MODULE SUPPLEMENT: NEUROLOGICAL SYSTEM
Clinical Vignette

Mr. Jones, an 88 year old Caucasian male, comes to clinic to establish care because he recently moved to this area from New York to be close to his oldest son. His past medical history is significant for hypertension which is currently treated with Hydrochlorothiazide. He denies having diabetes, thyroid problems, or other chronic conditions. On physical exam you are unable to elicit an ankle/Achilles reflex and the patellar reflex is diminished.

Are these findings normal? Or are they an indication that Mr. Jones has undiagnosed peripheral vascular disease or undiagnosed diabetes?

This can be a normal finding because the achilles tendon reflex can be very difficult to elicit, diminished or absent in older adults, especially those at an advanced old age both because of decreased tendon elasticity and slowed nerve conduction across this long reflex arc (Williams, 2001). However, changes should be symmetrical and other potential causes of peripheral neuropathy should be considered, including diabetes, peripheral vascular disease and vitamin B12 deficiency. Interestingly, in addition to age, height is also inversely correlated with nerve conduction velocity (Rivner, Swift, et al., 2001) and should be considered in the evaluation.

While you are doing your exam, Mr. Jones mentions that he continues to exercise but that he was curious about information that he read that said that maximum heart rate in response to exercise goes down with age.