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© Borgis - Postępy Nauk Medycznych 4/2010, s. 322-323
Dramatic increases of life expectancy in the developed countries have resulted in unprecedented numbers and proportions of older adults in the population. In Poland problem of growing population of people over 65 is still not known as a real danger for economic and health service. The need for existence of special geriatric wards (or even neurogeriatric) as a place to treat very old people with their illnesses is not fully understood in our country. Even so, we prove as I hope, in our journal that clinical picture of many so called typical neurological diseases in old age are different, and we also need to emphasize that as neurologists we do have manage neurological diseases in our old patients in different, peculiar way. For example even sclerosis multiplex could be different in old population. However the term late-onset multiple sclerosis is defined as appearing of the first symptoms suggesting MS in the age over 50. This type of diagnosis is made in 4-9,6% cases. The progression of disease and disability progression in the late-onset MS is usually quicker, and the prognosis is worse. The Late onset MS usually is the big diagnostic problem, and in process of establishing the proper diagnosis detailed differential diagnosis in necessary, which take into account vascular pathology of the brain and spinal core, compressive myelopathies, pathologies connected with arterial hypertension, and the metabolic diseases, vasculitis, degenerative and deficiency syndromes. SM in old population is rather rare for the other hand stroke is very typical in that period of life.Most of strokes will occur in the elderly population. Apart from age, the most important stroke risk factor, substantial impact on stroke incidence have widespread of hypertension, diabetes and obesity. Increase stroke incidence in elderly is also caused by increase frequency of cardiovascular changes. Different course of stroke in the elderly is determined by poorer cardiovascular response, multiple organ dysfunction, multiple medications consumption and presence of other neurological conditions. In the end the course of stroke is more severe, there are more complications and more adverse events connected to pharmacotherapy. Moreover there are more complications due to bedridden state. Early mortality in the stroke patients over 85 years old is twofold bigger as in younger patients. Additionally functional state is significantly worse in the elderly patients after stroke and institutional care is more often needed.
Inability of routine intravenous thrombolysis in patients over 80 years old is the most important difference in acute stroke management in the elderly patients. Very seldom disease in general population as sporadic CJD is mostly a disease of the elderly (around 65 years old), however, the number of deaths in persons over age 70 and higher is gradually rising. Even so CJD (sCJD) is a relatively rare disease in the elderly that resembles CJD in younger age groups. Alzheimers disease and Dementia with Lewy Bodies are likely clinical differentials, and autopsy is required to confirm the diagnosis and to allow subclassification of sCJD. The literature on the subject of this review is very limited The Polish data are very interesting in this respect: there are 6 of 30 cases of sCJD over 70 (20%); the 129 codon data are available for 3, 2 x MM, 1 x MV. From clinical point of view seizures were stressed as signs perhaps overrepresented in elderly sCJD patients. However still CJD is not very common in our old age cohort of patients our next problem discussed in that journal as depression is almost typical for them especially as e result of vascular disorders. Depression very often is tied up to coronary heart disease, and its vascular consequences, and also is an independent risk factor of stroke. Hypothesis of vascular depression is trying to combine all important risk factors, as heart diseases, vascular disease, diabetes, hyperlipidemia with its consequences in brain. Damage of small brain vessels disturb neurotransmitter systems, especially in fronto-subcortical circuit initiating inflammatory cascade, which shows on clinical level as subcortical depression. In different hypotheses regarding post-stroke depression polymorphism in transporter serotonin gene, serotoninergic dysfunction and localization, i.e. left frontal lobe seems to be important. Vascular and post-stroke depressions are characterized by chronic course, treatment resistance and higher rate of mortality. In therapy several approaches simultaneously should be implemented: treatment of comorbid physical diseases, antidepressants and psychotherapy. Safe and effective drugs in vascular and post-stroke depressions include serotoninergic and dopaminergic reuptake inhibitors. Among group very old patients we as a neurologists do have manage with essential tremor (ET) presenting more and more often. Symptoms of ET become more severe in older patients leading to a marked disability. Clinical features of ET among postural and kinetic tremor are ataxia, gait disturbances, oculomotor signs and cognitive deficits. Late onset essential tremor is usually more rapidly progressive and multisymptomatic. Pharmacotherapy and surgical treatment of ET has substantial limitations in older people. As depression also extrapyramidal symptoms could be caused by atherosclerosis widely distributed in old age population. However Vascular parkinsonism (VaP for nearly 80 years, has remained one of the most controversial entities in neurology. Since its first description by Critchley in 1920, introducing the term' artheriosclerotic parkinsonism', nomenclature of this clinically heterogeneous disorder had been evolving till 1980, when the term VaP was finally accepted. In terms of management, similarly to other disorders secondary to vascular pathology, the greatest emphasis is still put on prophylaxis, as symptomatic treatment options are limited. The last problem which we presented in this neurogeriatric journal is very dramatic and often not properly diagnosed: delirium. Delirium is a complex neuropsychiatric syndrome that is common in the elderly, especially those with pre-existing brain disorders. Urgent alteration in cognition as well as inattention are a key to improve detection. Underrecognition of the syndrome and poor understanding of the underlying disorders cause misdiagnosing depression or dementia. It requires a careful differential diagnosis for its underlying causes. Delirium is potentially preventable and treatable, although can result in long-term cognitive changes.
We presented in our neurogeriatric journal some, as we believe most important and interesting diseases of old age which are usually treated in neurological outpatients and inpatients wards. However as we do have some problems still not discussed, we will decided to prepare next part and we will publish them in june this year.
Maria Barcikowska, Zespół Kliniczno-Badawczy Chorób Zwyrodnieniowych CUN, IMDiK PAN im. Mirosława Mossakowskiego
Postępy Nauk Medycznych 4/2010
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