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This chapter addresses the following Geriatric Fellowship Curriculum Milestones: #16, #52, #55, #58

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LEARNING OBJECTIVES

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Learning Objectives

  • Learn about normal neurologic aging and aging-associated changes in neurologic examination.

  • Recognize the significance of focused history taking and accurate bedside techniques to examine older adults with neurologic diseases.

  • Understand the rationale and learn new skills to assess mental status, memory, attention, orientation, visuospatial, language, and executive function in the older population.

  • Learn correct ways to examine cranial nerves, motor and sensory system, coordination, gait, and higher cortical functions in older adults.

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Key Clinical Points

  1. An extensor plantar response is not a normal aging-associated change and is always associated with some pathology in the upper motor neuron.

  2. Comprehensive mental status examination includes observational, cognitive, functional, and neuropsychiatric evaluations.

  3. Altered level of alertness is always associated with cognitive deficits and an underlying medical illness that is almost always treatable.

  4. Language assessment involves evaluation of all aspects of communication, including spontaneous speech, comprehension, repetition, naming, reading, and writing.

  5. Reduced hearing for high-pitched sounds and lack of perception of background noise are common findings in older adults and do not suggest a pathologic finding.

  6. Mild muscular wasting without weakness or focal neurologic signs can be encountered in normal aging and commonly affect hand and foot muscles, calf, and shoulder girdle muscles.

  7. Ocular motility is commonly limited in older adults and can exhibit restricted convergence and limitation of conjugate upward gaze.

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THE NEUROLOGY OF AGING

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What Is Normal Neurologic Aging

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The diagnosis of neurologic disease in the older adult requires recognition not only of abnormal signs and symptoms but also an understanding of what changes are expected as part of the normal aging process. To distinguish neurologic dysfunction related to disease from the neurologic changes associated with normal aging, the clinician must conduct a comprehensive mental status and neurologic examination. When establishing a neurologic diagnosis, the clinical history (ie, history of the present illness, past medical history, social habits, occupational experience, family illness and disorders) assists the clinician in generating a differential diagnosis that can be further explored and refined by pertinent observations documented on the mental status and neurologic examinations. The mental status assessment should evaluate cognition, emotion, and behavior. Because cognitive and affective disorders occur commonly in older adults, historical information should be obtained not only from the patient but a reliable informant such as the spouse, adult child, or caregiver. The neurologic examination should be performed on all older adults regardless of the chief complaint as up to 60% of older patients have either a primary or secondary neurologic sign or symptom. A complete mental status and neurologic examination provides the necessary data to develop reasonable diagnostic hypotheses and drive the necessary laboratory, imaging, or specialized assessments to care for the patient.

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Age-Related Changes in the Neurologic Examination

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Before discussion ...

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