Neuromuscular

Disorders in Geriatric
Patients

Introduction
Neuromuscular disorders affect the nerves that
control your voluntary muscles. Voluntary muscles
are the ones you can control, like in your arms and
legs. Your nerve cells, also called neurons, send
the messages that control these muscles. When
the neurons become unhealthy or die,
communication between your nervous system and
muscles breaks down. As a result, your muscles
weaken and waste away. The weakness can lead to
twitching, cramps, aches and pains, and joint and
movement problems. Sometimes it also affects
heart function and your ability to breathe.

 There is too many causes for Neuromuscular Disorders

for geriatric patients like
Parkinson disease,
cervical spondylotic radiculomyelopathy,
lumbar spondylosis,
amyotrophic lateral sclerosis,
Guillain-Barr syndrome,
acquired demyelinating polyneuropathies,
myasthenia gravis,
inclusion body myositis,
polymyositis,
Huntington's disease
and polymyalgia rheumatica.

 In this presentation we will focus on

Parkinson disease
Cervical Spondylotic Radiculomyelopathy
Inclusion Body Myositis
Polymyalgia Rheumatica

1-Inclusion Body Myositis

it is an inflammatory disease, characterized
by slowly progressive weakness and
wasting of both distal and proximal
muscles,
produces progressive limb weakness over
years; the median time from onset to
diagnosis is 6 years. It is the most common
acquired myopathy in those over the age of
50 years, affecting more males than
females.

characteristics
Phenotype is weakness and atrophy of
wrist and finger flexors, quadriceps, and
foreleg muscles
instability of gait (especially when
descending stairs)
reduced grip strength
Dysphagia is present in 40%and facial
weakness in one-third.
myocardial involvement is not observed,
nor is there increased risk of malignancy.

treatment
Unfortunately, there is no effective drug therapy
Supportive treatment with physical and occupational
therapy, assistive walking devices/wheelchairs,
cricopharyngeal myotomy43 for severe dysphagia, and
patient support groups help improve quality of life for
these patients. Patients with later-onset (60-79 yr)
disease progress more rapidly, requiring a walker in 6
years as compared to those with earlier-onset (40-59
yr) disease, who take 10 years to require a walker.
There has been a recent report of a novel agent for
IBM treatment,Bimagrumab, which is still under study.

2-Cervical Spondylotic
Radiculomyelopathy
Wear and tear of the cervical spine leads to deterioration of
intervertebral disks with subsequent overgrowth of surrounding
bone, ligaments, and supporting elements.
This excessive tissue growth leads to compression of the spinal
cord and/or cervical nerve roots resulting in myelopathy or
radiculopathy, which rarely occur together.
Radiologic manifestations of cervical spondylosis increase with
age, occurring in 10% of persons in the third decade, 50% of
those in the fifth decade, and more than 90% of individuals in
the seventh decade.2 Despite the presence of prominent
radiologic abnormalities, the vast majority of older persons do
not have clinical manifestations of the radiculopathy or
myelopathy, making it challenging at times to distinguish
patients with symptomatic cervical spondylosis from those
whose symptoms are due to another process.

Symptoms
Localized neck pain and stiffness are characteristic, although shoulder
and upper arm aching or stabbing pain also frequently occur.
By contrast, lancinating radicular pain is less common.
Slowly progressive gait impairment is the hallmark of the myelopathy
but urinary symptoms are unusual.
Nonspecific numbness and paresthesias of the upper and/or lower
extremities are often encountered, but sensory loss is uncommon or
nonspecific (eg, diminished vibration perception at ankles). A narrowbased stiff gait, increased tone, and reflexes with Babinski signs indicate
the presence of corticospinal tract dysfunction.
The common sites for spondylotic overgrowth that damage the spinal
cord are at the C5-6 and C6-7 intervertebral spaces, so motor signs and
symptoms may be present in the hands (ie, clumsiness, weakness). If the
spondylotic overgrowth has a major lateral component, root compromise
may occur, producing weakness and muscle atrophy localized to a nerve
root distribution. Narrowing may occur at one or more levels.

Treatment
Treatment is usually conservative in nature.
Patient education on lifestyle modifications
and nonsteroidal anti-inflammatory drugs
(NSAIDs) and physical therapy have been
shown to manage such conditions
current surgical techniques are geared
toward correcting the mechanism of cord
injury with the use of posterior or anterior
decompression depending on site(s) of
spondylotic damage.

Polymyalgia Rheumatica
Polymyalgia rheumatica (PMR) is a relatively
common chronic inflammatory condition that
affects elderly individuals.
It is characterized by proximal myalgia of the hip
and shoulder girdles with accompanying morning
stiffness that lasts for more than 1 hour.
Approximately 15% of patients with PMR develop
giant cell arteritis (GCA), and 40-50% of patients
with GCA have associated PMR. Despite the
similarities of age at onset and some of the clinical
manifestations, the relationship between GCA and
PMR is not yet clearly established.

Treatment
Prednisoneis the drug of choice for PMRand treatment duration is
frequently greater than one year.If the patient does not experience
dramatic improvement after three days of 1020mg oral prednisone
per day, the diagnosis should be reconsidered.Sometimes relief of
symptoms occurs in only several hours.
Nonsteroidal anti-inflammatory drugs (NSAIDs) such asibuprofenare
ineffective in the initial treatment of PMR,but they may be used in
conjunction with the maintenance dose of corticosteroid.
Along with medical treatment, patients are encouraged to exercise
and eat healthily.Exercisewill help strengthen the weak muscles,
and help to prevent weight gain. A healthy diet will help to keep a
strong immune system, and also help build strong muscles and
bones.Patients are encouraged to eat a diet of fruits, vegetables,
whole grains, and low-fat meat and dairy products, avoiding foods
with high levels of refined sugars and salt.

Parkinson's Disease
Parkinson disease is recognized as one of the most
common neurologic disorders, affecting approximately 1%
of individuals older than 60 years.
Parkinson's disease (PD) is a chronic and progressive
movement disorder, meaning that symptoms continue and
worsen over time.
Parkinsons involves the malfunction and death of vital
nerve cells in the brain, called neurons. Parkinson's
primarily affects neurons in an area of the brain called
thesubstantia nigra. Some of these dying neurons
producedopamine, a chemical that sends messages to the
part of the brain that controls movement and coordination.
As PD progresses, the amount of dopamine produced in the
brain decreases, leaving a person unable to control
movement normally.

Signs and symptoms

Tremor :
Although tremor is the most common initial symptom in
Parkinson disease, occurring in approximately 70% of patients,
it does not have to be present to make the diagnosis.
Bradykinesia :
Bradykinesia refers to slowness of movement.
Rigidity :
Some patients may describe stiffness in the limbs, but this
may reflect bradykinesia more than rigidity

postural instability or impaired balance and

coordination

Treatment

Carbidopa/Levodopa -The most potent medication for Parkinsons is

levodopa. It is now combined with carbidopa to prevent this side effect.
Dopamine agonistsare drugs that stimulate the parts of the human
brain influenced by dopamine. In effect, the brain is tricked into thinking it
is receiving the dopamine it needs. In general, dopamine agonists are not
as potent as carbidopa/levodopa, and therefore are less likely to cause
dyskinesias. Dopamine agonists can be taken alone or in combination with
medications containing levodopa.
AnticholinergicsAnticholinergics can be helpful fortremorand may ease
dystonia associated with wearing-off or peak-dose effect. They have little
effect on other symptoms of Parkinsons.
MAO-B inhibitors selegiline block an enzyme in the brain that breaks
down levodopa. These drugs have a modest effect in suppressing the
symptoms of Parkinsons.
COMT inhibitors entacapone (Comtan) represent the newest class of
Parkinson's medications. These agents have no direct effect on PD
symptoms, but instead are used to prolong the effect of levodopa by
blocking its metabolism. COMT inhibitors are used primarily to help with
the problem of wearing-off, in which the effect of levodopa becomes shortlived.
Other medicationssuch as amantadine (Symmetrel) is a mild agent that
is used in early Parkinsons disease to help tremor. In recent years,