Neuromuscular Diseases in Geriatric Patients: Part I

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Citation:

Pages 17 - 24

Authors:

Evelyn Gleeson, MB BCh, and Leslie Wolfson, MD

Most biologic capabilities decline with age, although the extent of the decrements are usually modest and vary by function. Cross-sectional studies show that strength declines by approximately 30% from the third through eighth decades and that sensory changes, while difficult to measure, are comparable.1 The effects of disease are superimposed on age-related decreases often resulting in significant functional impairment. Many neuromuscular diseases are uncommon in older persons. This two-part article will focus on the conditions that occur with regularity in older persons or have a striking effect on their lives. Part I discusses cervical spondylotic radiculomyelopathy, lumbar spondylosis, amyotrophic lateral sclerosis (ALS), Guillain-Barré syndrome (GBS), and acquired demyelinating polyneuropathies. Part II, which will be published in the next issue of the Journal, will focus on myasthenia gravis, inclusion body myositis, polymyositis, and polymyalgia rheumatica.

The signature manifestation of neuromuscular disease is weakness with a loss of the function that it supports. Lower-extremity weakness impairs mobility, while weakness of the upper extremities may compromise activities of daily living (ADL) or instrumental activities of daily living (IADL), requiring use of the arms and/or hands. Evaluation of strength with manual motor testing in older persons is problematic for inexperienced clinicians because of age-related strength decrements and as a consequence of variability due to activity level and gender. To assist in interpretation of manual motor testing, comparison of muscles may serve as a framework for loss of strength in specific muscles (eg, right against left or distal vs proximal). Due to these problems, functional testing of the motor system is useful for assessing strength. Functional testing should include the following:

1. Arising from chair without use of arms. Lift-off requires strength of knee and hip extensors, while balance is required to control center of mass as it moves forward (about 24 in) from sitting position to being supported by lower extremities. If patient cannot arise, then allow use of arms to determine if lift (proximal strength), steadying (balance), or both are provided by upper extremities. Examiner may either hold both hands to determine role of upper extremity or estimate force exerted on chair’s arms. Weakness can be confirmed by manual motor testing of glutei and quadriceps, while balance will be tested by other functional testing.

2. Performing one- or two-leg heel and toe rises. Depending on age and frailty, this requires dorsi and plantar extension strength. Provide support by holding both of patient’s hands. Ask patient to lift (suspend) one leg and while providing support by holding both hands, ask him/her to lean forward, lifting up onto the toes, and then rocking backward onto the heel, lifting forefoot from ground. Perform on other lower extremity. If unable to perform on one leg, have the patient do it on both. Inability to go up onto toes indicates weakness of plantar flexion (gastrocnemius), while failure to rock backward onto heels suggests weakness of dorsiflexors (tibialis anterior). The extent of steadying required through support of the arms provides some indication of balance.

3. Performing single, tandem, or semi-tandem stance. This requires strength but primarily tests balance. Single or tandem (toe-to-toe) stance time for a healthy 80-year-old is 10 seconds or more, with lower times suggesting mild balance impairment. Ability to maintain balance only with feet together (side-by-side) suggests moderate impairment, and inability to maintain this stance indicates a more severe problem.

4. Testing balance using forward, backward, and side pulls. Examiner should pull patient toward him/herself to use his/her body to check motion before patient loses control of his/her body mass.

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