From the Guidelines
Myasthenia gravis symptoms in a 93-year-old patient typically include muscle weakness that worsens with activity and improves with rest, with common signs being drooping eyelids, double vision, difficulty swallowing or speaking, weakness in arms and legs, and shortness of breath. According to the American Society of Clinical Oncology clinical practice guideline 1, the management of myasthenia gravis involves grading the severity of symptoms and intervening accordingly. The symptoms can be categorized into different grades, with grade 1 being mild and grade 4 being severe. For a 93-year-old patient, it is essential to monitor for symptoms that may indicate a higher grade of severity, such as:
- Drooping eyelids (ptosis)
- Double vision
- Difficulty swallowing or speaking
- Weakness in arms and legs
- Shortness of breath
- Facial weakness
- Respiratory muscle weakness
Treatment for myasthenia gravis in a 93-year-old patient should be tailored to the individual's age and overall health, with a focus on minimizing side effects. The guideline recommends:
- Starting with lower doses of pyridostigmine, such as 30 mg orally three times a day, and gradually increasing to a maximum of 120 mg orally four times a day as tolerated and based on symptoms 1
- Administering corticosteroids, such as prednisone, at a dose of 1-1.5 mg/kg orally daily, if symptoms are grade 2 or higher 1
- Considering immunosuppressants, such as azathioprine, in addition to corticosteroids, to suppress the autoimmune response
- Avoiding medications that can worsen symptoms, such as certain antibiotics and beta-blockers
- Providing physical therapy to maintain muscle strength and regular monitoring for respiratory function to prevent myasthenic crisis.
From the FDA Drug Label
Myasthenic crisis due to an increase in the severity of the disease is also accompanied by extreme muscle weakness, and thus may be difficult to distinguish from cholinergic crisis on a symptomatic basis The symptoms of Myasthenia Gravis in a 93-year-old patient with advanced age are not directly addressed in the label, however, extreme muscle weakness is mentioned as a symptom of myasthenic crisis, which is an increase in the severity of the disease.
- Muscle weakness is the only symptom mentioned in relation to myasthenic crisis. 2
From the Research
Symptoms of Myasthenia Gravis in a 93-year-old Patient
The symptoms of Myasthenia Gravis (MG) in a 93-year-old patient can be similar to those experienced by younger patients, but may be more difficult to diagnose due to age-related changes. Some common symptoms of MG include:
- Ptosis (drooping eyelids)
- Diplopia (double vision)
- Facial and bulbar weakness
- Limb weakness
- Dysarthria (slurred speech)
- Dysphagia (difficulty swallowing)
- Fatigability during physical activity 3
- In severe cases, respiratory muscle involvement can occur 3, 4
Clinical Presentation in Elderly Patients
Elderly patients with MG may present with atypical symptoms, making diagnosis more challenging. For example, isolated dysarthria can be the sole manifestation of MG in some cases 4. Additionally, elderly patients may experience more severe symptoms due to age-related decline in physical function and comorbidities.
Treatment-Related Symptoms
Treatment with pyridostigmine, a common medication for MG, can also cause symptoms such as bradycardia and SA-block in some patients 5. It is essential to monitor patients closely for these potential side effects and adjust treatment accordingly.
Importance of Accurate Diagnosis
Accurate diagnosis of MG is crucial, especially in elderly patients, to ensure timely and effective treatment. A combination of clinical evaluation, serologic testing, and additional tests such as repetitive nerve stimulation and single fiber EMG can help establish a diagnosis of MG 3, 6.