Rare Conditions and Novel Treatment Innovations

Older adults often have a wide range of multicomorbidities and are typically on a long list of medications for chronic illnesses, which can make accurate diagnosis and effective treatment of new diseases particularly challenging. With care providers generally seeing a high number of patients for routine check-ups every week, uncommon conditions that manifest as routine illnesses have a greater potential to be missed by providers. Moreover, thinking outside of the box in terms of using treatments with alternative or emerging therapies can also become a daily challenge for busy professionals. 

Herpes zoster, caused by the reactivation of latent varicella zoster virus (VZV), is a routine condition in older adults that can occasionally result in unusual symptoms. The most common neurological sequel is postherpetic neuralgia, but cranial nerve palsies, meningoencephalitis, cerebellitis, zoster paresis, and vasculopathy can also ensue after reactivation of VZV. And, while an increasing amount of studies investigate symptoms and conditions that can result from VZV vasculopathy, its pathogenesis remains elusive, making early recognition of this entity a clinical challenge. Authors Aarthi Rajkumar, MD, FACP, and Elizabeth Baum, MD, CMD, share their case study of cerebral venous sinus thrombosis in an elderly woman during an episode of herpes zoster that posed a significant diagnostic dilemma.

Recognizing and treating the various presentations of dementia is another area that can prove clinically challenging. Frontotemporal dementia (FTD) is the second most common form of dementias for those younger than age 65, yet it is often misdiagnosed or not recognized. One reason for this is that only about one-third of patients diagnosed with FTD actually present with all of the core criteria generally associated with initial onset. Subramoniam Madhusoodanan, MD, DLFAPA, and colleagues discuss their experience of a 68-year-old woman who had drastic alterations in her personality yet had unremarkable laboratory workup. Further inquiry and testing found that the brain showed differential atrophy of the anterior temporal lobe and hippocampus. 

The prevalence of dementia and its many forms in the older population, in addition to sometimes posing a diagnostic challenge, can also test care providers when it comes to innovating treatment options. Patients with dementia, especially those in long-term care facilities, can at times experience agitation, which can lessen or worsen depending on the time of day. To calm residents and to also maintain order within facilities, antipsychotics have become the go-to medication to address agitation in residents, despite the high probability of adverse drug interactions and effects. In an effort to move beyond antipsychotic use for these cases, more and more professionals are seeking alternative treatment methods. Personalized music playlists can be an effective intervention to improve verbal communication and decipher the cause of the agitation. In her case report, Elizabeth M Long, DNP, APRN, GNPBC, discusses the effect of a personalized music playlist on a patient with dementia with significant evening agitation. The patient experienced increased communication and verbalization about her past history, which allowed the facility and providers to tailor her specific interventions, thereby decreasing the evening agitation.

Alternative treatment methods can also go beyond nonmedical therapies to include alternative care settings and unconventional environments. This issue also features an interview with Charlene Boyd, administrator of Providence Mount St Vincent, a nursing facility in Seattle, WA, that is dedicated to providing a refreshingly different experience for older adults through its integration of a licensed child care center on the same campus as the nursing center. Their Intergenerational Learning Center allows for intergenerational interactions to take place in the facility for the mutual benefit of the older residents and children. Over the past year, Providence Mount St Vincent has received widespread international attention and recognition as the result of being the subject of a forthcoming documentary by filmmaker Evan Briggs.

Cumulatively, the articles in this issue highlight the importance of constant diligence when diagnosing and treating older adults with multiple comorbidities and demonstrate how novel therapies and innovative thinking can yield far-reaching benefits.