by the American Academy SLEEP STAGING AND ARCHITECTURE of persistent respiratory effort. of Sleep Medicine as determinants of Rapid eye movement (REM) sleep, Central apnea: Absence of airflow for obstructive sleep apnea syndrome. 4 sometimes called dreaming sleep, and 10 seconds without evidence of any Well-documented risk factors for ob- non-REM (NREM) sleep are the two of respiratory effort. structive sleep apnea include obesity, large sleep states. NREM and REM sleep alter- Mixed Apnea: Absence of airflow for neck, upper airway structural abnormali- nate in recurring cycles of approximately 10 seconds with initial absence of ties, nasal congestion, endocrine abnormali- 90 minutes. NREM sleep had been di- effort followed by a return of respi- ties, muscular weakness and sedating drugs. vided into four stages (1-4), representing ratory effort before resumption of In aging and degenerative neurologi- progressive deepening of sleep. A recent airflow. cal disease there are additional risk factors revision of staging nomenclature now Hypopnea: The term hypopnea refers to a including laryngeal dysfunction and cen- identifies these stages as N1, N2 and N3.1 decrease in airflow. By CMS criteria: trally- induced dysynergy of upper airway In what has been thought to be “Hypopnea in adult patients is defined muscle activation in relationship to chest normal aging nocturnal awakenings as an abnormal respiratory event last- wall and diaphragmatic activation. and wake time increase. N3 sleep de- ing at least 10 seconds with at least a Central sleep apnea episodes usually creases and REM time usually remains 30% reduction in thorocoabdominal represent Cheyne-Stokes breathing, a cre- relatively constant. Stage one sleep in- movement or airflow as compared to scendo-decrescendo breathing pattern, creases as a reflection of sleep disrup- baseline, and with at least a 4% oxy- common in the elderly, especially those tion. Sleep efficiency, the ratio of time gen desaturation.”2 with congestive heart failure. Periods of asleep to time in bed, decreases second- Apnea Hypopnea Index (AHI): The central apnea or hypopnea predispose to ary to both increased time in bed and total number of apneas and obstruction as well, because low airflow increased wake. However, many of hypopneas are summed and divided contributes to airway collapse. This type these changes attributed to “normal” by the number of hours of sleep. of breathing abnormality, once consid- aging may also be exacerbated or in- When used with the definitions ered benign, may markedly disrupt duced by what we now know to be com- above, the index is useful as a stan- sleep. 4 mon and treatable sleep disruptors such dardized measure that reflects sever- 176 MEDICINE & HEALTH /RHODE ISLAND TREATMENT OF SLEEP-DISORDERED that disturb sleep (PLMS). Many medi- tation refers to the development of symp- BREATHING: cations are implicated in the induction toms earlier in the day with increasing se- Continuous positive airway pressure of periodic and aperiodic leg move- verity, further exacerbated by dosage in- (CPAP) is the mainstay of treatment for ments, most commonly SSRIs, SNRIs creases. This phenomenon occurs most dra- obstructive sleep apnea and for some pa- and tricyclic antidepressants. matically with the use of levodopa and less tients with predominantly central apnea. frequently with the dopaminergic agonists Airway pressure acts as a pneumatic splint Restless Legs Syndrome ropinirole and pramipexole. Gabapentin to maintain upper airway patency during Restless legs syndrome (RLS) is char- and low dose opioids are useful second line sleep. Bi-level positive pressure (BIPAP) is acterized by 1) an urge to move accompa- drugs that can be used alone or in combi- often better tolerated in the elderly because nied by uncomfortable sensations, predomi- nation with dopaminergic agonists for dos- it provides an expiratory pressure always nantly in the legs, that are 2) relieved by age sparing. Benzodiazepines are third line lower than inspiratory pressure, making movement, 3) occur when sedentary and 4) drugs because of limited efficacy and the expiration more natural and less effortful. are worse in the evening.5 This syndrome is development of tolerance. The inspiratory–expiratory pressure differ- closely associated with PLMD. Restless legs ence also acts to augment ventilation in dis- syndrome, however, is a syndrome based on REM Behavior Disorder orders associated with hypoventilation. clinical, not polysomnographic criteria. The Low muscle tone observed on PSGs New devices termed servo-ventilators are disorder is familial in approximately 50% of during REM correlates with the normal based on bi-level positive pressure technol- cases. Prevalence estimates vary between 5 paralysis that occurs during dreaming. This ogy, and can be used at home to treat pa- and 20% of the general adult population in temporary paralysis, termed REM sleep tients with central components of their North America and the disorder appears to atonia, prevents the dreaming subject sleep-disordered breathing, especially increase with age.5 Abnormalities of both from enacting dreams. REM Behavior Cheyne-Stokes respirations. These devices dopamine and iron metabolism are impli- Disorder is characterized by incomplete are an important addition to the treatment cated in the underlying pathophysiology. REM atonia associated with motoric acti- of sleep-disordered breathing in heart fail- Iron deficiency is known to exacerbate or vation during dreams.7) Typically the pa- ure. Many new mask styles and variations precipitate restless legs and periodic leg move- tient, bed partner, or caretaker complains on these devices including “smart” auto ti- ments in familial and non-familial cases. Sec- of violent, often injurious, activity during trating machines can improve patient tol- ondary causes of RLS are subject to some sleep. The patient may complain of a erance dramatically. Full face masks are debate due to limited data and include ure- change in dream content with violence now comfortable and useful in patients who mia, neuropathy, and medications, especially and running as typical themes. Sometimes may have rejected positive pressure previ- anti-dopaminergic drugs and SSRIs. the patient is able to incorporate ongoing ously because of nasal obstruction.3 conversation and activity into the dream, Cheyne-Stokes respirations often re- Management of Restless Legs giving rise to the misperception that he is spond to low-flow oxygen delivered and Periodic Limb Movements confused or hallucinating until he sud- through nasal prongs that generally are Periodic leg movements are often denly awakens and appear to “clear” his better tolerated than positive pressure. O2 found incidentally on sleep studies and are mental status. Underlying dementia or tends to decrease over-responsiveness to not generally treated unless they are either acute illness may impair the patient’s abil- CO2 that perpetuates the hyperventilation- accompanied by symptomatic restless legs, ity to report the perception of dreaming, apnea cycle. Obstructive episodes exacer- or clearly contribute to arousals. Recom- resulting in misdiagnosis. Hospital care- bated by central apneas may also improve. mendations for the management of restless takers usually dismiss even detailed dream- Sedating medications, especially hypnotics legs have recently been published.6 Serum ing reports as confusion. The disorder is and narcotics, can exacerbate sleep disor- ferritin should be checked in all patients; frequently mistaken for “sundowning” or, dered breathing and are best avoided when iron replacement is recommended in pa- because of the violent quality of the sleep-disordered breathing is suspected.3 tients with ferritins below 45-50 ug/ml. dreams, post-traumatic stress disorder. Response to iron replacement may not oc- REM behavior disorder occurs most SLEEP RELATED MOVEMENT cur in all patients and usually takes months frequently in older men with a mean age DISORDERS to years; some clinicians advocate intrave- of 60. Over time it has become clear that Sleep-related movement disorders nous replacement in severe cases. Because RBD precedes other clinical signs or symp- include conditions in which simple ste- antidepressant and antihistamine medica- toms of some degenerative diseases, espe- reotyped movements are present during tions may exacerbate restless legs they cially Parkinson’s disease, dementia with sleep and induce sleep disruption. Diffi- should be avoided if possible. Some clini- Lewy bodies and multisystem atrophy, (the culty initiating and/or maintaining sleep cians routinely screen for neuropathy with “synucleinopathies.”) by years. Conversely, are the typical complaints. exam and metabolic studies. Ropinirole the prevalence of RBD in Parkinson’s dis- (Requip) and pramipexole, (Mirapex), both ease is in the range of 33-60%. The com- Periodic Limb Movement Disorder dopaminergic agonists FDA approved for bination of degenerative dementia and The most prevalent of these disor- RLS, are markedly effective. Because of the RBD is highly correlated with the diag- ders is periodic limb movement disor- possibility of inducing a syndrome termed nosis of dementia with Lewy bodies, based der (PLMD), characterized by periods “augmentation”, it is best to use as low a on clinical and pathologic criteria. There of repetitive stereotyped leg movements single evening dose as possible. Augmen- are rare published reports of RBD with a 177 VOLUME 91 NO. 5 MAY 2008 “tauopathy” (e.g. pure Alzheimer’s disease, REFERENCES Jean K. Matheson, MD, is Neurologi- frontotemporal dementia, progressive su- 1. The AASM manual for the scoring of sleep and cal Medical Director, Sleep Disorders Cen- associated events. Westchester, IL: American Acad- pranuclear palsy). Some medications, es- ter, Beth Israel Deaconess Medical Center, emy of Sleep Medicine, 2007. pecially NSRIs and SSRIs are known to 2. Medicare National Coverage Determinations and Associate Professor of Neurolog y, precipitate and exacerbate the disorder. Manual Chapter 1, Part 4 Section 240.4. http:// Harvard Medical School. Idiopathic RBD also exists.7 www.cms.hhs.gov/manuals/downloads/ ncd103c1_Part4.pdf 3. Kryger MH, Roth T, Dement WC. Principles and Disclosure of Financial Interests Circadian Rhythm Disorders: Practice of Sleep Medicine. 4th ed. Philadelphia, The author has no financial inter- Advanced Phase Sleep Disorder PA: Elsevier/Saunders, 2005. ests to disclose. The tendency for elderly patients to 4. The international classification of sleep disorders Discussion(s) of off-label usage of any : Diagnostic & coding manual, ICSD-2. 2nd ed. spend more time asleep during the day Westchester, IL: American Academy of Sleep products or services: gabapentin for rest- and less time asleep at night raises the pos- Medicine, 2005. less legs syndrome, clonazepam for REM sibility that neurological dysfunction of the 5. Allen RP Picchietti D, et al. Restless legs syndrome: , Behavior Disorder biologic clock within the suprachiasmatic Diagnostic criteria, special considerations, and epi- demiology. A report from the restless legs syn- nucleus of the hypothalamus mediates drome diagnosis and epidemiology workshop at CORRESPONDENCE these changes. Advanced phase sleep dis- the National Institutes of Health. Sleep Med Jean K. Matheson, MD order is a well-recognized circadian disor- 2003;4(2):101-119. Sleep Disorders Center, CCE866 6. Silber MH, Ehrenberg BL, et al. An algorithm for der in which patients complain of diffi- Beth Israel Deaconess Medical Center the management of restless legs syndrome. Mayo culty staying awake in the evening and Clin Proc 2004;79:916-22. 330 Brookline Ave early morning awakening.5 This disorder 7. Boeve BF, Silber MH, et al. Pathophysiology of Boston MA 02215 is common in the elderly and may be mis- REM sleep behaviour disorder and relevance to Phone: (617) 667-4307 neurodegenerative disease. Brain 2007. taken for early morning insomnia. e-mail: email@example.com 8. Campbell SS, Dawson D, Anderson MW. Alle- Phase advance is exacerbated by vi- viation of sleep maintenance insomnia with timed sual impairment and low light exposure exposure to bright light. J Am Geriatr Soc during the day; evening light exposure 1993;41:829-36. can therapeutically delay rhythms and improve sleep maintenance.8 Driving Safety Among Older Adults Melissa M. Amick, PhD, and Brian R. Ott, MD The number of individuals in the United driving tests compared to their non-de- While performance on neuropsychologi- States who are age 65 and older is expected mented counterparts. 4 For example, cal measures does predict driving abilities, to double by 2030.1 As this population in- Duchek and colleagues found that 43% our research has found that PD drivers are creases, so will the number of licensed older of participants with mild Alzheimer’s dis- infrequently observed to be unsafe drivers: drivers. Increasing age is a significant risk ease (AD) failed the road test, compared only one of 25 participants assessed actu- factor for unsafe driving. The risk for crash to 13% of patients with very mild AD and ally failed our road test. Rather, most par- involvement increases dramatically after the 3% of non-demented control participants.3 ticipants received marginal or safe ratings.5 age of seventy; and drivers 85 and older Longitudinal data indicated that patients Research in dementia and Parkinson’s dis- have the highest driver fatality rate.2 Driv- with mild AD experienced a more rapid ease emphasizes that mild degrees of motor ers over the age of 70 have the highest an- decline in driving skills compared to the slowing, cognitive dysfunction, and changes nual fatality rate per miles driven compared control group; however, patients with very in vision may not adversely affect driving to all age groups, except those aged 25 and mild AD did not differ significantly from skills, and that these diagnoses alone are not younger.2 In a study of mild dementia and either group.3 Comparing crash rate absolute indicators of unsafe driving. non-demented drivers, baseline age signifi- records collected by the state registries, only The American Medical Association’s cantly predicted performance on a road test one study has observed that patients with Physician’s Guide to Assessing and Coun- independent of cognitive status.3 These dementia are more frequently involved in seling Older drivers lists acute medical findings suggest that, as older people age, accidents compared to a control group.4 events such as myocardial infarction, stroke, the risk of unsafe driving increases, and care There is also concern about the driv- syncope, seizure, surgery, and delirium as providers will need to monitor their aging ing skills of patients with Parkinson’s dis- well as chronic conditions such as disease patients’ driving safety. ease (PD), because of the motor and non- affecting vision, cardiovascular disease, neu- Research on driving safety in the eld- motor symptoms (visual changes and cog- rological disorders, psychiatric illnesses, erly has mainly focused on drivers with de- nitive dysfunction). Interestingly, motor metabolic conditions, musckuloskeletal mentia, who consistently perform more symptom severity and visual functioning do impairments, and respiratory disease as risk poorly on open road tests and simulated not consistently predict driving skills.5 factors for unsafe driving.6 Detailing the 178 MEDICINE & HEALTH /RHODE ISLAND specific conditions that may be associated accidents and traffic violations, whereas less or at home physical therapy exercises) and with unsafe driving is beyond the scope of accurate raters emphasized dementia his- vision interventions (speed of information this brief review. Interested readers are tory, global neuropsychological perfor- processing training or at home exercises to referred to chapter 2 of the AMA’s guide. mance, eye examination results, general improve visual perception) were reported.10 medical history, and language skills9. Taken Educational programs were associated with OFFICE BASED ASSESSMENTS FOR together, these findings suggest that driv- some improvements in driving safety be- DRIVING SAFETY ing safety is best not determined by perfor- haviors.10 Unfortunately the two studies (self In a sample of 460 primary care phy- mance on a single measure, but rather monitoring program and California’s ma- sicians in Canada approximately 72% in- based on consideration of many patient ture drivers program) that examined the dicated that physicians should be legally characteristics. Importantly, compared to benefit of driver education programs upon responsible for reporting unsafe drivers to physical examinations or neuropsychologi- crash rates found no significant effect.10. state licensing authorities.7 Strikingly, only cal tests, a road test conducted by a profes- The limited research should not com- 55% of the surveyed physicians believed sional driving instructor or certified occu- pletely dissuade clinicians from recom- they were most qualified to make this de- pational therapist appears to be the gold mending these “refresher courses” to their cision, and 88% felt that they would ben- standard for determining driving safety. older drivers. Driver education programs efit from additional training in this area.7 can help individual drivers, and some in- The AMA’s guide recommends that phy- surers provide discounts to older adults who sicians assess visual function (acuity and …a road test participate in AARP’s driver reeducation visual fields), cognition (Clock drawing conducted by a program. Until these programs are empiri- test and Trails B, a visual motor task re- cally validated, however, it is difficult to quiring participants to alternate between professional driving judge their relative benefit as well as which connecting numbers and letters) and mo- instructor or certified elements of the course are associated with tor function (20 foot walk and manual test the best remediation of driving skills. of range of motion and motor strength), occupational with cutoff scores for each measure.6 therapist appears to CESSATION OF DRIVING While office-based tests can assist cli- nicians in making recommendations about be the gold standard states’The AMA Guide has compiledrefer- reporting procedures for easy each driving safety, some have argued that there for determining 6 ence. In Rhode Island “Any physician who is not enough research linking these mea- diagnoses a physical or mental condition sures to unsafe driving. For example, driving safety. which, in the physician’s judgment, will sig- Molnar and colleagues performed a system- nificantly impair the person’s ability to safely atic review of research studies (1984-2005) OLDER DRIVER RE-EDUCATION operate a motor vehicle may voluntarily re- examining the predictive utility of office- Changes in sensory, motor, or cogni- port the person’s name and other informa- based screening measures for determining tive functioning do not always mean that tion relevant to the condition to the medical driving safety.8 They found only sixteen ar- the older patient should retire from driv- advisory board within the Registry of Mo- ticles were of high enough quality to include ing. In some cases evaluation and training tor Vehicles. Any physician reporting in good in the review and only one study provided by an occupational therapist or private driv- faith and exercising due care shall have im- cutoff scores for determining driving safety. ers’ education program may help older munity from any liability, civil or criminal. The review indicated that Trails B was vari- adults become safe drivers again. Modifi- No cause of action may be brought against ably related to driving performance; and cations can be made to vehicles to make any physician for not making a report.”6 none of the studies examined clock-draw- them easier to use. For example, older adults Massachusetts is a self-reporting state. It is ing performance. At the present time clini- with limited range of motion in their necks the responsibility of the driver to report to cians are expected to make recommenda- may benefit from parabolic mirrors. Driv- the Registry of Motor Vehicles any medical tions, without empirical evidence to sup- ers with limited motion in their arms may condition that may impair driving ability. port office-based assessments. need a knob on their steering wheel. However, physicians are encouraged to re- Ott and colleagues examined the ac- The most common driving re-educa- port unfit drivers to the Registry of Motor curacy of physician assessments (based on tion program is the AARP Driver Safety Vehicles. The law does not provide any pro- chart review) for determining a professional Program, which is run as a classroom course tection from liability, nor does it promise con- driving instructor’s rating of AD patients’ and available on-line. AAA and state agen- fidentiality due to the “Public Records” law standardized road test performance.9 Phy- cies also offer informational materials as well which states simply that a driver is entitled sicians’ accuracy ranged from 62% to 78%.9 as classroom education. Research on the to any information upon receipt of written Clinicians also indicated which portions of benefits of older driver re-education is very approval” 6 pg30-31. the evaluation they relied upon for making limited. Kua and colleagues performed a Clinicians who recommend driving ces- their decision.9 Raters with higher accuracy systematic review of the older drivers re- sation to their patients should suggest alter- emphasized dementia duration, dementia education literature and found that only native transportation. In Rhode Island patients severity (CDR and MMSE), neuropsycho- eight studies demonstrated sufficient inter- can be referred to the Department of Elderly logical measures of praxis, visuospatial abil- nal validity to be included.10 Limited ben- Affairs Pocket Manual of Elder Services,11 ity, executive function, attention, history of efits of physical (range of motion exercises which lists the different RIDE programs as 179 VOLUME 91 NO. 5 MAY 2008 well as a phone number to schedule paratansit test and computerized office tests. For more 9. Ott BR, Anthony D, et al. Clinician assessment of the driving competence of patients with de- for individuals unable to use public transpor- information about participation or referrals, mentia. J Am Geriatr Soc 2005;53:829-33. tation. Care providers will want to closely contact Lindsay Miller at 444-0789. 10. Kua A, Korner-Bitensky N, et al. Older driver retrain- monitor these patients for signs of depression, A third and final priority is to exam- ing. J Safety Res 2007;38:81-90. Epub 2007 Feb 14. self-neglect, and isolation as all can occur as a ine the benefits of driver education pro- 11. The Rhode Island Department of Elderly Affairs. Pocket Manual of Elder Services. http:// result of loss of driving privileges (see the AMA grams. If physicians are going to recom- w w w. d e a . s t a t e . r i . u s / d o c u m e n t s / guide for specific monitoring methods). 6 mend these interventions, as with any other 2007%20Pocket%20Manual.pdf treatment, efficacy trials are necessary. FUTURE DIRECTIONS Melissa Amick, PhD, is Staff Neuropsy- There is much research to be done in REFERENCES chologist, Memorial Hosiptal of RI, and Clini- the area of assessing older driver safety. As 1. US Interim Projections by Age, Sex, Race, and His- cal Assistant Professor, The Warren Alpert panic Origin. Table 2a. Projected Population of the Molnar and colleagues point out, the estab- United States, by Age and Sex: 2000 to 2050. http:/ School of Medicine at Brown University. lishment of empirically validated cut scores /www.census.gov/ipc/www/usinterimproj/ Brian R. Ott, MD, is Director, The for visual functioning, motor skills, and cog- 2. US Department of Transportation National High- Alzheimer’s Disease & Memory Disorders nition is necessary to help physicians confi- way Traffic Safety Administration. Traffic Safety Center, Rhode Island Hospital, and Profes- Facts 2000. http://www-nrd.nhtsa.dot.gov/ dently identify truly at risk drivers.8 Pubs/2000OLDPOP .PDF sor, Department of Clinical Neurosciences, A second priority is to establish clini- 3. Duchek JM, Carr DB, et al. Longitudinal driving The Warren Alpert Medical School of cally meaningful outcome measures. Cer- performance in early-stage dementia of the Alzheimer Brown University. type. J Am Geriatr Soc 2003;51:1342-7. tainly poor performance on a simulated driv- 4. Man-Son-Hing M, Marshall SC, et al. Systematic ing test or pre-determined driving route is review of driving risk and the efficacy of compen- Disclosure of Financial Interests an indication for concern and monitoring, satory strategies in persons with dementia. J Am The authors have no financial inter- but there is not a perfect correlation between Geriatr Soc 2007;55:878-84. ests to disclose. 5. Amick MM, Grace J, Ott BR. Visual and cognitive these measures and crash risk. In this regard, predictors of driving safety in Parkinson’s disease a new study examining risk factors for poor patients. Arch Clin Neuropsychol 2007;22:957-67. CORRESPONDENCE drivers in a naturalistic setting has begun at 6. The American Medical Association. Physician’s Guide Melissa M. Amick, PhD Rhode Island Hospital. In this study, funded to Assessing and Counseling Older Drivers. http:// Memorial Hospital of RI www.ama-assn.org/ama/pub/category/10791.html by the National Institute of Health, older 7. Jang RW, Man-Son-Hing M, et al. Department of Medical Rehabilitation drivers both with and without dementia will Family physicians’ attitudes and practices regard- 111 Brewster Street be examined by video camera recordings in ing assessments of medical fitness to drive in older Pawtucket RI, 02860 their own cars and driving in their neigh- persons. J Gen Intern Med 2007;22:531-43. Phone: (401) 729-2326 8. Molnar FJ, Patel A, et al. Clinical utility of office-based borhoods. These recordings will be com- cognitive predictors of fitness to drive in persons with e-mail: Melissa_Amick@brown.edu pared to performance on a standardized road dementia. J Am Geriatr Soc 2006;54:1809-24. Geriatric Neurorehabilitation In the New Millenium Stephen T. Mernoff, MD Rehabilitation interventions have changed need inpatient rehabilitation. Medicare re- benefit from at least three hours of therapy little in the last few decades, aside from im- cipients comprise 75-80% of admissions to per day. Subacute rehabilitation units pro- provements in materials and medical care. acute rehabilitation facilities (ARFs). In vide programs for patients who cannot tol- Most neurorehabilitation research involves 2007, the average age of patients admitted erate, or will not benefit from, more inten- geriatric patients since most disabling neu- to ARFs in the US was 67 years. After an sive therapy. Home therapy may often be rologic disease occurs in older populations. average stay of 16 days,1 73% of these pa- suboptimal due to lack of equipment and Proving rehabilitation intervention efficacy tients returned home. With limited staffing inefficient scheduling. Outpatient therapy is difficult for methodological reasons. and ill patients, acute care hospitals usually varies between one and five sessions a week New technologies and neuroscience ad- provide one or two brief therapy treatments for medically stable patients. Patients may vances allow us to foresee development of evi- a day. Immobilization for even only a few move between these settings, depending on dence-based neurorehabilitation interventions days causes deconditioning which takes medical status and rehabilitation needs. improving functional outcomes. The need longer to reverse than to develop; therapy for such interventions will increase as the popu- should be initiated as soon as possible. Long- ROLE OF PHYSICIANS IN lation ages. Developing patient-specific reha- term acute care (LTAC) facilities manage REHABILITATION bilitation programs using selected tools at selected patients with persistent intensive nursing and Primary care physicians and/or times during recovery now seems within reach. medical care needs. Acute rehabilitation hos- physiatrists provide general medical manage- pitals admit 50-60% of their patients with ment and help to prevent complications. Im- REHABILITATION SETTINGS neurologic diagnoses, generally providing mobility increases risks of infection, deep Approximately 6-8% of Medicare pa- the most intensive rehabilitation programs venous thrombosis, and skin breakdown, tients admitted to acute care hospitals will available for patients who can tolerate and which can usually be effectively prevented. 180 MEDICINE & HEALTH /RHODE ISLAND Inadequate sleep interferes with therapy, pos- to months, cells in the ischemic penumbra of an impaired arm leads to preferential use sibly contributing to cognitive impairments. recover somewhat. These cells may have of the unaffected arm.7 CIMT is a “forced Obesity and depression must be treated early greater potential for synaptic plasticity via in- use” paradigm. The use of the unaffected arm and aggressively. Reassessment of medications creased expression of genes for neurotrophins is limited (by a sling or mitt) and the affected is critical; patients often come to rehabilita- and angiogenesis.3 The third stage is thought arm/hand undergoes intense therapy. Mul- tion on medications they no longer need. to consist of distant undamaged tissue taking tiple animal and human studies, including the The role of the neurologist has expanded on the functions of lost tissue. Several mecha- landmark EXCITE trial, have demonstrated as patients survive acute neurologic disease at nisms may subserve neural plasticity includ- the technique to be quite effective in certain progressively higher rates and more is known ing synaptogenesis, axonal regrowth, populations. There is some evidence that mea- about neurologic recovery. First and foremost neurotrophins, and neurogenesis(stem cells).4 surable cortical reorganization results. CIMT is accurate diagnosis; some patients arrive to These mechanisms seem to be inhibited has been investigated mainly in patients with rehabilitation with incorrect diagnoses. Pa- in more mature tissue. Enhancing natural stroke and cerebral palsy, but is also being tients with traumatic brain injury must be mechanisms of plasticity may improve recov- applied to lower limb impairment, traumatic monitored for hydrocephalus and subdural ery. For example, antibodies to MAG promote brain injury, and even aphasia. hematomas. The neurologist’s role in educat- axonal regrowth.5 Although motor control is ing therapists, patient, and family, by describ- virtually fixed after adolescence, the reorgani- STROKE INPATIENT REHABILITATION ing impairments, expected course of recov- zation occurring in damaged neurologic tissue REINFORCEMENT OF WALKING ery, and prognosis, is critical to program de- may present an opportunity to intervene. Po- SPEED (SIRROWS)8 sign and realistic goal-setting. tential interventions, including neurotrophins, Gait speed may be a surrogate marker stem cells, and pharmacologic potentiation, are for gait quality, often the major limiting factor EVOLUTION OF technically challenging and expensive. Elegant, for home discharge. Faster gait improvement NEUROREHABILITATION AS A noninvasive, and less expensive methods that in the inpatient rehabilitation setting might CLINICAL SPECIALTY2 may enhance neural plasticity are being inves- result in more efficient recovery with shorter Rehabilitation Medicine as a medical tigated. Different approaches will likely be ap- lengths of stay. The World Federation of subspecialty, the disciplines of Physical, Oc- plicable in different situations. Neurorehabilitation (WFNR), in collabora- cupational, and Speech Therapies, and dedi- tion with the American Society of cated Rehabilitation Units developed in the NEW NEUROREHABILITATION Neurorehabilitation (ASNR), is running the early to mid 20th century as a result of war TECHNOLOGIES UNDER SIRROWS trial to determine if this is true. injuries (amputations) and polio. The “tradi- INVESTIGATION This elegant and simple RCT involves giving tional” rehabilitation model was based on Neurorehabilitation research is coming patients daily feedback about their walking static impairments and compensation for, of age. Improvements in outcome measures speed, with encouragement to walk faster, rather than restoration of, function. In the and study design allow new techniques to safely. SIRROWS is the first attempt to de- late 20th century, improved survival from be investigated in the context of random- velop an internationally controlled multicenter acute neurologic injury and an emphasis on ized, controlled, often multi-centered trials trial in neurorehabilitation. T wenty centers, evidence-based practice resulted in improved (RCTs). The EXCITE trial, a study of Con- mostly outside of the US, are involved. RHRI outcome measures and a “neurologic” model straint-Induced Movement Therapy, dem- will soon become a SIRROWS study site. of rehabilitation incorporating pathology and onstrates that multicenter RCTs for rehabili- prognosis. Powerful technologies and greater tation interventions are feasible, and is serv- “MEDIUM TECH” INTERVENTIONS understanding of plasticity present the possi- ing as a model for design of future studies.6 Sensory Enhancement bility of enhancing natural recovery processes The Center for Restorative and Regen- Afferent Corporation (Providence, RI) has and evaluating these techniques. Clinicians erative Medicine (a collaboration of Brown several devices under development. Afferent’s will be able to develop the rehabilitation “holy University and the Providence VA Medical technology involves applying subthreshold grail”: evidence-based patient-specific reha- Center led by Roy Aaron, MD, and John mechanosensory stimuli to affected limbs to bilitation programs using selected techniques Donoghue, PhD), in collaboration with MIT enhance afferent information flow to the brain. at selected times during recovery. and Harvard, is becoming a major center for The premise is that sensory impairment con- such research. Other local entities, including tributes to functional impairment after nervous MECHANISMS OF RECOVERY AND Cyberkinetics, Inc. (Foxboro, MA), Afferent system injury. Improving sensory function THE CONCEPT OF NEUROPLASTICITY Corporation (Providence, RI), and Rehabili- could improve recovery by enhancing plastic- A brief summary of recovery mecha- tation Hospital of Rhode Island (RHRI, ity. Studies show the system to be effective in nisms in stroke with a three-stage model is in- North Smithfield), are at the forefront of these sensory-mediated gait disorders.9 A pilot study, structive. In the first stage, reduction of edema efforts. Some of these investigational interven- using the technology in patients with arm weak- (causing mass effect and metabolic depression) tions are briefly described below. ness after stroke, is being conducted at over days to weeks improves the function of Spaulding Rehabilitation Hospital in Boston. noninfarcted tissue as intercellular commu- “LOW TECH” INTERVENTIONS nication improves. The second and third stages Constraint-Induced Movement “HIGH TECH” INTERVENTIONS of recovery are marked by spontaneous neu- Therapy (CIMT) is based on the concept of Robotics rophysiologic adaptations referred to as neu- “learned nonuse” in monkeys, a behavioral Various robotic devices are being stud- ral plasticity. In the second stage, over weeks suppression in which lack of success with use ied for use in rehabilitation settings. The MIT- 181 VOLUME 91 NO. 5 MAY 2008 MANUS robots, under development over the that detect and decode brain signals, allow- last 15 years at the MIT biomedical engineer- ing control of external devices. The Braingate REFERENCES ing department, are devices designed to pro- (Cyberkinetics, Inc, Foxboro, MA) device, 1. eRehabdata.com and Bazemore, Lisa (eRehab) personal communication 10/17/07. vide consistent doses of intense limb exercise. developed in John Donoghue’s laboratory 2. Dobkin BH. The Clinical Science of Neurologic Reha- They provide decreasing levels of assistance as at Brown University, is an electrode array bilitation, 2nd edn. Oxford University Press, 2003 the patient’s own abilities improve. The devices implanted on the cerebral cortex. A com- 3. Wei L, et al. Collateral growth and angiogenesis also provide kinematic data that measure ef- puter decodes detected signals to determine around cortical stroke. Stroke 2001; 32:2179-84. 4. Kempermann, et al. J Neurosci 2002;22:635-8. fectiveness of the technique and give insight the individual’s intended movements. A pi- 5. Lehmann M, et al. Inactivation of Rho signaling into natural recovery. Initial studies are encour- lot trial with human subjects has demon- pathway promotes CNS axon regeneration. J aging, and demonstrate improved motor func- strated that patients can operate cursors on Neurosci 1999; 19:7537-47. tion in involved limbs which appears to be sus- computer screens with their thoughts,11,12 al- 6. Wolf SL, et al. Effect of CIMT on upper extrem- ity function 3-9 months after stroke. JAMA 2006; tained for years after a therapeutic trial of 4-8 lowing control of external devices such as 296:2095-104. weeks.10 A VA multicenter trial (supervised by televisions and robotic arms. 7. Taub E, et al. Technique to improve chronic motor Albert Lo, MD, PhD, of the Providence VA) A less invasive device, the Wadsworth deficit after stroke. Arch PM&R 1993; 74:347-54. utilizing various versions of MIT-MANUS ro- BCI Home System (Laboratory of Nervous 8. Latham N, et al. Physical therapy during stroke rehabilitation for people with different walking bots for stroke patients is currently underway. System Disorders, The Wadsworth Center, abilities. Arch PM&R 2005; 86:41-50. NY State Dept of Health), uses surface elec- 9. Priplata AA, et al. Noise-enhanced balance con- Treadmill Devices trodes and software to detect and compile trol in patients with diabetes and patients with EEG signals which patients learn to modu- stroke. Ann Neurol 2006;59:4-12. Several devices combining a treadmill 10. Volpe B, et al. Is robot-aided sensorimotor train- with partial-weight-bearing-support have late to select characters on a computer screen. ing in stroke rehabilitation a realistic option? Cur been developed over the last 10 years. The This system has enabled some patients with Op Neurol 2001;14:745-52. Lokomat (Hocoma, Inc., Switzerland) de- ALS and other severely disabling disorders 11. Serruya MD, Hatsopoulos NG, et al. Instant neu- ral control of a movement signal. Nature vice has the added feature of a lower body to communicate and send email. A 2002;14;416:141-2. exoskeleton providing partial assistance for multicenter trial is being planned to better 12. Hochberg LR, Serruya MD, et al. Neuronal en- stepping, and has shown benefit in patients assess the effectiveness and efficacy of this semble control of prosthetic devices by a human with spinal cord injury. Studies of benefit system with ALS patients on a larger scale. with tetraplegia. Nature 2006; 442: 164-71. to patients with stroke have been mixed. Results of the first study of its use in pa- CONCLUSIONS Stephen T. Mernoff, MD is Chief, tients with multiple sclerosis (Albert Lo, Plasticity exists particularly in the post- Neurology Section, Providence VA Medi- MD, PhD) should be available shortly. The injury period, even in the older population. cal Center, Clinical Assistant Professor of Autoambulator, a similar device developed Many possible new treatments are being de- Clinical Neurosciences, The Warren Alpert for HealthSouth, is also being studied. veloped. Particular epochs during the Medical School of Brown University, Di- postinjury period may be windows of oppor- rector, Neurorehabilitation Program, Re- Cortical Stimulation tunity for intervention. Optimization of thera- habilitation Hospital of Rhode Island, and Brain stimulation might enhance neu- pies for different types of patients is a major Diplomate, American Board of Psychiatry ral plasticity. Noninvasive devices (including challenge. Ongoing research will determine and Neurology (Neurolog y). Transcranial Magnetic Stimulation and DC which treatments should be done for which Current Stimulation) designed to stimulate patients, and when. New models of recovery Disclosure of Financial Interests the cerebral cortex during therapy are un- are under development to enable us to capi- The author has no financial inter- der investigation. A multicenter controlled talize on advances in neuroscience and tech- ests to disclose. trial is currently underway to determine if nology to improve rehabilitation outcomes. Discussion(s) of off-label usage of any an epidurally implanted electrode (Northstar Several landmark studies (recent, on- products or services: Several devices de- Neuroscience), providing subthreshold going, and upcoming) are demonstrating scribed in the article are investigational stimulation during physical therapy, en- that neurorehabilitation research is no longer but are approved by the FDA for inves- hances recovery (Spaulding Rehabilitation in the back reaches of anecdotal evidence tigational use: devices by Afferent Hospital in Boston is a participant). and unprovable theories. Both low-tech but Coporation, MIT-MANUS r obot, elegant interventions and sophisticated tech- Locomat, Autoambulator, Northstart Brain-Computer Interfaces nologies clearly have roles in improving the device, Braingate (Cyberkinetics, Inc.), Patients with severe neurologic disabili- functioning of patients with both mild and and Wadsworth BCI Home System. ties usually have some residual muscle func- severe neurologic disabilities, by enhancing tion (finger, eyelid, or eye movements) allow- the nervous system’s natural plasticity. This CORRESPONDENCE ing at least rudimentary communication. goal is a huge challenge, particularly in the Stephen T. Mernoff, MD Some patients (e.g., ALS, brainstem stroke) geriatric population. We now have tech- Providence VA Medical Center, 111N are completely paralyzed despite having nor- niques to perform valid and reliable studies 830 Chalkstone Avenue mal or only mildly impaired cognition of these interventions. Neurorehabilitation Providence, RI 02908 (“locked-in”), resulting in inability to com- is worthy of being considered a medical sub- Phone: (401) 273-7100x3427 municate or influence the environment. specialty subject to the standards of evidence- e-mail: firstname.lastname@example.org Brain-computer interfaces (BCI) are devices based medicine. 182 MEDICINE & HEALTH /RHODE ISLAND RHODE ISLAND DEPARTMENT OF HEALTH • DAVID G IFFORD, MD, MPH, DIRECTOR OF HEALTH E DITED BY JAY S. BUECHNER, PHD The Value Equation: Costs and Quality of Rhode Island’s Health Plans Bruce Cryan, MBA, MS Two health plans, Blue Cross and Blue Shield of Rhode Is- ing, treatment, access, and satisfaction). For definitions of these land (Blue Cross), and United Healthcare of New England measures, see the source report.2 To ascertain relative perfor- (United), provide health coverage to a large majority of Rhode mance, the measures for each plan are compared to the aver- Island (RI) residents who are commercially insured. To assess age of all commercial health plans in New England.3 whether the purchasers of these plans’ products are receiving value, one must necessarily examine its two components, cost and qual- RESULTS ity. For Rhode Islanders to receive good returns from their expen- Of Rhode Island’s 342,000 commercially insured popu- ditures for health insurance, that coverage should be equally or lation, most are covered by two carriers, Blue Cross, with a less expensive and deliver the same or better quality services than 2006 market share of 64.8%, and United, with a share of similar plans elsewhere. Information about how these two plans 14.6%. The remainder of the market (20.6%) consists of a perform is therefore essential to evaluating their relative value. In response to this need for information, the RI General Assembly passed the Health Care Accessibility and Quality Assurance Act in 1996 (Rhode Island General Laws 23- 17.13).1 The Act instituted health plan performance re- porting in the state, which is summarized annually, and most recently in the Rhode Island Health Plans’ Performance Re- port (2006).2 The information presented here is derived from that report. Figure 1. Average health plan premium per member per month, by component, Blue Cross of Rhode Island, United Healthcare of New England, and New England aggregate, 2006. METHODS The Rhode Island Depart- ment of Health’s Center for Health Data and Analysis con- ducts an annual health plan data collection from three primary audited sources: Statutory Filings to the state’s Department of Busi- ness Regulation and Health Plan Employer Data and Information Set (HEDIS) reports and Con- sumer Assessment of Healthcare Providers and Systems (CAHPS) survey data submitted to the Department of Health.3 From these data, 32 mea- sures are evaluated, comprising eight separate dimensions of Figure 2. Health plan member satisfaction with health plan and health care, Blue Cross of performance (enrollment, costs, Rhode Island, United Healthcare of New England, and New England average, 2006. utilization, prevention, screen- 183 VOLUME 91 NO. 5 MAY 2008 measures are worth examination. For example, the low rates of chlamydia screening (Blue Cross: 40%; United: 39%) and antidepressant medication management (Blue Cross: 26%; United: 24%) highlight the need for further improvement in these areas. Proxy measures of whether members per- ceive value in their plans may be obtained from member satisfaction surveys. Member satisfac- tion with Blue Cross’ performance as a health plan was 4 percentage points higher than the regional rate in 2006 (69% versus 65%), while member satisfaction with United was 15 percent- age points below that comparable (50% versus 65%). (Figure 2) There was little difference in members’ satisfaction with their healthcare ser- vices between the two plans and in comparison with the New England rate. Interestingly, re- gardless of geographic area or health insurer, more members were satisfied with their healthcare services than with their health plans. DISCUSSION Increasingly, the public, purchasers, pro- viders, and policymakers are requiring mean- ingful information about health plans. Since 1998, the Department of Health has tracked the performance of this industry and produced annual reports on the subject.2 With the small number of health plans in the state and the market dominance of Blue Cross, most Rhode Islanders have lim- number of smaller plans, none of which are domiciled in Rhode ited choice of carrier. The lack of widespread selective con- Island. [Note that these data include only the insurers’ “fully- tracting also means that most plans deliver services through a insured” members and exclude members of plans where the similar network of physicians, hospitals, and other providers, purchaser (employer) is self-insured.] and the lack of differentiation between the two plans in their On average in 2006, commercial health insurance cost healthcare satisfaction rates bears this out. slightly less in RI than in New England. (Figure 1) Blue Cross’ Therefore, the real value in publishing this information is monthly premiums were 2% lower than regional premiums less in aiding consumer choice and more in fostering account- ($317 vs. $325), and United’s premiums were 6% lower ability of the industry. Purchasers deserve to know how well ($305 vs. $325). In addition, both RI plans spent relatively the plans are performing and policymakers need empirical evi- less on medical services for their members (2% less for Blue dence to inform their efforts. An added benefit is that the Cross and 15% less for United). performance of health plans will likely improve if for no other With few exceptions, both Blue Cross and United gener- reason than the results are made public. ally performed at or below average when their clinical quality measures were compared to the New England values. (Table Bruce Cryan, MBA, MS, is a Health Policy Analyst in the Cen- 1) For Blue Cross, 12 of its 20 quality measures were equiva- ter for Health Data and Analysis, Rhode Island Department of Health. lent to the regional averages, one measure was better, and the remaining seven were worse than these comparables. For Disclosure of Financial Interests United, nine of its 20 quality measures were equivalent to the The author has no financial interests to disclose. regional averages, two measures were better, and the remain- ing nine were worse than these comparables. Given that New REFERENCES England health plans consistently post some of the highest qual- 1. See http://www.rilin.state.ri.us/Statutes/TITLE23/23-17.13/INDEX.HTM. 2. Cryan B. Rhode Island Health Plans’ Performance Report 2006. Providence RI: ity (and satisfaction) scores in the country, this regional com- Rhode Island Department of Health and Office of the Health Insurance Com- parison provides a rigorous benchmark for RI plans. missioner. In press. In addition to an individual plan’s relative performance on 3. For information on the HEDIS and CAHPS programs, see the website of the the clinical measures, the absolute values on some of the clinical National Committee for Quality assurance (NCQA) - http://www.ncqa.org. 184 MEDICINE & HEALTH /RHODE ISLAND DAVID GIFFORD, MD, MPH, DIRECTOR OF HEALTH RHODE ISLAND DEPARTMENT OF HEALTH E DITED BY JOHN P. FULTON, PHD Rhode Island Leads In Regulating Office-Based Cosmetic Surgery Shaun Najarian A recent decision by the Rhode Island Director of Health range of output – and the potential for lasers to do irreparable to close an unlicensed ambulatory surgery center and to sus- harm to a patient if used incorrectly. Thus, in Rhode Island, indi- pend the medical license of the owner underscores the need viduals who wish to perform any of these cosmetic laser surgeries in for the appropriate regulation of cosmetic surgery. an office setting must apply for a special license. In September 2007, the Rhode Island Department of Health In December 2003, the Rhode Island Board of Medical (HEALTH) closed an ambulatory surgery center owned and oper- Licensure and Discipline strengthened its regulatory position ated by a physician licensed in the State of Rhode Island after the on the use of medical lasers with the following decision: Rhode Island Board of Medical Licensure and Discipline (“the Board”) concluded that the owner/operator had performed a vari- 12/15/2003 - Policy statement on office based esthetic ety of cosmetic surgeries in an unlicensed outpatient facility. As well, procedures: the Board concluded that the physician had allowed unqualified It is the position of the Board that office based cosmetic or employees to deliver anesthesia to patients at the facility. esthetic procedures that require the use of medical lasers, high- Public Health is invested in the accreditation, licensure, and frequency radio waves, or injection of sclerosing chemicals or regulation of physicians, surgeons and their facilities. Many states biologically active compounds [e.g. Botulinum toxin A, Botox] are medical procedures. have considered legislation regarding the licensure and regulation of office-based surgery, but few have followed though. At present, Therefore, prior to undergoing such procedures patients must only six states have statutes of this type in place: Rhode Island, Cali- receive a medical evaluation for appropriateness by a licensed fornia, Florida, New Jersey, Pennsylvania, and Texas.1 In Rhode Is- and qualified physician or other practitioner acting within his/her scope of practice. Although these procedures may be land, legislation was passed in 1999 requiring physicians to be spe- performed by an appropriately trained nonphysician working cially licensed by HEALTH in order to perform office-based sur- under the supervision and direction of a physician or other gery, and in 2001, the law was amended, requiring that the facilities practitioner acting within his/her scope of practice, it is the be accredited for Level II and Level III anesthesia (intravenous and supervising physician’s [or other practitioner acting within his/ general) within 24 months of licensure.2 To ensure the highest level her scope of practice] responsibility to assure that procedures of patient safety, all states should consider similar legislation. are conducted appropriately; with appropriate assessment, con- Under Rhode Island law, as specified by “Rules and Regu- sent and follow-up; and upon appropriate patients; and that all patient records are maintained according to standards ap- lations for the Licensure of Physician Ambulatory Surgery Cen- plicable for medical records; and that patient privacy is pro- ters and Podiatry Ambulatory Surgery Centers (R23-17-PASC),” tected. The supervising physician or other practitioner acting surgery is defined as follows: within his/her scope of practice is responsible for any proce- dures carried out by nonphysicians under his/her direction. 1.21 “Surgery” means the excision or resection partial/com- Physicians [or other practitioner acting within his/her scope of plete, destruction, incision or other structural alteration of practice] who perform and supervise such procedures must be human tissue by any means. Surgery shall have the same able to demonstrate appropriate training and experience. Such meaning as “operate.” training and experience may include, but is not limited to, resi- Certain procedures are exempt from R23-17-PASC: dency or fellowship. The physician or other practitioner acting within his/her scope of practice is responsible to assure and docu- 1.8 “Exempt procedures” means: a) Minor surgical proce- ment adequate training for individuals under his/her supervision. dures such as excision of skin lesions, moles, warts, lipomas and repair of lacerations, incision and drainage of superficial Additionally, other cosmetic procedures such as dermabrasion or abscesses, or surgery limited to the skin and subcutaneous the application of potentially scarring chemical treatments [e.g. tissue performed under topical or local anesthesia not in- so-called chemical peels] should also meet this same standard. volving drug induced alteration of consciousness other than [Rhode Island Board of Medical Licensure and Discipline. “Policy minimal pre-operative tranquilization of the patient; b) Pro- statement on office based esthetic procedures.” December 15, cedures not requiring or using conscious sedation techniques or pre-operative medications other than minimal pre-opera- 2003. http://www.health.ri.gov/hsr/bmld/positions.php] tive tranquilization of the patient; c) Procedures requiring or using only local, topical, or no anesthesia.” Despite increased vigilance such as this, office-based laser hair removal remains especially troublesome to regulate All medical laser procedures fall under the aegis of the Rhode throughout the United States. Many unlicensed facilities per- Island statute, including ablative and non-ablative skin rejuvena- form the work, unaware of potential dangers and of existing tion procedures, tattoo removals, treatment of pigmented and vas- safety regulations, e.g., those that limit maximum laser expo- cular lesions, and laser hair removal. The reason for regulating all sure or require eye protection. At least one death in the United medical laser procedures, including laser hair removal, is the sheer States has been attributed to an overdose of anesthetic cream variety (and changing variety) of laser devices – including a wide before laser hair removal.3 185 VOLUME 91 NO. 5 MAY 2008 Several national organizations seek to improve the quality of a service provider may consult HEALTH’s website: http:// of office-based surgical practices: www.health.ri.gov/hsr/professions/license.php. • The American Association for Accreditation of Ambu- REFERENCES latory Surgery Facilities (AAAASF) 1. Lapetina EM, Armstrong EM. Preventing errors in the outpatient setting. • The Accreditation Association for Ambulatory Health Health Affairs 2002; 21: 28. Care (AAAHC) 2. Springer R. An update on office surgical regulations. Plastic Surgical Nurs 2004;24: 172. • The Joint Commission for Accreditation of Healthcare 3. On February 18, 2005, National Public Radio’s (NPR’s), Adam Hochberg dis- Organizations (JCAHO) cussed the dangers of an unregulated laser industry on his show “All Things Consid- ered.” Hochberg reported on the case of a North Carolina woman who died from an The JCAHO recently released safety goals for office-based overdose of anesthetic cream that she applied before her laser treatment in January. surgeries. Despite the best efforts of HEALTH, some health profes- Shaun Najarian is an undergraduate at Providence College sionals may continue to perform cosmetic surgical procedures in who served as an intern for the Rhode Island Department of unlicensed facilities. It is important for healthcare providers Health, Office of Medical Licensure and Discipline. throughout the state to be vigilant for this possibility. At present, in addition to licensed hospitals and licensed freestanding surgi- Disclosure of Financial Interests cal centers, only five “office operatories” are licensed in Rhode The author has no financial interests to disclose. Island. Those who wish to verify the license status of a facility or Point of View Creative and Sensory Therapies Enhance the Lives of People With Alzheimers John Stoukides, MD Today physicians have access to an enormous body of research Although treatment is not available today that can delay or and knowledge regarding the pathophysiology of Alzheimer’s dis- stop the deterioration of brain cells in Alzheimer’s disease, studies ease. Pharmacologic treatment options have also increased signifi- have consistently shown that active medical management of cantly over the past few years. However, pharmacologic treatment Alzheimer’s and other dementias can significantly improve quality is only one part of the overall care plan for improving the quality of of life through all stages of the disease for diagnosed individuals life of patients suffering from Alzheimer’s and related dementias. and their caregivers. Active medical management includes the inte- Long-term care facilities and adult day centers throughout Rhode gration of support services like adult day services that offer creative Island use a variety of creative and sensory therapies to enhance the lives and sensory therapies into the overall treatment plan. of people with Alzheimer’s including aromatherapy and massage; paint- Most of the participants in the Hope Center’s art therapy pro- ing, pottery, sculpting; music and dance; exercise and cooking. gram live at home, where they are cared for by family and friends. The “Memories Fade…Love Inspires” art exhibit, recently held at Even when care is provided at home, most families also seek other the Bellini Ruggeri Gallery in Providence, showcased a collection of sources of help, particular as the disease progresses. As a trusted watercolor paintings and pottery pieces created by participants at the information source for family caregivers, physicians can discuss the Hope Alzheimer’s Center. The cover of this journal features the beau- benefits of choosing an adult day program or long-term care pro- tiful work of Theresa Aiello, a long time participant in the therapeutic vider that offers creative and sensory therapies for people with art program at the Hope Center. Although Theresa, age 91, has had no Alzheimer’s and other forms of memory loss. formal art training, she is able to express herself through vivid color Since opening its doors in 1995, art therapy has been a center- John Stoukides, MD, is Medical Director of the Rhode Island Mood piece of the adult day program at the Hope Center. Through the & Memory Research Institute and Director of Geriatric Medicine at years, the Center has reported seeing many withdrawn and quiet Roger Williams Medical Center. participants begin to engage in lively conversations about a special place or time in their life reflected in the painting. Disclosure of Financial Interests Research conducted in the field of Alzheimer’s shows clear evi- The author has no financial interests to disclose. dence that art therapy is a powerful, nonmedical way to engage minds in the grip of this disease. For people with memory loss, CORRESPONDENCE creative and sensory activities can help: John Stoukides, MD e-mail: email@example.com Promote well being Help maintain skills Aid communication by Enhance relationships using sensory rather Utilize past skills than cognitive pathways Express emotion Facilitate decision making Encourage cooperation Combat depression with others 186 MEDICINE & HEALTH /RHODE ISLAND Physician’s Lexicon The Prefixes of the Past The prefix, particularly when employed pallidus] and Paleocene [the geologic ep- ing the appreciation of vibration, is from for the technical terms such as those which och preceding the Eocene.] Palin-, in the Greek, pallo, meaning to quiver. serve medicine, informs us about the root Greek meaning backwards, appears in The Greek prefix, presby-, meaning ven- of the noun: its size [eg, macro-, micro-,], its words such as palindrome [a word or erable or ancient, is seen in words such as pres- spatial relationship [eg, juxta-, infra-, supra- phrase reading the same backward or for- byopia, presbycusis, an older euphemism for ], as well as an array of attributes to define ward], palingenesis [meaning regeneration deafness, and Presbyterian. The Latin prefix, for us more precisely the modified mean- or rebirth] and palinopsia [a recurrent vi- pretero-, meaning coming before or beyond, ing of the root word. A special group of sual disorder.] appears in words such as preternatural [a syn- prefixes, either Latin or Greek, also tells us The pal- prefix such as in palinopsia, onym for supernatural] and preterition. whether or not the noun is old, ancient, however, can be confusing. Palisade, for Medical terms beginning with the backwards or primitive. These prefixes in- example, is derived from the Latin word, Latin prefixes pro- and pre- are too numer- clude the following: ante-, paleo-, palin-, palus, meaning a stake. Palliation, mean- ous to list. Precocity, for example, is from pre-, presby-, pretero- and proto-. ing to extenuate, to cloak [and, specifically, the Latin praecox, meaning to ripen early, Ante-, Latin signifying before or prior to lessen pain] comes from the Latin, pal- thus explaining the phrase, dementia prae- to, is seen in words such as antecubital and lium, meaning a cloak. Pallid, meaning cox, an older term for schizophrenia. Pre- antenatal [but not antigen or antacid.] ashen or pale, is from the Latin, pallidus, cipitation is from the Latin, praecipitare, Paleo-, from the Greek meaning primitive meaning pale or colorless [as in globus meaning to cast down headlong, and ulti- or ancient, appears in such technical terms pallidus.] Paludism, an archaic name for mately derives from capitus, meaning head. as paleopathology, paleontology, paleo- malaria, is from the Latin, palus, meaning striatum [a synonym for the globus marsh or swamp. And pallesthesia, mean- – STANLEY M. ARONSON, MD RHODE ISLAND DEPARTMENT OF HEALTH D AVID GIFFORD, MD, MPH V I TA L S TAT I S T I C S DIRECTOR OF HEALTH EDITED BY C OLLEEN FONTANA, STATE REGISTRAR Underlying Reporting Period Rhode Island Monthly Cause of Death May 12 Months Ending with May 2007 2007 Vital Statistics Report Number (a) Number (a) Rates (b) YPLL (c) Provisional Occurrence Diseases of the Heart 223 2,730 255.2 3,601.5 Malignant Neoplasms 201 2,261 211.4 6,077.5 Data from the Cerebrovascular Diseases 36 388 36.3 562.0 Division of Vital Records Injuries (Accidents/Suicide/Homicde) 43 565 52.8 9,003.0 COPD 50 434 40.6 392.5 Reporting Period (a) Cause of death statistics were derived from Vital Events November 12 Months Ending with the underlying cause of death reported by physicians on death certificates. 2007 November 2007 (b) Rates per 100,000 estimated population of Number Number Rates 1,067,610 Live Births 942 13,521 12.7 * Deaths 826 9,943 9.3* (c) Years of Potential Life Lost (YPLL) Infant Deaths (9) (108) 8.0# Neonatal Deaths (6) (74) 5.5# Note: Totals represent vital events which occurred in Rhode Marriages 394 6,879 6.4* Island for the reporting periods listed above. Monthly pro- Divorces 187 3,026 2.8* visional totals should be analyzed with caution because the numbers may be small and subject to seasonal variation. Induced Terminations 386 4,919 363.8# Spontaneous Fetal Deaths 49 994 73.5# * Rates per 1,000 estimated population Under 20 weeks gestation (45) (920) 68.0# # Rates per 1,000 live births 20+ weeks gestation (4) (74) 5.5# 187 VOLUME 91 NO. 5 MAY 2008 The Official Organ of the Rhode Island Medical Society Issued Monthly under the direction of the Publications Committee VOLUME 1 PER YEAR $2.00 NUMBER 1 PROVIDENCE, R.I., JANUARY, 1917 SINGLE COPY, 25 CENTS NINETY YEARS AGO, MAY, 1918 FIFTY YEARS AGO, MAY 1958 Frank J. McCabe, MD, in “Eye Strain as Related to Gen- Eugene T. Lothgren, MBA, general agent, Northwestern eral Practice,” discussed types of asthenopia: accommodative, Mutual Life Insurance Company, contributed “Tax Savings in “due to errors of refraction and to strain of the…muscle;” Estate Planning for Physicians.” He urged: “action is essential muscular, “due to an abnormal condition of the…muscles of to security and peace of mind.” the eye;: nervous, “due to some faulty condition of the nervous The Division of Vital Statistics of the Rhode Island De- system;” and reflex, “due to abnormalities in the organism out- partment of Health contributed “Acute Poliomyelitis in Rhode side of the eye and the nervous system.” Accommodative strains Island, 1948-57.” Many Americans, including Rhode Island- were the most common. ers, were not yet vaccinated. “Unless there is a speedup in the Frederick V. Hussey, MD, in “A Review of 100 Consecu- polio vaccination program it is the opinion of the Surgeon Gen- tive Cases of Acute Diseases of the Appendix, Gall Bladder, eral, Leroy E. Burney, that serious outbreaks of poliomyelitis Duodenal and Gastric Ulcers Which Have Come to Opera- could occur this summer.” The State traced wide fluctuations tion,” faulted general physicians’ “lack of courage – reluctance in incidence: in 1948, 8 cases; in 1949, 157 cases; in 1950, 55 to advise radical measures in the beginning, without first try- cases; in 1951, 15 cases. The toll rose to 295 in 1953, dropped ing out some of the older methods of treatment, which brings to 123 in 1954, peaked at 421 in 1955. his patient into an extreme condition.” The author conceded Robert W. Hyde, MD, in “Butler Health Center Today,” that often patients wanted to avoid surgery. Of 46 cases of acute described the 1957 reorganization of Butler Hospital into a gangrenous appendicitis, all drained, three died; the average Health Center, with outpatient and day services. hospital length of stay for those patients was 3 weeks. David S. Liang, MD, and Asdrubal De Carvalho, MD, in In a War Department memo, the Office of the Surgeon “Leiomyoma of the Prostate,” described an 87 year-old man, General, Washington, reminded physicians of the rule forbid- admitted to Joseph’s with “painful gross hematuria for 2 days.” ding publication of professional papers related to official Surgeons found and removed an intravesical tumor. records or military service, without permission. Bencel L. Schiff, MD, in “Dermatitis from Acetozolamide An editorial, “Illegal Operations,” described the case of a (Diamox),” discussed the case of a 45 year-old woman who woman recently convicted of an “illegal operation.” “The had been given 250 mg daily for treatment of glaucoma, and woman had enjoyed a lucrative clientele for some time, pursu- the case of a 57 year-old man, treated for hypertension and left ing her work in a respectable residential section of Providence.” ventricular failure. The editor assumed that this was the first case of a woman con- victed in Rhode Island for the “crime of performing abortions, TWENTY-FIVE YEARS AGO, MAY 1983 and, furthermore, … the conviction did not depend upon the Carl H. Critz, MD, W. Martin DeLuca, PA, and Arun K. death of the unfortunate patient.” The editorial congratulated Singh, MD, in “Iatrogenic Extra-Corporeal Hemolysis during both the police and the Attorney General. “…decent public Cardiac Surgery in a Child: A Case Report,” postulated “shear- opinion cannot fail to approve of the outcome.” stress in transfusion filter as the cause of the hemolysis.” A four year-old girl had been admitted to Rhode Island Hospital for surgical correction of both an atrial septal defect and pulmo- nary valvular stenosis. Frank Newman, PhD, President, The University of Rhode Island, delivered the 1982 Fiorindo A. Simeone oration at The Miriam Hospital: “Notes from Underground.” His subject was the anatomy of recovery. He detailed his experience of hospi- talization, including “coping with fear,” and “role of the self in healing.” A.J. Migliaccio, MD, FACS, and A.V. Migliaccio, MD, FACS, contributed “The Use of a Feeding Gastrostomy as a Means of Preventing Staple Line Disruption in Gastric Opera- tions for Morbid Obesity.” 188 MEDICINE & HEALTH /RHODE ISLAND integrity whatdrivesyou? Whatever it is that sustains you through the daily challenges of your profession, know that you have an ally in NORCAL. (800) 652-1051 ● www.norcalmutual.com Call RIMS Insurance Brokerage Corporation at (401) 272-1050 to purchase NORCAL coverage.
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