November/December 2019

Carpal Tunnel Syndrome in Older Adults — The Impact of Age on Diagnosis and Treatment
By Lindsey Getz
Today’s Geriatric Medicine
Vol. 12 No. 6 P. 14

It’s likely you’ve seen patients with symptoms of carpal tunnel syndrome (CTS) in your practice. After all, research indicates it affects as many as 10 million Americans and is more common among older adults. In most patients, CTS worsens over time, indicating the importance of prompt diagnosis and early treatment. However, it’s important to take the patient’s age into account when making any diagnosis and treatment recommendations, as other common conditions may cause similar symptoms.

What Is CTS?
CTS is the most common entrapment neuropathy. It’s a condition in which the median nerve is compressed during its passage through the tunnel formed by the wrist bones (the carpal tunnel). The median nerve is one of the main nerves of the hand and originates as a group of nerve roots in the neck. These roots ultimately form a single nerve that travels down the forearm and passes through the carpal tunnel at the wrist. Anything that compresses or irritates the median nerve can lead to CTS.

The exact cause of most cases of CTS remains unknown, though it is believed wrist anatomy, existing health problems (eg, diabetes, rheumatoid arthritis, and thyroid gland imbalance), and repetitive hand motion can contribute to it. Activities that involve extreme flexion or extension of the hand for prolonged periods may also aggravate tendons in the wrist and put pressure on the median nerve.

There’s likely no single cause, but rather a combination of risk factors that leads to the condition.

“Age in and of itself is a risk factor,” says Ryan M. Danowski, DO, an orthopaedic surgeon at Virtua Health System in Cherry Hill, New Jersey. Other risk factors he points to are obesity, renal diseases, smoking, and alcohol use. “Repetitive activities and vibration are risk factors as well. People who use power tools, play tennis, type frequently, or participate in sports with repetitive throwing may have a higher risk.”

Dori Neill Cage, MD, FAAOS, a spokesperson for the American Academy of Orthopaedic Surgeons (AAOS) and a surgeon with San Diego Hand Specialists, says CTS can have an impact on quality of life for patients. Tasks that were once easy can become difficult for patients with pain or weakness as a result of CTS. “They might start dropping objects or have trouble with fine manipulation, such as buttoning a sweater,” she says. “It can also affect sleep quality, as sleep positions can lead to painful flare-ups that wake them.”

For these reasons, it’s important for patients exhibiting symptoms of CTS to pursue treatment.

CTS Presentation
Typically, the chief complaints related to CTS are pain, numbness, weakness, and paresthesia such as tingling, pricking, and burning. According to Cage, it’s not uncommon at her practice for older adults to present with more severe symptoms than those of younger patients—oftentimes because they’ve ignored the initial symptoms. When CTS remains untreated, it can progress to atrophy of the muscles of the hand under the thumb.

“Unfortunately, when you ignore carpal tunnel syndrome, it’s only going to get worse,” Cage says. “Many studies have shown that when you treat earlier, the results are better. But if you delay, it’s increasingly more likely that you’ll have a worse outcome because the nerves have been permanently injured and are less likely to heal.”

Cage says that, whereas her younger patients will often tell her they wake up at night with numbness and tingling, many of her older patients describe vague numbness, stiffness, or even complete loss of muscle control—again all likely due to the fact that they have more serious cases.

Cage’s anecdotal findings in practice are in line with research performed by Steven Herskovitz, MD, a professor of neurology and director of Neuromuscular Medicine and EMG Lab at Montefiore Medical Center at Albert Einstein College of Medicine in Bronx, New York. His study published in Muscle & Nerve found that electrophysiologic abnormalities were more common and more severe in older patients.

“The set of symptoms of CTS is no different in older adults, comprising various combinations of hand pain, finger numbness or paresthesia, nocturnal exacerbation, and hand weakness or clumsiness,” Herskovitz says. “Our study of CTS patients referred to a neuromuscular service showed that older adults tend to present with more severe clinical and electrophysiologic signs of hand weakness and atrophy, so clinicians should be sensitive to those features.”

 One of the most common reasons older adults ignore CTS may be that they don’t believe they could have it, Cage says. There’s a common misconception among the general population that CTS is only caused by an overuse injury, such as typing. “So many of my patients say, ‘I’m not on the computer all day; I can’t possibly have this,’” Cage says. “In reality, overuse is only one of many possible factors. If they’re ignoring it, it’s worsening, so it’s an important message to get out to patients that carpal tunnel syndrome is not solely caused by repetitive use; that way they will be encouraged to seek treatment sooner.”

Diagnosing and Treating CTS
Doctors can make an effective diagnosis of CTS by reviewing symptoms and performing a physical exam during which pressure is placed on the median nerve to reproduce the symptoms. However, evaluation of the hand, in terms of symptoms and signs, may be confounded by arthritis or other comorbidities in older adults. Electrodiagnostic studies (eg, electromyography, nerve conduction studies) and ultrasound are excellent tools to establish the diagnosis and severity in all age groups; such tests may be performed to determine the severity of the median nerve irritation.

According to Herskovitz, treatment options for CTS are the same, regardless of age. All treatment options aim at making more room for the nerve so it can heal. The extent of damage obviously will affect how well a patient recovers.

“The best data supports splinting, steroid injections, and surgery as options,” he says. “Most studies suggest that the older adult has a salutary response to surgery regardless of the severity, though residual deficits are likely in severe cases.”

Danowski always starts conservatively, beginning with splinting, which will relieve the pressure on the nerve while the patient sleeps. Because most people bend their wrists when they sleep (and put pressure on the median nerve), a brace can help prevent this by keeping the wrist in a straight, neutral position.

Corticosteroid injections into the carpal tunnel can also be utilized to reduce inflammation and swelling and, therefore, reduce pressure on the median nerve. These injections are typically used in an effort to avoid surgery, if possible, Danowski says.

“Corticosteroid injections can be a once-and-done treatment and the patient feels relief and the nerve heals,” Cage adds. “Or it may be relief that lasts for six months to a year and then they require another injection. For an older adult population who are purposely looking to avoid surgery, it can be an effective option. But surgery is an important option if the injections aren’t providing relief.”

How Old Is Too Old for CTS Surgery?
As with any surgery or treatment, it’s always important to weigh the risks vs the benefits. But research and anecdotal evidence seem to point toward CTS surgery being a viable option for most patients, regardless of age.

“There is always risk associated with surgery; however, if left untreated, patients can develop permanent loss of sensation and numbness in that hand, so it’s important to pursue surgery if the symptoms persist,” Danowski says. “It’s not a major surgical procedure, and patients tend to recover quite well.”

A study by Todnem and Lundemo, published in the journal Muscle & Nerve, confirmed that many older adults can benefit from surgery to correct CTS. In the study, three groups of patients were compared: One group of patients aged 70 to 89 underwent surgery, a second group aged 30 to 69 also underwent surgery, and a third group of patients aged 25 to 83 did not have surgery.

The older patients had significant improvement after surgery, comparable to that of the younger patients who had surgery. Both young and old patients who did not receive surgery also improved, but not as much as did the group that had surgery.

“I’ve operated on 99-year-old patients for carpal tunnel syndrome,” Cage says. “I had one 99-year-old patient who had heart surgery and the fluid shift from the surgery caused the carpal tunnel syndrome, so she had surgery to repair that. It’s a simple surgery and not very taxing on the heart or lungs. It can be performed under local anesthesia so that the patient doesn’t even have to go to sleep.”

Cage says that the actual surgery takes 20 minutes at most. There are two surgical approaches—open and endoscopic.

“With both the endoscopic and the mini open procedure, the tight ligament (the transverse carpal ligament) over the nerve is cut. In the endoscopic, it is cut from underneath while viewing the ligament with a camera through a small incision. With the mini-open procedure, a slightly larger incision is made and the ligament is cut when directly viewing it from above the ligament.” After surgery, the ligament comes back together but with more room for the median nerve.

Research, Cage says, indicates both methods are effective, and the choice is typically based on what physicians are most comfortable with. Because the openings are smaller with endoscopic surgery, it’s generally believed that the incision site recovery time may be quicker.

“With either method, patients start moving their hands right away in the recovery room and feel that immediate relief from the pressure being relieved,” Cage says. “There’s really not a lot of downtime with this and they can resume light activity the same day. The older adult population almost never even requires pain medication—at most they’ll take a Tylenol or Advil.”

Danowski adds that following carpal tunnel surgery, he limits patients to lifting no more than 5 lbs with the arm on which surgery was performed for two weeks. By six weeks, patients have typically resumed all normal activity.

Similar Conditions to Consider
Cage cautions that it’s important to note conditions that are similar to CTS, as well as correlations that need to be considered, such as an association with arthritis.

“The bones in the wrist make a little cup, and there are structures in the middle of that cup,” Cage explains. “When patients have arthritis, the inflammation can make the space smaller and therefore put additional pressure on the median nerve. This is why there is an association with arthritis.”

In addition, Cage says, some of her patients present assuming they have arthritis or CTS when in fact they have a condition called trigger finger, in which a finger gets stuck in a bent position and then snaps straight.

“Trigger finger is another entirely separate diagnosis, also common in older adults, and also incredibly treatable,” she says. “The bottom line is that there are solutions for many orthopaedic conditions related to the hand and wrist, and physicians working with older adults should encourage their patients to take the next step with a specialist in order to be properly diagnosed. Many of these conditions only worsen with time, making time truly of the essence.”

— Lindsey Getz is an award-winning freelance writer in Royersford, Pennsylvania.