Medical Grand Rounds featuring Drs. John Puxty and Leah Nemiroff
Devon Cole, MSc Candidate, Translational Medicine
During April 11th medical grand rounds, Dr. Puxty and Dr. Nemiroff presented on the topic of traumatic encephalopathy syndrome (TES) in non–athletic older adults. Dr. Nemiroff began her schooling in marine biology, however through her time at Dalhousie University, her desire to help others led her to pursue a degree in medicine. After completing an internal medicine residency, she decided to specialize in geriatrics due to its complexity and being able to make a meaningful difference to her patients. Dr. Puxty found himself in the discipline of medicine after a grade-school teacher told him he could never be a doctor. Dr. Puxty has clearly proved him wrong, as he is now Chair of the Division of Geriatric Medicine at Queen’s University.
TES refers to the clinical syndrome associated with repetitive head injuries. TES may or may not be accompanied by chronic traumatic encephalopathy (CTE) neuropathologies, such as the formation of neurofibrillary tangles due to an excess of phosphorylated tau protein. To be diagnosed with TES, the individual has to have a history of multiple impacts to the head, as well as the presentation of one of three core clinical features. TES can impact an individual’s ability to complete activities of daily living, making it very frustrating for patients and caregivers alike.
During our post-rounds discussion, Drs. Puxty and Nemiroff elaborated on the phrase “when you hear hoofbeats think horses not zebras” in terms of a patient presenting with symptoms of dementia. TES is a zebra, generally being diagnosed after other forms of dementia have been ruled out. When making a diagnosis of TES, Drs. Puxty and Nemiroff reiterated how important a thorough, detailed history is. Supportive family members play a key role in this process as they often spread light on events that the patient may not disclose. Specific to diagnosing TES in non–athletic older adults, is the occurrence of head injuries resulting from domestic abuse. There is still much stigma surrounding the topics of spousal and elder abuse, therefore patients may feel uncomfortable disclosing this information. Family members can help physicians by filling in some of the blanks in the patient’s history, leading to more well-informed patient care. Prevention of CTE as a result of abuse was also discussed. A great point was made that by educating social workers and counsellors on TES and CTE, it may help victims of abuse leave an abusive relationship before multiple head injuries have been sustained.
An interesting topic discussed in both current literature on TES and CTE and in our discussion is the need to identify biomarkers for CTE. Currently a differential diagnosis of CTE can only be made post-mortem, therefore biomarkers could help provide more accurate diagnosis and treatment in the living patient. PET imaging of tau-specific tracers is currently being examined to identify aggregated tau associated with CTE however more research is needed to determine the sensitivity and specificity of this method. During rounds, Dr. Puxty also discussed the use of statins in individuals at high risk of developing CTE, such as professional athletes, to reduce inflammation associated with brain injury in hopes of preventing or slowing the development of CTE. Research into the inflammatory mechanisms behind CTE could prove useful in identifying more potential targets for prevention therapies.
Overall our discussion with Drs. Puxty and Nemiroff was very informative. Touching on both social and medical issues surrounding TES and CTE, it opened our minds to the field of geriatrics and some of its complexities.