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August 13, 2020
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PCPs ‘first line’ of defense against projected increase in neurological disorders

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Researchers observed a U-shaped trend in age-adjusted mortality rates from neurological disorders from 1999 to 2017. The recent upward trend suggests these disorders are an “imminent threat to public health,” they wrote in JAMA Neurology.

Using CDC’s WONDER database and ICD codes, Eric Karl Oermann, MD, assistant professor in the department of neurosurgery at NYU Langone Medical Center, and colleagues found that in 1999, the age-adjusted mortality rate from neurological disorders was 98.6 per 100,000 deaths. By 2013, that rate had dropped to 84.2, but by 2017 it returned to 98.6 and is expected to keep rising. Researchers attributed the findings to lower rates of cerebrovascular mortality such as stroke, and higher rates of mortality from neurodegenerative disorders such as Alzheimer’s disease.

Age-adjusted mortality rates from neurological disorders per 100,000 deaths went from 98.6 in 1999, to 84.2 in 2013 and back to 98.6 in 2017.
Reference: Neifert SN, et al. JAMA Neurol. 2020;doi:10.1001/jamaneurol.2020.1878.

In an interview with Healio Primary Care, Oermann, who was instructor in the department of neurosurgery at the Mount Sinai Health System at the time of his research, discussed the role of primary care physicians in the diagnosis and management of neurological disorders.

Eric Oermann
Eric Karl Oermann

Q: What neuro degenerative disorders pose the biggest threat to public health in the future?

A: The most common of these disorders are dementias, and the foremost of those is Alzheimer’s. The second most common neurodegenerative disorder is Parkinson’s disease. All of these diseases are associated with aging. Unfortunately, we do not fully understand the mechanisms of most neurodegenerative disorders and with an aging population in the United States, these neurodegenerative diseases threaten public health in the future.

While we cannot make definitive conclusions and our paper does not involve projecting future mortality from neurological diseases, we are concerned about the aging population's risk for neurodegenerative diseases. Our hope is that more attention will be paid to these problems in the future.

Q: What role do PCPs have in the management of neurological disorders?

A: PCPs are the first-line connection between patients and the health care system — their role in recognizing neurological diseases cannot be understated. Ensuring that PCPs take full advantage of their role as front-line care providers and screen for neurological diseases is essential. The value of performing a succinct but complete neurological exam cannot be understated.

Q: Can you walk our readers through the steps of performing “a succinct but complete neurological exam”?

A: Patients’ families often can make the best diagnosis for conditions such as Alzheimer’s and Parkinson’s disease since they know the patients better than anyone and can best identify when patients are not being themselves.

Regarding cerebrovascular disorders, the most common of these being stroke, PCPs can teach their patients the acronym FAST — Facial droop, Arm weakness, Speech difficulty and Time to call an ambulance — to help them recognize this condition’s presentation.

Q: When should a PCP recommend a patient with one of these disorders see a specialist?

A: These conditions affect different populations and present in numerous ways. The decision to refer a patient to a specialist depends on several factors, such as the condition, the severity of the presentation and the PCP's own confidence in their ability to manage the patient.

One such disease, Alzheimer’s disease, can be particularly challenging to diagnose, due to its subtle symptoms and insidious onset. Often the first symptom is a worsening of episodic memory which subtly underpins many tasks of daily life. Many patients, especially those who have early onset Alzheimer’s, have difficulties performing their job or accomplishing simple household tasks. Other symptoms such as difficulty with language and behavioral changes present later in the course of the disease.

Q: Your data indicate the South was the only U.S. region to see an increase in total neurological disease age-adjusted mortality. What is your message to physicians in th is region?

A: Our results support the known phenomenon of cerebrovascular disease being particularly problematic in the southern United States, a region also known as the Stroke Belt. Physicians may not be as aware that Other studies have suggested that the higher cerebrovascular mortality in the South is partially driven by a higher percentage of the population living in rural areas and having less access to diagnostic care and treatment. Physicians also need to know is that there is also a shortage of physicians in this region.