Assessing Fatigue and Balance Issues in an 85-Year-Old: Possible Neurological Concerns

An 85-year-old father experiences easy fatigue, unsteady gait with shuffling steps, and nighttime finger numbness. His physical strength has declined significantly over the past six months. What kind of examinations should be conducted?

An 85-year-old father has experienced a stair-step decline in physical strength over the past six months, with no history of hypertension or diabetes.
He is currently taking medication for dry syndrome (NOOTROPIL), white matter changes (GENIQUIN), mild lower limb venous obstruction (COFARIN), and gout.
There is a family history of hyperthyroidism and autoimmune diseases such as vitiligo.

His sleep pattern is from 8:00 PM to 3:00 AM, and his blood pressure typically ranges from 135 to 145; during times of inflammation, illness, or high temperature, it can rise to 148-158.
His recent hospitalization history includes three episodes of sudden unilateral paralysis since 2008, diagnosed as non-bacterial viral encephalitis (January 2009, February 2014, August 2016).
During the first hospitalization at age 75 in 2008, he was found to have white matter changes and began a regular medication regimen.
After the third episode in 2016, he underwent immunological evaluation and continued medication.

In May 2019, he accidentally swallowed a 5 cm fish bone, which led to abdominal pain and an emergency small bowel resection three days later.
In October 2019, he developed cellulitis due to onychomycosis of the left foot.

Current symptoms include:
1.
Fatigue and instability starting in April 2019, with noticeable fatigue beginning around noon.
His walking distance and time in the morning have decreased to half or two-thirds of what they were six months ago (20-25 minutes).
2.
Short strides (20-25 cm normally, 10-15 cm when fatigued) and reduced grip strength in his feet, often feeling that his slippers stick to the floor.
He can walk steadily indoors for about 10 minutes but struggles to maintain balance outdoors for even 5 minutes, quickly expressing fatigue; getting up from a car is difficult, and he feels weak when trying to rise from the floor.
3.
Increased sensitivity to heat; high temperatures or feelings of warmth lead to severe cognitive and mobility decline, dizziness, irritability, and occasional slurred speech.
In June 2019, he experienced a heat allergy with itching on his back.
4.
Numbness and stiffness in his fingers at night, sometimes lasting into the day.
5.
Frequent urination, needing to use the restroom every 30 minutes now, compared to 50-60 minutes a year ago.
He underwent prostate surgery ten years ago and reports needing to urinate twice, which he attributes to aging.
6.
Feelings of fear and anxiety when alone, with emotional outbursts every 3-4 months related to feelings of neglect or being undervalued, possibly indicating depressive symptoms due to significant instability in walking and cognitive changes related to fatigue and temperature perception.
What examinations do you recommend? Is there a possibility of peripheral neuropathy or multiple sclerosis? Would you suggest a visit to an integrative clinic? I look forward to your response.
Thank you!

Chen, 30~39 year old female. Ask Date: 2019/10/29

Dr. Jiang Junyi reply Neurology

Hello,
Your father, due to his advanced age, is experiencing several degenerative diseases.
First, I would like to correct the medications you mentioned.
They should be GENIQUIN for dry syndrome and NOOTROPIL for cerebral white matter issues.
You noted that over the past six months, he has shown significant instability while walking, with a short stride and occasional forward leaning that leads to falls.
His cognitive function seems to fluctuate due to fatigue or self-perceived temperature changes.

What examinations do you recommend? I suggest conducting brain imaging studies to clarify the presence of conditions such as hydrocephalus or Parkinson's disease.
Is there a possibility of peripheral neuropathy or multiple sclerosis? I recommend performing neurophysiological tests to clarify any peripheral nerve disorders.

Regarding multiple sclerosis, it typically occurs in younger women.
Would you recommend a visit to an integrative clinic? Consider consulting with a geriatric medicine integrative clinic or a neurology department.

Wishing you good health and peace.

Dr.
Jiang, Neurology Department, Taoyuan Medical Center.

Reply Date: 2019/10/29

More Info

Assessing fatigue and balance issues in an elderly individual, particularly an 85-year-old, requires a comprehensive understanding of various potential neurological concerns. Given your father's complex medical history, including previous strokes, medication use, and recent symptoms, it is crucial to approach this situation with a thorough evaluation.

Possible Neurological Concerns
1. Cerebrovascular Issues: Your father's history of transient ischemic attacks (TIAs) or strokes (as indicated by his previous episodes of hemiplegia) raises concerns about ongoing cerebrovascular health. The fatigue and balance issues may be linked to insufficient blood flow to the brain, which can result in cognitive decline and physical instability.

2. White Matter Changes: The diagnosis of "white matter changes" suggests underlying vascular dementia or other forms of cognitive impairment. These changes can affect balance and coordination, leading to increased fall risk and fatigue.

3. Peripheral Neuropathy: Symptoms such as foot dragging and difficulty in maintaining balance may indicate peripheral neuropathy, which can be caused by various factors, including diabetes, vitamin deficiencies, or medication side effects. Given your father's medication regimen, it is essential to evaluate whether any of these drugs could contribute to peripheral nerve damage.

4. Multiple Sclerosis (MS): While MS is less common in older adults, it can present with fatigue, balance issues, and cognitive changes. The episodic nature of your father's symptoms could suggest a demyelinating process, which warrants further investigation.

5. Medication Side Effects: The medications your father is taking, including Nootropil and Geniquin, may have side effects that contribute to fatigue and cognitive changes. It is essential to review these medications with a healthcare provider to determine if adjustments are necessary.

Recommended Evaluations
1. Neurological Examination: A thorough neurological assessment by a neurologist is crucial. This should include a detailed history, physical examination, and cognitive testing to evaluate the extent of any cognitive impairment.

2. Imaging Studies: MRI or CT scans of the brain can help assess for ongoing vascular changes, white matter lesions, or other structural abnormalities that may explain the symptoms.

3. Electromyography (EMG) and Nerve Conduction Studies: These tests can help evaluate for peripheral neuropathy, assessing the function of the peripheral nerves and muscles.

4. Blood Tests: Comprehensive blood work should include tests for vitamin deficiencies (such as B12), thyroid function, and metabolic panels to rule out any systemic causes of fatigue and cognitive decline.

5. Psychiatric Evaluation: Given the reported anxiety, fear, and possible depressive symptoms, a psychiatric evaluation may be beneficial. Addressing mental health is crucial in managing overall well-being in elderly patients.

Management Strategies
1. Physical Therapy: Engaging in physical therapy can help improve balance, strength, and mobility. A tailored exercise program can significantly enhance functional independence and reduce fall risk.

2. Medication Review: Regularly reviewing medications with a healthcare provider can help identify any that may be contributing to fatigue or cognitive decline. Adjustments or alternatives may be necessary.

3. Cognitive Support: Cognitive training exercises and activities that stimulate mental engagement can help maintain cognitive function and potentially slow decline.

4. Environmental Modifications: Ensuring a safe living environment with adequate support systems can help mitigate fall risks and enhance your father's quality of life.

5. Regular Follow-ups: Continuous monitoring and follow-up appointments with healthcare providers are essential to adapt the care plan as needed.

Conclusion
Your father's symptoms warrant a multifaceted approach involving neurological assessment, imaging, and possibly psychiatric evaluation. Given the complexity of his medical history, an integrated care approach involving specialists in neurology, geriatrics, and psychiatry may provide the best outcomes. Early intervention and tailored management strategies can significantly improve his quality of life and functional abilities.

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