Dysautonomia in the older patient: clinical presentation and assessment.
Main Article Content
Abstract
The Autonomic Nervous System is represented by neurons in ganglia outside the brain and spinal cord that seemed to have functions independent of the Central Nervous System. Autonomic failure may be due to primary autonomic disorders such as Multiple System Atrophy or Pure Autonomic Failure or be secondary to diseases, such as diabetes mellitus or malignancies.
The temporal profile of the disease and its manifestations may be either acute, subacute for post-infective or paraneoplastic syndromes, or chronic for diabetes, alcoholism, and amyloidosis. Autonomic dysfunction may result in impairment of cardiovascular, thermoregulatory, gastrointestinal, urogenital, sudomotor, and pupillomotor functions in different combinations and degrees of severity. Orthostatic hypotension is a frequent cause of syncope, especially in the older patient; is the main feature of cardiovascular autonomic failure in clinically established Multiple System Atrophy, but may also be drug-related, or be the first manifestation of malignancy or anemia.
The present paper will discuss the different causes of dysautonomia in the older patient, focusing on neurodegenerative forms and paraneoplastic neuropathies, from clinical presentation to differential diagnosis.
Keywords:
cancer, older patient, dysautonomia, orthostatic hypotension, syncope, autonomic neuropathy
Article Details
How to Cite
RAFANELLI, Martina; UNGAR, Andrea Ungar.
Dysautonomia in the older patient: clinical presentation and assessment..
Medical Research Archives, [S.l.], v. 6, n. 10, oct. 2018.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/1848>. Date accessed: 29 apr. 2024.
doi: https://doi.org/10.18103/mra.v6i10.1848.
Section
Review Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
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18. Kaufmann H, Nahm K, Purohit D, et al. Autonomic failure as the initial presentation of Parkinson disease and dementia with Lewy bodies. Neurol-ogy 2004;63:1093–1095.
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38. Freeman R, Wieling W, Axelrod FB, et al. Consensus statement on the de-finition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome. Clin Auton Res 2011;21:69–72.
39. Rafanelli M, Morrione A, Landi A, et al. Neuroautonomic evaluation of pa-tients with unexplained syncope: in-cidence of complex neurally mediated diagnoses in the elderly. Clin Interv Aging 2014;9:333-8.
40. Mussi C, Ungar A, Salvioli G, et al. Evaluation of Guidelines in Syncope Study 2 Group. Orthostatic hypoten-sion as cause of syncope in patients older than 65 years admitted to emer-gency departments for transient loss of consciousness. J Gerontol A Biol Sci Med Sci 2009;64:801-6.
41. Wieling W, Krediet CT, van Dijk N, et al. Initial orthostatic hypotension: review of a forgotten condition. Clin Sci 2007;112:157–165.
42. Robinovitch SN, Feldman F, Yang Y, et al. Video capture of the circums-tances of falls in elderly people resid-ing in long-term care: an observation-al study. Lancet 2013;381:47–54.
43. Gibbons, C. H. and R. Freeman. Clin-ical implications of delayed orthostatic hypotension: a 10-year follow-up study. Neurology 2015;85:1362-1367.
44. Marrison VK, Fletcher A, Parry SW. The older patient with syncope: Prac-ticalities and controversies. Interna-tional Journal of Cardiology 2012;155:9–13.
45. Cheshire WP, Freeman R. Disorders of sweating. Semin Neurol 2003;23:399–406.
46. Furness JB. The enteric nervous sys-tem and neurogastroenterology. Nat Rev Gastroenterol Hepatol 2012;9:286–294.
47. Panicker JN, Fowler CJ. The bare es-sentials: uro-neurology. Pract Neurol 2010;10:178–185.
48. Goldstein DS. Catecholamines 101. Clin Auton Res 2010;20:331–352.
49. Low PA. Autonomic nervous system function. J Clin Neurophysiol 1993;10:14–27.
50. Gibbons CH, Illigens BM, Centi J, et al. QDIRT: quantitative direct and in-direct test of sudomotor function. Neurology 2008;70:2299–2304.
51. Booth RW, Ryan JM. The clinical use of the Valsalva maneuver. Heart Bull 1961;10:111–113.
52. Brignole M, Moya A, de Lange FJ, et al. 2018 ESC Guidelines for the diag-nosis and management of syncope. The Task Force for the diagnosis and management of syncope of the Euro-pean Society of Cardiology (ESC) Developed with the special contribu-tion of the European Heart Rhythm Association (EHRA). Eur Heart J 2018;00:1–69.
53. Mathias CJ. Cardiovascular autonom-ic dysfunction in parkinsonian pa-tients. Clinl Neurosci 1998;5:153–66.
54. Parati G, Di Rienzo M, Mancia G. How to measure baroreflex sensitivi-ty: from the cardiovascular laboratory to daily life. J Hypertens 2000;18:7–19.
55. Ziemssen T, Reichmann H. Cardi-ovascular autonomic dysfunction in Parkinson's disease. Journal of the Neurological Sciences 2010;289:74–80.
56. Feigin A, Antonini A, Fukuda M, et al. Tc-99m ethylene cysteinate dimer SPECT in the differential diagnosis of parkinsonism. Mov Disord 2002;17:1265–1270.
57. Kwon KY, Choi CG, Kim JS, et al. Comparison of brain MRI and 18F-FDG PET in the differential diagnosis of multiple system atrophy from Parkinson’s disease. Mov Disord 2007;22:2352–2358.
58. Braune S, Reinhardt M, Schnitzer R, et al. Cardiac uptake of [123I] MIBG separates Parkinson's disease from multiple system atrophy. Neurology 1999;53:1020–5.
2. Langley JN. The autonomic nervous system. Cambridge. W Heffer and Sons Ltd:1921.
3. Cannon WB. The emergency function of the adrenal medulla in pain and in the major emotions. Am J Physiol 1914;33:356–72.
4. Cannon WB. The Wisdom of the body. New York. WW Norton:1939.
5. Jain S, Goldstein DS. Cardiovascular dysautonomia in Parkinson Disease: From pathophysiology to pathogene-sis. Neurobiol Dis 2012;46:572–580.
6. Benarroch EE. The clinical approach to autonomic failure in neurological disorders. Nat Rev Neurol 2014;10:396–407.
7. Fanciulli A, Wenning G. Multiple-System Atrophy. N Engl J Med 2015;372:249-63.
8. Multiple-System Atrophy Research Collaboration. Mutations in COQ2 in familial and sporadic multiple-system atrophy. N Engl J Med 2013;369:233–244.
9. Ozawa T. Pathology and genetics of multiple system atrophy: an approach to determining genetic susceptibility spectrum. Acta Neuropathol 2006;112:531-538.
10. Gilman S, Wenning GK, Low PA, et al. Second consensus statement on the diagnosis of multiple system atrophy. Neurology 2008;71:670-6.
11. Freeman R. Clinical practice. Neuro-genic orthostatic hypotension. N Engl J Med 2008;358:615-24.
12. Winge K, Fowler CJ. Bladder dys-function in Parkinsonism: mechan-isms, prevalence, symptoms, and management. Mov Disord 2006;21:737–745.
13. Iranzo A. Sleep and breathing in mul-tiple system atrophy. Curr Treat Op-tions Neurol 2007;9:347–353.
14. K.llensperger M, Geser F, Seppi K, et al. Red flags for multiple system atro-phy. Mov Disord 2008;23:1093-9.
15. Kaufmann H, Hague K, Perl D. Ac-cumulation of alpha-synuclein in au-tonomic nerves in pure autonomic failure. Neurology 2001;56:980–981.
16. Goldstein DS, Holmes C, Sato T, et al. Central dopamine deficiency in pure autonomic failure. Clin Auton Res 2008;18:58–65.
17. Goldstein DS, Holmes C, Sharabi Y. Cerebrospinal fluid biomarkers of central catecholamine deficiency in Parkinson’s disease and other synuc-leinopathies. Brain 2012;135:1900–1913.
18. Kaufmann H, Nahm K, Purohit D, et al. Autonomic failure as the initial presentation of Parkinson disease and dementia with Lewy bodies. Neurol-ogy 2004;63:1093–1095.
19. Ziemssen T, Reichmann H. Non-motor dysfunction in Parkinson's dis-ease. Parkinsonism Rel Disord 2007;13:323–32.
20. Jost WH. Autonomic dysfunctions in idiopathic Parkinson's disease. J Neu-rol 2003;250:128–30.
21. Braak H, Ghebremedhin E, Rub U, et al. Stages in the development of Par-kinson's disease-related pathology. Cell Tissue Res 2004;318:121–34.
22. Freeman R. Autonomic peripheral neuropathy. Lancet 2005;365:1259–70.
23. Iodice V, Sandroni P. Autonomic neuropathies. Continuum (Minneap Minn) 2014;20:1373–1397.
24. Vernino S, Hopkins S, Wang Z. Au-tonomic ganglia, acetylcholine recep-tor antibodies, and autoimmune gan-glionopathy. Auton Neurosci 2009;146:3–7.
25. Sandroni P, Low PA. Other autonom-ic neuropathies associated with gan-glionic antibody. Autonomic Neurosci 2009;146:13–17.
26. Vernino S, Sandroni P, Singer W, et al. Autonomic ganglia: target and novel therapeutic tool. Neurology 2008;70:1926–1932.
27. Graus F, Delattre J, Antoine J, et al. Recommended diagnostic criteria for paraneoplastic neurological syn-dromes. J Neurol Neurosurg Psychia-try 2004;75:1135–1140.
28. Koike H, Watanabe H, Sobue G. The spectrum of immune-mediated auto-nomic neuropathies: insights from the clinicopathological features. Journal of Neurology, Psychiatry and Neurosurgery 2013;84:98–106.
29. Oki Y, Koike H, Iijima M, et al. Ataxic vs painful form of paraneop-lastic neuropathy. Neurology 2007;69:564-572.
30. Koike H, Sobue G. Small neurons may be preferentially affected in gan-glionopathy. Journal of Neurology, Neurosurgery and Psychiatry 2008;79:113.
31. Lucchinetti CF, Kimmel DW, Lennon VA. Paraneoplastic and oncologic profiles of patients seropositive for type 1 antineuronal nuclear autoanti-bodies. Neurology 1998;50:652–657.
32. Yu Z, Kryzer TJ, Griesmann GE. CRMP-5 neuronal autoantibody: marker of lung cancer and thymoma-related autoimmunity. Annals of Neu-rology 2001;49:146–154.
33. McKeon A, Lennon VA, Lachance DH, et al. Ganglionic acetylcholine receptor autoantibody: oncological, neurological, and serological accom-paniments. Archives of Neurology 2009;66:735–741.
34. Etienne M, Weimer LH. Immune-mediated autonomic neuropathies. Current Neurology and Neuroscience Reports 2006;6:57–64.
35. Lee HR, Lennon VA, Camilleri M, et al. Paraneoplastic gastrointestinal motor dysfunction: clinical and laboratory characteristics. American Journal of Gastroenterology 2001;96:373–379.
36. Giometto B, Vitaliani R, Lindeck-Pozza E, et al. Treatment for para-neoplastic neuropathies. Cochrane Database of Systematic Reviews 2012;12:CD007625.
37. Moya A, Sutton R, Ammirati F, et al. Guidelines for the diagnosis and man-agement of syncope (version 2009): the Task Force for the Diagnosis and Management of Syncope of the Euro-pean Society of Cardiology (ESC). Eur Heart J 2009;30:2631-71.
38. Freeman R, Wieling W, Axelrod FB, et al. Consensus statement on the de-finition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome. Clin Auton Res 2011;21:69–72.
39. Rafanelli M, Morrione A, Landi A, et al. Neuroautonomic evaluation of pa-tients with unexplained syncope: in-cidence of complex neurally mediated diagnoses in the elderly. Clin Interv Aging 2014;9:333-8.
40. Mussi C, Ungar A, Salvioli G, et al. Evaluation of Guidelines in Syncope Study 2 Group. Orthostatic hypoten-sion as cause of syncope in patients older than 65 years admitted to emer-gency departments for transient loss of consciousness. J Gerontol A Biol Sci Med Sci 2009;64:801-6.
41. Wieling W, Krediet CT, van Dijk N, et al. Initial orthostatic hypotension: review of a forgotten condition. Clin Sci 2007;112:157–165.
42. Robinovitch SN, Feldman F, Yang Y, et al. Video capture of the circums-tances of falls in elderly people resid-ing in long-term care: an observation-al study. Lancet 2013;381:47–54.
43. Gibbons, C. H. and R. Freeman. Clin-ical implications of delayed orthostatic hypotension: a 10-year follow-up study. Neurology 2015;85:1362-1367.
44. Marrison VK, Fletcher A, Parry SW. The older patient with syncope: Prac-ticalities and controversies. Interna-tional Journal of Cardiology 2012;155:9–13.
45. Cheshire WP, Freeman R. Disorders of sweating. Semin Neurol 2003;23:399–406.
46. Furness JB. The enteric nervous sys-tem and neurogastroenterology. Nat Rev Gastroenterol Hepatol 2012;9:286–294.
47. Panicker JN, Fowler CJ. The bare es-sentials: uro-neurology. Pract Neurol 2010;10:178–185.
48. Goldstein DS. Catecholamines 101. Clin Auton Res 2010;20:331–352.
49. Low PA. Autonomic nervous system function. J Clin Neurophysiol 1993;10:14–27.
50. Gibbons CH, Illigens BM, Centi J, et al. QDIRT: quantitative direct and in-direct test of sudomotor function. Neurology 2008;70:2299–2304.
51. Booth RW, Ryan JM. The clinical use of the Valsalva maneuver. Heart Bull 1961;10:111–113.
52. Brignole M, Moya A, de Lange FJ, et al. 2018 ESC Guidelines for the diag-nosis and management of syncope. The Task Force for the diagnosis and management of syncope of the Euro-pean Society of Cardiology (ESC) Developed with the special contribu-tion of the European Heart Rhythm Association (EHRA). Eur Heart J 2018;00:1–69.
53. Mathias CJ. Cardiovascular autonom-ic dysfunction in parkinsonian pa-tients. Clinl Neurosci 1998;5:153–66.
54. Parati G, Di Rienzo M, Mancia G. How to measure baroreflex sensitivi-ty: from the cardiovascular laboratory to daily life. J Hypertens 2000;18:7–19.
55. Ziemssen T, Reichmann H. Cardi-ovascular autonomic dysfunction in Parkinson's disease. Journal of the Neurological Sciences 2010;289:74–80.
56. Feigin A, Antonini A, Fukuda M, et al. Tc-99m ethylene cysteinate dimer SPECT in the differential diagnosis of parkinsonism. Mov Disord 2002;17:1265–1270.
57. Kwon KY, Choi CG, Kim JS, et al. Comparison of brain MRI and 18F-FDG PET in the differential diagnosis of multiple system atrophy from Parkinson’s disease. Mov Disord 2007;22:2352–2358.
58. Braune S, Reinhardt M, Schnitzer R, et al. Cardiac uptake of [123I] MIBG separates Parkinson's disease from multiple system atrophy. Neurology 1999;53:1020–5.