From the Guidelines
To investigate a 78-year-old woman with neurological symptoms, a comprehensive approach including history, physical examination, and diagnostic tests is essential, with a focus on identifying potential causes such as stroke, neurodegenerative diseases, or other conditions that may impact morbidity, mortality, and quality of life. The investigation should begin with a detailed medical and ocular history, including specific questions about patient symptoms, speed of onset of the symptoms, and possible associated unilateral or bilateral neurological signs 1. A comprehensive physical examination, including a complete neurological examination, should be performed to assess mental status, cranial nerves, motor strength, sensation, reflexes, coordination, and gait assessment.
The diagnostic workup should include basic laboratory tests such as complete blood count, comprehensive metabolic panel, thyroid function tests, vitamin B12 level, and inflammatory markers. Brain imaging, preferably with MRI, is crucial for better visualization of brain tissue, white matter changes, and potential stroke or mass lesions 1. An electroencephalogram (EEG) may be considered if seizures are suspected. Lumbar puncture may be necessary to analyze cerebrospinal fluid for infections, autoimmune conditions, or demyelinating disorders, especially if there are signs of increased intracranial pressure or meningeal signs 1.
Additional specialized tests, such as carotid ultrasound to assess stroke risk, nerve conduction studies for peripheral neuropathy, or cognitive assessments like the Montreal Cognitive Assessment (MoCA) for memory concerns, may be indicated based on the specific symptoms and clinical presentation 1. The investigation should be tailored to the individual patient, taking into account the potential for multiple causes of cognitive impairment, including vascular cognitive disorders, neurodegenerative diseases, and mixed dementia 1. Early and thorough investigation is crucial, as prompt diagnosis can significantly impact treatment options and outcomes in this age group, ultimately affecting morbidity, mortality, and quality of life.
From the Research
Investigating a 78-year-old Woman with Neurological Symptoms
To investigate a 78-year-old woman with neurological symptoms, several steps can be taken:
- Evaluate the patient's medical history and perform a physical examination to identify any potential causes of the neurological symptoms.
- Consider laboratory tests such as erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) to assess for inflammation, as elevated levels can be indicative of giant cell arteritis (GCA) 2.
- Temporal artery biopsy (TAB) is the gold standard for diagnosing GCA, but a negative biopsy does not rule out the disease 3.
- The timing of TAB is crucial, as the duration of corticosteroid treatment can affect the positivity of TAB, with a trend towards lower rates of positive TAB after more than 7 days of steroid treatment 4.
Diagnostic Considerations
When investigating a 78-year-old woman with neurological symptoms, the following diagnostic considerations should be taken into account:
- GCA is more common in individuals over 50 years of age, with a peak incidence in the seventh decade 3.
- The mean age of patients with GCA is around 77.8 years, and age is a significant factor in predicting positive TAB results 5.
- Vitamin B12 deficiency can also cause neurological symptoms, and evaluation of serum vitamin B12 levels and MRI changes can be useful in diagnosis 6.
Laboratory Tests and Imaging
The following laboratory tests and imaging studies can be useful in investigating a 78-year-old woman with neurological symptoms: