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Immobility

Medicine > Medicine of older adult

Differential Diagnosis Schema 🧠

Neurological Causes

  • Stroke: Acute loss of motor function, often with other neurological signs such as facial droop, aphasia, or hemiplegia.
  • Parkinson’s Disease: Progressive movement disorder with bradykinesia, rigidity, and postural instability leading to immobility.
  • Multiple Sclerosis: Demyelinating disorder causing episodes of weakness, spasticity, and sensory loss.
  • Spinal Cord Injury: Trauma or disease affecting the spinal cord, resulting in paralysis below the level of injury.
  • Motor Neuron Disease: Progressive degeneration of motor neurons, leading to muscle weakness and eventual immobility.
  • Peripheral Neuropathy: Damage to peripheral nerves causing weakness, sensory loss, and difficulty walking.
  • Myasthenia Gravis: Autoimmune disorder causing muscle weakness, typically worse with activity and improving with rest.
  • Cerebral Palsy: Non-progressive neurological disorder from early brain injury, leading to varying degrees of motor impairment.

Musculoskeletal Causes

  • Osteoarthritis: Degenerative joint disease causing pain, stiffness, and reduced mobility, particularly in weight-bearing joints.
  • Rheumatoid Arthritis: Autoimmune disease causing chronic inflammation of joints, leading to pain, deformity, and reduced mobility.
  • Hip Fracture: Common in elderly patients following a fall, leading to pain and inability to mobilize.
  • Muscle Wasting: Secondary to prolonged immobility, chronic illness, or malnutrition, leading to reduced muscle strength.
  • Spinal Stenosis: Narrowing of the spinal canal causing pain, numbness, and weakness in the legs, leading to difficulty walking.
  • Polymyalgia Rheumatica: Inflammatory disorder causing pain and stiffness in the shoulders and hips, particularly in older adults.
  • Gout: Inflammatory arthritis caused by uric acid crystal deposition, often affecting the big toe, causing pain and immobility.
  • Fibromyalgia: Chronic pain syndrome with widespread musculoskeletal pain, fatigue, and tenderness, leading to reduced activity.
  • Prolonged Immobilization: Leads to joint contractures, muscle atrophy, and decreased bone density, exacerbating immobility.

Cardiovascular and Respiratory Causes

  • Heart Failure: Reduced cardiac output leading to fatigue, shortness of breath, and reduced exercise tolerance.
  • Chronic Obstructive Pulmonary Disease (COPD): Chronic respiratory disease causing dyspnea, fatigue, and reduced mobility.
  • Peripheral Arterial Disease: Reduced blood flow to the legs causing pain (claudication) and limiting mobility.
  • Deep Vein Thrombosis (DVT): Pain, swelling, and risk of pulmonary embolism, leading to reduced mobility.
  • Anemia: Reduced oxygen-carrying capacity of blood leading to fatigue and reduced exercise tolerance.
  • Pulmonary Embolism: Acute blockage of pulmonary arteries causing sudden dyspnea, chest pain, and immobility.
  • Postural Hypotension: Sudden drop in blood pressure on standing, leading to dizziness, falls, and reduced mobility.

Other Causes

  • Depression: Major depressive disorder can lead to reduced motivation, energy, and physical activity, contributing to immobility.
  • Dementia: Cognitive decline can impair the ability to mobilize safely, leading to increased risk of immobility.
  • Delirium: Acute confusion can lead to disorientation, falls, and immobility, particularly in hospitalized patients.
  • Sedative Medications: Drugs like benzodiazepines or antipsychotics can cause sedation, weakness, and contribute to immobility.
  • Malnutrition: Inadequate nutrition can lead to muscle wasting, weakness, and reduced mobility.
  • Prolonged Hospitalization: Bed rest in hospital can lead to deconditioning, muscle atrophy, and joint stiffness.
  • Obesity: Excess body weight can limit mobility, contribute to joint pain, and increase the risk of falls.
  • Dehydration: Can cause weakness, dizziness, and confusion, contributing to immobility.
  • Frailty: A syndrome of decreased physiological reserve, increasing vulnerability to adverse health outcomes, including immobility.
  • Chronic Pain: Pain from any cause can limit physical activity and contribute to immobility.
  • Advanced Age: Age-related decline in muscle strength, balance, and coordination can lead to immobility.
  • Infections: Acute infections like pneumonia or urinary tract infections can cause weakness, fatigue, and immobility, especially in the elderly.
  • Environmental Factors: Lack of accessibility in the home or community can limit mobility, particularly in individuals with disabilities.
  • Fear of Falling: Can lead to self-imposed activity limitation and subsequent immobility.

Key Points in History 🥼

Symptom History

  • Onset and Duration: Sudden onset suggests acute causes like stroke or fracture, while gradual onset suggests chronic conditions like osteoarthritis or Parkinson’s disease.
  • Pain: Assess location, duration, and severity of pain; common in musculoskeletal causes of immobility.
  • Weakness: Evaluate for muscle weakness, which can suggest neurological or musculoskeletal causes.
  • Fatigue: Consider systemic causes like anemia, heart failure, or chronic lung disease.
  • Balance and Coordination: Assess for dizziness, balance issues, and falls, suggesting neurological or cardiovascular causes.
  • Cognitive Function: Assess for confusion, memory loss, or mood changes, which may indicate dementia, delirium, or depression.
  • Recent Trauma or Falls: Can indicate fractures, soft tissue injuries, or exacerbation of chronic pain.
  • Medication Use: Review medications that may cause sedation, dizziness, or muscle weakness.
  • Activities of Daily Living (ADLs): Assess the impact on basic self-care activities, such as bathing, dressing, and toileting.
  • Previous Medical History: Including history of chronic diseases, surgeries, and previous episodes of immobility.
  • Social History: Evaluate living conditions, support systems, and access to mobility aids or home modifications.
  • Psychosocial Factors: Consider the impact of immobility on mental health, social interactions, and quality of life.
  • Dietary and Nutritional Status: Assess for signs of malnutrition or dehydration that may contribute to weakness and immobility.
  • Functional Status: Review baseline mobility and recent changes in physical function.
  • Bowel and Bladder Function: Assess for incontinence, constipation, or urinary retention, which may exacerbate immobility.
  • Hydration Status: Assess for signs of dehydration, which can cause weakness and confusion, contributing to immobility.
  • Vision and Hearing: Consider sensory impairments that may contribute to immobility and risk of falls.
  • Weight Changes: Unintentional weight loss or gain may indicate underlying disease or contribute to immobility.
  • Sleep History: Poor sleep can exacerbate fatigue and contribute to immobility.
  • Environmental Barriers: Evaluate the home environment for obstacles that limit mobility, such as stairs, clutter, or lack of support devices.
  • Fear of Falling: Can lead to self-imposed activity limitation and subsequent immobility.
  • Functional Impact: Assess the impact of symptoms on daily functioning, including work, family life, and mental health.
  • Immunization History: Consider relevance in cases of infectious causes, such as pneumonia or urinary tract infections.
  • Psychiatric History: Consider underlying psychiatric conditions that may manifest with somatic symptoms.
  • Family Planning: In women, discuss future pregnancy plans, as this may impact management in cases like hyperemesis gravidarum.
  • Lifestyle Factors: Consider the impact of lifestyle choices on symptoms, including work stress, sleep patterns, and exercise.
  • Comorbid Conditions: Review of other chronic conditions, such as diabetes, hypertension, or renal disease, which may complicate management.

Possible Investigations 🌡️

Initial Laboratory Tests

  • Full Blood Count (FBC): To assess for anemia, infection, or malignancy that may contribute to weakness and immobility.
  • Electrolyte Panel: Important to assess for electrolyte imbalances, particularly hyponatremia, hyperkalemia, and metabolic acidosis.
  • Renal Function Tests: Assess for renal impairment, particularly in cases of severe dehydration or chronic kidney disease.
  • Liver Function Tests: To assess for hepatic involvement or dehydration.
  • Serum Glucose: Important in ruling out diabetic ketoacidosis as a cause of nausea and vomiting.
  • Thyroid Function Tests: To assess for hyperthyroidism as a potential cause of vomiting.
  • Urinalysis: To assess for ketonuria, which is indicative of dehydration or starvation.
  • Arterial Blood Gas (ABG): To assess for acid-base disturbances in severe cases.
  • Pregnancy Test: Mandatory in women of childbearing age to rule out or confirm pregnancy-related causes.
  • Serum Amylase/Lipase: To rule out pancreatitis in cases of epigastric pain.
  • Infection Markers (CRP, ESR): To assess for underlying infection or inflammation.
  • Coagulation Profile: May be relevant in assessing the risk of bleeding or in cases of liver dysfunction.
  • Blood Cultures: If sepsis is suspected, particularly in febrile patients.
  • Toxicology Screen: To assess for substance use or overdose.
  • Cortisol Levels: To assess for adrenal insufficiency, particularly in patients with hypotension or electrolyte abnormalities.
  • Vitamin and Nutrient Levels: In chronic cases, assess for deficiencies in vitamins (e.g., B12, folate) and electrolytes.
  • Hepatitis Serology: Consider in cases with liver involvement or risk factors for viral hepatitis.
  • Urine Drug Screen: In cases where substance abuse is suspected.
  • Serum Calcium: To assess for hypercalcemia as a potential cause of nausea and vomiting.
  • C-Reactive Protein (CRP): To assess for inflammation or infection.
  • Bone Profile: To assess for osteoporosis, particularly in elderly or immobilized patients.
  • Creatine Kinase (CK): Elevated in muscle injury or myopathies contributing to immobility.
  • Vitamin D Levels: To assess for deficiency contributing to muscle weakness and immobility.
  • Iron Studies: To assess for anemia or iron deficiency contributing to fatigue and immobility.
  • Rheumatoid Factor (RF) and Anti-CCP: In suspected rheumatoid arthritis or autoimmune causes of immobility.
  • Thyroid Stimulating Hormone (TSH): To assess for hypothyroidism contributing to immobility.
  • Antinuclear Antibody (ANA): In suspected autoimmune causes of immobility.
  • Electromyography (EMG): To assess for neuromuscular causes of immobility, such as myasthenia gravis or motor neuron disease.
  • D-dimer: To assess for venous thromboembolism in patients with risk factors for DVT or PE.
  • Immunoglobulins: To assess for immune system involvement in chronic conditions contributing to immobility.
  • HIV Serology: In cases where opportunistic infections or HIV-related myopathy are suspected.
  • Lactate Dehydrogenase (LDH): Elevated in tissue damage or inflammation, may be relevant in some cases.
  • Lumbar Puncture: In cases where CNS infection or inflammatory conditions like multiple sclerosis are suspected.
  • Blood Pressure Monitoring: Particularly important in patients with suspected postural hypotension contributing to falls and immobility.
  • Pulse Oximetry: To assess for hypoxia, particularly in patients with chronic lung disease or pulmonary embolism.
  • Echocardiogram: To assess cardiac function in patients with heart failure or valvular disease contributing to immobility.
  • Spirometry: To assess for obstructive lung disease contributing to dyspnea and immobility.
  • Immunoglobulin Levels: To assess for immune deficiency contributing to recurrent infections and immobility.
  • Thyroid Ultrasound: In cases where thyroid nodules or goiter are suspected contributors to symptoms.
  • CT or MRI of the Brain: To assess for stroke, tumor, or other CNS causes of immobility.
  • Doppler Ultrasound of Lower Limbs: To assess for DVT in patients with leg swelling and immobility.
  • CT or MRI of the Spine: To assess for spinal stenosis, disc herniation, or other causes of spinal cord compression.
  • Bone Density Scan (DEXA): To assess for osteoporosis in elderly patients or those with chronic immobility.
  • Nerve Conduction Studies: To assess for peripheral neuropathy contributing to immobility.
  • Barium Swallow or Upper GI Series: May be indicated in cases of suspected esophageal or gastric motility disorders.
  • CXR (Chest X-ray): To assess for lower lobe pneumonia or other thoracic causes of nausea.
  • H. Pylori Testing: In cases of suspected peptic ulcer disease.
  • Thyroid Ultrasound: If there is suspicion of thyroid pathology contributing to symptoms.
  • Endocrine Testing: Cortisol, ACTH, and aldosterone levels may be indicated in suspected adrenal or pituitary dysfunction.
  • EEG: In cases of suspected neurological causes, particularly if there are associated seizures or altered consciousness.
  • Laparoscopy: May be considered in cases of unexplained abdominal pain with persistent vomiting.
  • Holter Monitoring: If cardiac arrhythmias are suspected in relation to symptoms.
  • ENT Referral: For suspected ENT causes like vestibular disorders or postnasal drip contributing to symptoms.
  • Psychiatric Evaluation: In cases where psychogenic vomiting or eating disorders are suspected.
  • Nutritional Assessment: In chronic cases, assess for malnutrition and the need for nutritional support.
  • Serum Ketones: To assess for ketoacidosis, particularly in diabetic patients.
  • Cervical Spine Imaging: Consider in cases of suspected cervical spine pathology contributing to nausea and vomiting.

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Medicine of older adult