and seen whenever possible. Most often the
patient reports with strokes, seizures and dementia. The physical
disability and physical problems such as dressing, shaving,
climbing stairs etc., sample of speech and writing should
In general examination, the pulse in all
peripheral vessels must be felt. For every cerebral vessel
blocked, 2 coronaries and 4 peripheral vessels are blocked.
Palpate the skin and scalp, palpate the tongue in all cases
of wasting to differentiate from malignancy. Tremors, bradykenesia
must be recorded. Respiratory rate is important; hypopnea
is often missed.
The routine neurological examination is time-consuming.
In the crowded out-patient department of the PHC, the neurological
patient is to be seen last. A routine methodical testing is
essential. Assessment of mental function is very important
in the elderly. The level of alertness of the patient must
be ascertained, attention and orientation must be assessed.
Atleast one verbal and one non-verbal test for memory must
be administered. Insight into the illness is enquired for.
To test right brain function, spatial orientation must be
tested: e.g., the direction of the patient's village, the
direction of the nearest city and an important nearby landmark.
Left brain function can be assessed by finding out whether
propositional speech is present by asking the patient to give
an account of himself. Assess for apraxia and agnosia. These
are essential to identify early cases of dementia.
Cerebrovascular disorder is never diagnosed
on the basis of a single symptom. It is observed that transient
attacks cause stroke in 50% of individuals within 2 to 3 months.
The territories are usually carotid and basilar arteries.
Electrocardiography is a must in all cases. Bruits in the
neck generally indicate an arterial disease. However bruits
do not signify much in the elderly.
The commonest cause of syncope in old age
is cardiac and not neurological. Car-diogenic neurological
problems are generalised and they recover when blood pressure
is reestablished. Syncope never produces focal neurological
deficit. In a case of syncope, the blood pressure has to be
correlated with fall in blood pressure and cardiac arrest.
The patient should be allowed to lie down as lying increases
blood pressure, pulse rate and enhances blood supply. Carotid
sinus sensitivity can be diagnosed when patient gives history
of syncope on shaving, moving the neck etc. Atropine ½
tablet checks the attacks. Micturition syncope, cough syncope
and anoxia can cause fits.
Headache in the elderly is due to (i) hypertension
(ii) vasodilation (iii) tension headache and (iv) collagen
diseases. It is said that migraine and bronchial asthma should
not be diagnosed first time during one's life in old age.
Though collagen disease is rare it is to be remembered that
steroid therapy is a fruitful mode of therapy in such cases.
Increased intracranial tension slows the pulse. Tumors cause
headache, fits and confusion. Acute confusional states can
occur in the elderly due to extracerebral causes like chronic
bronchitis, hypoxia, congestive cardiac failure, drugs, prolonged
hypotension and hypoglycaema. Evaluation of the patient's
attention, concentration, orientation, memory, intellect and
personality changes must be done. Organic brain syndromes
due to cerebral lesions cause acute confusional states.
The incidence is 2 to 3 patients per year
only. There is weakness of one arm and one leg with a fluctuating
level of consciousness. There is usually a quick recovery.