Everything on this planet has a shelf life or ‘best by date’. Humans are no different. Some of us may age gracefully, but age does catch up with all of us as most systems of the body wear out, leading ultimately to death as a natural progression of our lives. There certainly is no immortality on earth!
Brain, the crown jewel of the body, is no exception to this rule. The natural reduction in blood circulation due to narrowing and stiffness of the arteries, diminishing efficacy of neurotransmitters (neurons than conduct messages from the brain) and hormonal content, results in impairment of memory and difficulty in carrying out daily tasks which were taken for granted when young. In abnormal situations, the process gets accentuated, resulting in Stroke (blood circulation defects),
Dementia (neuronal defects), Parkinson’s disease (neurotransmitter deficiency), Hypo-pituitarism and Dyselectrolytaemia (hormonal deficiency), etc.
The commonly occurring neurological problems involving brain in old age are Stroke, Dementia (Alzheimer’s disease being the most common cause), Parkinson’s Disease (PD), Normal Pressure Hydrocephalus (NPH), Subdural Haematoma (SDH), Delirium due to low sodium or hyponatraemia (Dyselectrolytaemia). In the spine, the most common condition in this group of patients is a degenerative spine, otherwise known as spondylosis.
Stroke is the sudden death of brain cells due to the lack of oxygen caused by a blocked artery. They can beIschaemicor haemorrhagic. Ischaemic stroke accounts for about 85% of all strokes. The complete stoppage of blood flow for longer than five minutes produces irreversible damage to brain cells. Nowadays, acute ischaemic stroke can be treated with clot-dissolving agents (within four hours of onset). Prompt pre-hospital and emergency management of patients affected with stroke yields good results. Left untreated, the affected area enlarges, leading to greater damage.
Haemorrhagic stroke is caused by a blood clot in the brain.
Advancing age has an adverse effect on mental functions like memory, intelligence, behaviour, orientation, mood, initiative, etc. For some people even simple activities like brushing teeth, cleaning oneself and dressing up become more and more difficult, and subsequently, they may require help from others. This condition is known as Dementia.
Alzheimer’s disease (AD) is a specific type of Dementia, where the deposition of plaque results in neuronal dysfunction. Although there is no specific treatment available yet, some medications help in slowing this degenerative process. MRI of the brain is the most commonly used diagnostic tool. At present, the mainstay of managing such patients is providing specific help and assistance, usually by family members or support groups.
The other common group of Dementia is vascular Dementia resulting from uncontrolled or long-standing diabetes and hypertension. Regular physical and mental activities, proper recreational activities and adequate control of diseases like diabetes and hypertension can prevent vascular Dementia to a large extent.
Parkinson’s disease is a progressive degenerative disease of the brain occurring usually after the age of 50. It is associated with the dysfunction of brain cells producing dopamine. Movement disorder, excessive salivation, constipation, depression, excessive dreaming are some of the common symptoms. Movement disorders may include tremor, rigidity and gait problems.
The treatment is essentially medical and rehabilitative. Medicines are mainly aimed at increasing the availability of dopamine at the nerve endings of the brain, regulating coordination of motor movements. The role of family or social support is essential in the advanced stage. Patients with PD are prone to sustaining injuries due to repeated falls.
Severe movement disorders that don’t respond to a high dose of medications may benefit from surgery -Deep Brain Stimulation (pacemaker for the brain) or Lesioning (permanent destruction of the part of the nucleus using radiofrequency energy delivered through a microelectrode).
Chronic Subdural Haematoma (CSDH)
The volume of the brain tends to diminish with age, resulting in a process called cerebral atrophy. As a result, the space between the brain and the skull bone increases, thereby, putting pressure on the thin-walled veins. Mild to moderate head injuries can result in bleeding from these ruptured veins, thereby, causing CSDH. This process occurs slowly fora period of days to weeks. Hence the term ‘chronic’ is used.
Small amounts of CSDH can be absorbed by a natural process but repeated bleeding and the use of blood-thinning tablets, common in the elderly, can result in a large amount of blood collection, causing pressure on the brain. Headache, vomiting and paralysis are common outcomes. Surgery may be required when a significant amount of CSDH is produced.
Normal Pressure Hydrocephalus (NPH)
The discrepancy between cerebrospinal fluid (CSF) production and absorption inside the brain can result in an excessive amount of CSF collection in the ventricles. This condition is called hydrocephalus. In elderly patients, this process develops very slowly, and the pressure exerted by the fluid on the brain is usually minimal. It often is a normal part of ageing. Gait difficulties, urinary incontinence and dementia are common symptoms.
A lumbar puncture can show a significant improvement in the symptoms. Eventually, however, patients may be required to undergoa procedure called shunting. The opening pressure of the shunt can be controlled from outside by the use of the programmer to adjust to the required pressure setting, thereby avoiding complications due to over or under drainage.
Due to the use of diuretics in controlling blood pressure, patients in the elderly age group are likely to develop hyponatraemia (low serum sodium), especially when salt intake is restricted. This may also occur due to severe diarrhoea or vomiting. Acute confusion is the most obvious symptom and it is a common cause of falls at home. Correction has to be a slow and careful process, as faster corrections of sodium can result in irreversible damage that can lead to disability or death.
Normal wear and tear (degeneration) of the spine is known as spondylosis. The human spine is beautifully designed by nature to cater to modern living. Its basic functions are stability and mobility. The balance between these functions, which happens naturally when young, gets disturbedwith advancing age. This is due to the stiffness of the joints between the vertebrae, fragility of the ligaments binding them, dehydration of the disks in between the vertebrae and weakness of the bones. This may result in fractures, slipped disks, sciatica (due to nerve root compression by the disks), listhesis (slipping of one vertebra over the other), difficulty in gait due to spinal canal narrowing causing pain and disability of various proportions.The initial treatment is medical and physiotherapy. Surgery may be necessary in advanced cases.
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Dr Tripathy is Sr. Consultant Neurosurgeon & Director, Medica Institute of Neurological Diseases & Vice-Chairman, Medica Superspecialty Hospital, Kolkata