Diagnostic Approach to Peripheral Neuropathy

Initial Evaluation

The American Diabetes Association suggests that the combination of balance issues, weakness, gait instability, numbness, and tingling in the legs in a 76-year-old strongly suggests peripheral neuropathy with loss of protective sensation (LOPS) 1, 2
Diabetes is the most common identifiable cause of peripheral neuropathy, and diabetic peripheral neuropathy (DPN) was found to be a component cause in 78% of patients with ulcerations, according to the American Diabetes Association 2
The American College of Physicians recommends checking vitamin B12 level as nutritional deficiencies are common reversible causes of peripheral neuropathy 3

The American Academy of Neurology recommends performing a focused neurological examination emphasizing 10-g monofilament testing, which is the most useful test to diagnose LOPS 1, 2
The American Geriatrics Society suggests assessing gait and balance, as gait instability increases fall risk 12-fold in symptomatic older adults 6
The American Heart Association recommends assessing pedal pulse palpation to evaluate for peripheral arterial disease (PAD) 2

The American Geriatrics Society recommends conducting immediate falls screening, including questions about previous falls, unsteadiness, and fear of falling 6
If positive responses, consider detailed assessment with Get Up and Go test, Tinetti Balance Assessment, or Berg Balance Scale, as recommended by the American Geriatrics Society 6

The American Diabetes Association recommends checking fasting blood glucose and HbA1c to identify diabetic peripheral neuropathy 2
The American College of Physicians suggests checking serum ferritin if restless legs syndrome symptoms are present, as values <50 ng/mL suggest iron deficiency-related restless legs syndrome 5
The American Academy of Neurology recommends checking erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) if the patient reports scalp tenderness, jaw claudication, or pain, to evaluate for giant cell arteritis 4

The American Diabetes Association recommends assessing for diabetic foot complications, including inspecting feet for skin integrity, deformities, and ulcers 1, 2
The American Geriatrics Society suggests initiating fall prevention counseling, including assessing home safety and considering activity restrictions until diagnosis is established 6, 8
The European Society of Cardiology recommends screening for autonomic dysfunction, including asking about orthostatic symptoms, as orthostatic hypotension commonly coexists with peripheral neuropathy in elderly patients 5, 9