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and seen whenever possible. Most often the patient reports with strokes, seizures and dementia. The physical disability and physical problems such as dressing, shaving, climbing stairs etc., sample of speech and writing should be recorded.

In general examination, the pulse in all peripheral vessels must be felt. For every cerebral vessel blocked, 2 coronaries and 4 peripheral vessels are blocked. Palpate the skin and scalp, palpate the tongue in all cases of wasting to differentiate from malignancy. Tremors, bradykenesia must be recorded. Respiratory rate is important; hypopnea is often missed.

The routine neurological examination is time-consuming. In the crowded out-patient department of the PHC, the neurological patient is to be seen last. A routine methodical testing is essential. Assessment of mental function is very important in the elderly. The level of alertness of the patient must be ascertained, attention and orientation must be assessed. Atleast one verbal and one non-verbal test for memory must be administered. Insight into the illness is enquired for. To test right brain function, spatial orientation must be tested: e.g., the direction of the patient's village, the direction of the nearest city and an important nearby landmark. Left brain function can be assessed by finding out whether propositional speech is present by asking the patient to give an account of himself. Assess for apraxia and agnosia. These are essential to identify early cases of dementia.

Cerebrovascular disorder is never diagnosed on the basis of a single symptom. It is observed that transient attacks cause stroke in 50% of individuals within 2 to 3 months. The territories are usually carotid and basilar arteries. Electrocardiography is a must in all cases. Bruits in the neck generally indicate an arterial disease. However bruits do not signify much in the elderly.

The commonest cause of syncope in old age is cardiac and not neurological. Car-diogenic neurological problems are generalised and they recover when blood pressure is reestablished. Syncope never produces focal neurological deficit. In a case of syncope, the blood pressure has to be correlated with fall in blood pressure and cardiac arrest. The patient should be allowed to lie down as lying increases blood pressure, pulse rate and enhances blood supply. Carotid sinus sensitivity can be diagnosed when patient gives history of syncope on shaving, moving the neck etc. Atropine ½ tablet checks the attacks. Micturition syncope, cough syncope and anoxia can cause fits.

Headache in the elderly is due to (i) hypertension (ii) vasodilation (iii) tension headache and (iv) collagen diseases. It is said that migraine and bronchial asthma should not be diagnosed first time during one's life in old age. Though collagen disease is rare it is to be remembered that steroid therapy is a fruitful mode of therapy in such cases. Increased intracranial tension slows the pulse. Tumors cause headache, fits and confusion. Acute confusional states can occur in the elderly due to extracerebral causes like chronic bronchitis, hypoxia, congestive cardiac failure, drugs, prolonged hypotension and hypoglycaema. Evaluation of the patient's attention, concentration, orientation, memory, intellect and personality changes must be done. Organic brain syndromes due to cerebral lesions cause acute confusional states.

Subdural haematoma

The incidence is 2 to 3 patients per year only. There is weakness of one arm and one leg with a fluctuating level of consciousness. There is usually a quick recovery.

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