What is the evaluation, testing, and treatment for an 83-year-old female with peripheral neuropathy (PN) of the feet?

Evaluation, Testing, and Treatment for Peripheral Neuropathy in an 83-Year-Old Female

The comprehensive management of peripheral neuropathy in an elderly female requires systematic evaluation with the 10-g monofilament test plus at least one other neurological assessment tool, followed by treatment with first-line medications such as duloxetine, pregabalin, or gabapentin for painful neuropathy. 1

Evaluation and Testing

Initial Assessment

• History taking: Focus on:
  • Duration of symptoms
  • Pattern of sensory disturbances (numbness, pain, burning)
  • Diabetes history and control
  • Medication history
  • History of claudication or rest pain
  • Previous ulcerations or amputations 1, 2

Physical Examination

1. Neurological assessment:

   • 10-g monofilament test (essential)
   • At least one additional test from:
     • Pinprick sensation
     • Temperature perception
     • Vibration perception with 128-Hz tuning fork
     • Ankle reflexes 1, 2

2. Vascular assessment:

   • Pulse examination of dorsalis pedis and posterior tibial arteries
   • Assessment of capillary refill time
   • Check for rubor on dependency and pallor on elevation 1

3. Skin and structural assessment:

   • Inspect for skin integrity, especially between toes and under metatarsal heads
   • Assess for foot deformities (bunions, hammertoes, prominent metatarsals)
   • Look for calluses or pressure points 1, 2

Laboratory Testing

• Complete blood count
• Comprehensive metabolic profile
• Fasting blood glucose and HbA1c
• Vitamin B12 level
• Thyroid-stimulating hormone level
• Erythrocyte sedimentation rate 2, 3

Advanced Testing (if initial evaluation is inconclusive)

• Referral for electrodiagnostic studies (nerve conduction studies, electromyography)
• Doppler ultrasound with pulse volume recordings if PAD is suspected 1, 3

Treatment Approach

Pain Management

1. First-line medications for painful neuropathy:

   • Serotonin-norepinephrine reuptake inhibitors (SNRIs):
     • Duloxetine 60-120 mg/day 4
   • Anticonvulsants:
     • Pregabalin 300-600 mg/day 5
     • Gabapentin 900-3600 mg/day 2
   • Tricyclic antidepressants (TCAs):
     • Amitriptyline (use with caution in elderly due to anticholinergic side effects) 1

2. Topical treatments:

   • Capsaicin 8% patch or 0.075% cream
   • Lidocaine 5% patch (especially for localized pain) 1

Risk Stratification and Follow-up

Based on the International Working Group on the Diabetic Foot risk stratification system 1:

• Category 0 (Very low risk): No LOPS, no PAD - Annual examination
• Category 1 (Low risk): LOPS or PAD - Examination every 6-12 months
• Category 2 (Moderate risk): LOPS + PAD, or LOPS + foot deformity, or PAD + foot deformity - Examination every 3-6 months
• Category 3 (High risk): LOPS or PAD with history of ulcer, amputation, or end-stage renal disease - Examination every 1-3 months

Foot Care Education

• Daily foot inspection
• Proper footwear selection (wide toe box, cushioned soles)
• Avoid walking barefoot
• Regular nail and skin care
• Prompt attention to any injuries or skin changes 1, 2

Special Considerations for Elderly Patients

1. Medication adjustments:

   • Start at lower doses and titrate slowly
   • Monitor for adverse effects, particularly with duloxetine and pregabalin which require dose adjustment in renal impairment 4, 5
   • Be cautious with TCAs due to increased risk of anticholinergic side effects in elderly 1

2. Fall prevention:

   • Duloxetine has been associated with increased fall risk in elderly patients 4
   • Regular assessment of balance and gait
   • Home safety evaluation

3. Comorbidity management:

   • Optimize glycemic control if diabetic
   • Address cardiovascular risk factors
   • Manage concurrent conditions that may exacerbate neuropathy 2

Referral Criteria

• Persistent symptoms despite initial management
• Unclear etiology
• Rapid progression of symptoms
• Presence of foot ulcers or significant deformities
• Signs of peripheral arterial disease requiring vascular intervention 1, 2

Common Pitfalls to Avoid

1. Failing to perform comprehensive foot examination with both 10-g monofilament and at least one other neurological assessment tool
2. Overlooking non-diabetic causes of neuropathy in elderly patients
3. Using opioids for long-term management (not recommended due to lack of evidence for long-term efficacy and risk of adverse effects) 1
4. Neglecting patient education on foot care and self-examination techniques
5. Inadequate follow-up frequency based on risk stratification

By following this systematic approach to evaluation, testing, and treatment, the management of peripheral neuropathy in this 83-year-old female can be optimized to improve symptoms, prevent complications, and maintain quality of life.