Prevalence of Peripheral Neuropathy Among Very Old Adults: Evidence from the Michigan Neuropathy Screening Instrument

Abstract

Background:

Emerging evidence suggests that peripheral neuropathy (PN), which has been associated with mortality, is more common in older adults than previously recognized. However, most studies define PN by loss of protective sensation alone, a late form of PN. We aimed to quantify the prevalence and risk factors PN in very old community-dwelling adults regardless of diabetes using the Michigan Neuropathy Screening Instrument(MNSI), a validated screening tool.

Methods:

We conducted a cross-sectional analysis of participants aged 78–100 years old in the Atherosclerosis Risk in Communities Study(2022–2023). PN was defined by a score >2 on the MNSI physical examination or ≥7 on the MNSI questionnaire. We report the prevalence rates and age-, sex-, race-center-adjusted odds ratios(aOR) of PN associated covariates using logistic regression.

Results:

Among 1,068 participants(median age 84.1 years, SD 3.9; 40.0% male; 17.5% Black; 26.8% with diabetes), 62.4% had PN. MNSI-detected PN was present in 67.4% of participants with diabetes, 61.9% with prediabetes, and 59.2% without diabetes(p = 0.14). Covariates associated with PN included advanced age(≥90 years vs 75–80 year: aOR 2.92), male sex vs female sex: aOR 2.38), taller height (height quartile 4 vs1: aOR 2.28), low short physical performance battery scores(vs highest scores: aOR 2.35), hypertension(aOR 1.56), and lumbosacral stenosis(aOR 1.76). In a sensitivity analysis, PN prevalence was lower when using the monofilament test(38.9%) compared to the MNSI(p <0.001). Diabetes was significantly associated with PN when assessed using monofilament testing for loss of protective sensation(aOR: 1.85; 95%CI: 1.31–2.61) compared to the MNSI(aOR: 1.42; 95%CI: 1.00–2.03).

Conclusion:

PN detected by the MNSI is highly prevalent among very old adults, regardless of diabetes status. The MNSI detected a higher prevalence of PN in older adults compared to the monofilament test. Routine screening of high-risk adults using the MNSI may be warranted to facilitate early detection and management.

Graphic Abstract

Peripheral neuropathy is highly prevalent in the very old adult population, regardless of diabetes status. This has been demonstrated using a validated screening tool, the Michigan Neuropathy Screening Instrument (MNSI), which captures a spectrum of neuropathy presentations. However, monofilament insensitivity, indicative of more advanced peripheral neuropathy, is significantly more prevalent in individuals with diabetes.

INTRODUCTION

Peripheral neuropathy (PN) is a distal symmetric polyneuropathy that is traditionally associated with diabetes^1,2. Previous studies have shown that PN contributes to substantial morbidity including extremity complications, autonomic/sensory dysregulation, traumas, and mortality in adults with diabetes.^3–6. PN risk increases with age, but research on its etiology and outcomes beyond diabetes is limited. Prevalence estimates vary widely due to differences in PN diagnostic criteria and study populations^5,7,8.

We have previously reported the prevalence of PN based on monofilament test using NHANES (National Health and Nutrition Examination Survey) and ARIC (Atherosclerosis Risk in Communities) studies⁹. We demonstrated that PN is present in approximately 42% of adults aged ≥70 years, regardless of diabetes^9,10. However, the monofilament test detects the loss of protective sensation, which represents a more advanced neurodegeneration^1,10. PN manifests on a broad spectrum of symptoms, and the true prevalence of less severe PN in older adults is likely higher than previously reported (34–42%)⁹.

The Michigan Neuropathy Screening Instrument (MNSI) is a validated screening tool developed to detect diabetic PN¹¹. It consists of two components: a 15-item questionnaire addressing symptom burden, and a provider-administered physical assessment based on visual inspection, ankle reflex assessment, vibration perception, and the monofilament test. PN prevalence data in older adults using the MNSI are limited, particularly among those without diabetes, despite evidence showing that PN is independently associated with all-cause and cardiovascular mortality regardless of diabetes status⁶. We aimed to report the prevalence and risk factors associated with PN as defined by the MNSI in very old community-dwelling adults.

METHODS

Study Population:

The ARIC study is a community-based cohort launched in 1985 across four U.S. sites: Forsyth County, North Carolina; Jackson, Mississippi; Minneapolis, Minnesota; and Washington County, Maryland.¹² All participants provided informed consent, and study was approved by institutional review boards at each sites.

We conducted a cross-sectional analysis of ARIC participants who completed the MNSI exam at Visit 10 (2022–2023), excluding those with missing MNSI components (n= 324), diabetes status (n=46), or key covariates (n= 131) (Supplementary Figure 1).

Peripheral Neuropathy:

PN was defined using MNSI¹¹. The questionnaire is a self-administered 15-item questionnaire (score range: 0–13; Supplementary Figure 2). Questions 4 and 10, related to impaired circulation and asthenia, were excluded to be consistent with the published scoring algorithm^11,13,14

The MNSI physical assessment, performed by trained technicians, included foot inspection, vibration sensation, ankle reflex, and monofilament testing. Feet were inspected for cracks/fissures, callouses, ulcers, deformities, or Charcot foot (score=1 per abnormal foot). A vibration perception test was conducted using a 128Hz tuning fork on the great toe, with participants’ eyes closed, and scored as present (0), reduced (0.5), or absent (1), based on the duration of the participant’s perception compared to that of the examiner. Ankle reflexes were assessed by tapping the Achilles tendons with a reflex hammer, using the Jendrassik maneuver when necessary, and scored as present (score= 0), reduced/reinforcement-required (score= 0.5), or absent (score= 1). The monofilament test was performed using the 5.07 Semmes–Weinstein monofilament, delivering 10-g filament force. Pressure was applied to the plantar surface of the feet at the first, fifth metatarsal head, and hallux bilaterally, in random order. With eyes closed, participants were presented with two touches, with and without monofilament, and were asked to indicate which touch they felt. If a participant’s initial response was correct, no further testing was conducted at that site. If incorrect, the test was repeated up to three times to obtain two consistent responses. A site was classified as insensate if there were two incorrect responses (score= 1). The physical assessment has a score range of 0–8, with each foot contributing a maximum of 4 points.

A score of ≥7 on MNSI questionnaire or >2 on the physical assessment was considered abnormal^11,13,14 and used to define PN. As a sensitivity analysis, we reported PN using monofilament testing alone. Participants with ≥1 insensate site on either foot during the monofilament test were classified as having PN⁹.

Covariates of Interest:

We evaluated risk factors potentially associated with PN including demographic factors (age, sex), social determinants of health (race-center, baseline education, Area Deprivation Index [ADI])¹⁵, physical factors (body mass index [BMI], sex-specific height quartiles), physical functioning (using Short Physical Performance Battery scores [SPPB])^16–18, lifetime lifestyle habits (smoking, drinking history), frailty, cardiovascular disease, hypertension, hypercholesterolemia, cancer, chronic kidney disease, lumbosacral stenosis, and diabetes.

Race-center combined race and ARIC field centers to account for uneven racial distribution across sites. ADI was calculated with zip codes¹⁵. Diabetes was defined as self-reported physician-diagnosed diabetes, glucose-lowering medication use, or a hemoglobin A1c (HbA1c) level of ≥6.5%. Pre-diabetes was defined as HbA1c level between 5.7–6.4% in individuals without diabetes. Drinking/smoking status was classified as never, former, or current based on self-report. Prevalent cardiovascular disease was defined as history of myocardial infarction, heart failure, or ischemic stroke¹⁹. Hypertension was defined as systolic blood pressure ≥130mmHg, diastolic blood pressure ≥80mmHg, or taking antihypertensive medications²⁰. Hypercholesterolemia was defined as plasma total cholesterol ≥240mg/dL or taking cholesterol medications. Chronic kidney disease was defined as urinary albumin-to-creatinine ratio >30mg/g²¹. Lumbosacral stenosis was identified using ICD codes linked to Centers for Medicare & Medicaid Services data.

The SPPB is a standardized tool that assesses lower extremity physical function through balance, gait speed, and chair stands (score range 0–12). SPPB results were categorized into low (0–6), fair (7–9), and good (10–12)^16–18. Frailty was defined by unintentional weight loss, slow walking speed, and weak grip strength^17,22–24. Weight loss was defined as >5% reduction between Visit 9 (2021–2022) and 10 (2022–2023) or BMI <18.5 kg/m².²⁵ Slow walking speed and weak grip strength was defined as <20^th percentile^17,24.

Statistical Analysis:

We quantified the prevalence of MNSI-detected PN overall and by diabetes status. We used logistic regression models to evaluate the age-, sex- and race-center-adjusted associations of risk factors with MNSI-defined PN. As a sensitivity analysis, we repeated analyses for PN defined using monofilament testing. We performed analyses using Stata, version 18.0 (StataCorp), with P<0.05 denoting statistical significance.

RESULTS

Prevalence of Peripheral Neuropathy based on MNSI

We included 1,068 ARIC participants who completed the MNSI (age range 78–100 years) (Table 1). The prevalence of MNSI-detected PN was 62.4%. When stratified by diabetes status, the prevalence was 60.2% among participants without diabetes, 61.7% among participants with pre-diabetes, and 67.5% among participants with diabetes (P= 0.14; Figure 1).

Table 1.

Participant Demographics and Clinical Characteristics, Atherosclerosis Risk in Communities (ARIC) Study, Visit 10 (2022–2023)

	N = 1,068 %
Age, years, median (range)	84 (78 – 100)
Age, years
75–79	7.1
80–84	53.5
85–89	29.4
≥ 90	0.0
Sex
Male	40.0
Race-Center
Forsyth County – White	21.1
Forsyth County – Black	2.1
Jackson – Black	15.3
Minneapolis – White	30.7
Minneapolis – Black	0.1
Washington – White	30.7
Washington – Black	0.1
Baseline Education
Below high school	7.8
High school or vocational school	43.9
At least College	49.3
National Area Deprivation Index
Quartile 1	28.9
Quartile 2	24.9
Quartile 3	26.0
Quartile 4	20.1
Diabetes status
No diabetes	35.3
Pre-diabetes	37.9
Diabetes	26.8
Body mass index, kg/m2
0–24.99	36.3
25–29.99	40.8
≥30	22.8
Sex-specific height quartile
Quartile 1	27.6
Quartile 2	25.2
Quartile 3	23.1
Quartile 4	24.1
Frailty Measures
Slow Walking Speed	20.5
Weight Loss	19.7
Weak Grip Strength	37.4
Short Physical Performance Battery
Good (10–12)	37.7
Fair (7–9)	24.3
Low (0–6)	11.0
Unknown	30.0
Smoking status
Never	36.3
Ever	53.0
Unknown	10.7
Drinking status
Never	15.5
Former	32.2
Current	38.3
Unknown	14.0
Comorbidities
Prevalent cardiovascular disease	58.4
Hypertension	85.2
Hypercholesterolemia	66.5
Chronic Kidney Disease	21.4
Cancer	18.4
Lumbosacral stenosis	20.4

Figure 1.

Peripheral Neuropathy Prevalence Stratified by Diabetes Status: 2022–2023, Atherosclerosis Risk in Communities Study, Visit 10

Questionnaire and Physical Assessment Components of MNSI

Almost all participants with MNSI-detected PN (96.7%) scored <7 points on the questionnaire, indicating a low self-reported symptom burden (Supplementary Table 1). Participants with MNSI-detected PN reported a high symptom burden of lower extremity numbness, pain, paresthesia, and worsened neuropathic symptoms, particularly at night and with movement. Participants with MNSI-detected PN were more likely to report prior foot sores and a physician diagnosis of PN (Supplementary Figure 3). In the physical assessment, foot deformities/ulcers (20.1%) and monofilament insensitivity (62.5%) were exclusive to the PN group. Abnormal vibration perception (32.1 vs 14.3%) and ankle reflex (33.1 vs 29.6%) were more prevalent among participants with PN (Supplementary Table 1).

Risk Factors

Age, male sex, taller height, lower SPPB scores, slower walking speed, hypertension, and lumbosacral stenosis were significantly associated with MNSI-detected PN. Diabetes was associated with MNSI-detected PN, although this result was of borderline statistical significance (Table 2).

Table 2.

Age, Sex, and Race-Center- Adjusted Prevalence [%, (SE)] and Odds Ratios [OR (95% CI)] of Peripheral Neuropathy Detected by the Michigan Neuropathy Screening Instrument and the Monofilament Insensitivity Test: 2022–2023, Atherosclerosis Risk in Communities Study, Visit 10

	Adjusted Prevalencea % (SE)		Adjusted Odds Ratiosb (95% CI)
	MNSI Positive n = 666	Monofilament Insensitivity n = 402	MNSI Positive n = 666	Monofilament Insensitivity n = 402
Age in years
75–79	53.0 (5.4)	38.1 (5.5)	1 (Ref.)	1 (Ref.)
80–84	58.9 (2.0)	34.1 (1.9)	1.30 (0.79, 2.16)	0.83 (0.49, 1.40)
85–89	66.9 (2.6)	46.2 (2.7)	1.90 (1.11, 3.24)	1.43 (0.83, 2.47)
≥ 90	75.0 (4.1)	44.6 (4.6)	2.92 (1.51, 5.64)	1.34 (0.71, 2.52)
Sex
Female	55.1 (1.9)	29.2 (1.8)	1 (Ref.)	1 (Ref.)
Male	73.3 (2.1)	53.7 (2.4)	2.38 (1.80, 3.13)	2.90 (2.24, 3.76)
Race-Center
Forsyth- White	57.5 (3.2)	42.2 (3.2)	1 (Ref.)	1 (Ref.)
Forsyth- Black	58.8 (10.3)	31.9 (9.6)	1.06 (0.42, 2.66)	0.62 (0.23, 1.64)
Jackson- Black	51.9 (3.8)	25.4 (3.4)	0.79 (0.52, 1.19)	0.44 (0.28, 0.70)
Minneapolis- White	51.9 (3.8)	40.5 (2.6)	0.90 (0.63, 1.28)	0.93 (0.65, 1.33)
Washington- White	78.8 (2.2)	42.3 (2.6)	2.89 (1.96, 4.25)	1.01 (0.71, 1.44)
Baseline Education
At least College	61.2 (2.0)	37.7 (2.0)	1 (Ref.)	1 (Ref.)
High school or vocational school	62.9 (2.2)	38.6 (2.2)	1.09 (0.82, 1.44)	1.04 (0.79, 1.37)
Below high school	67.8 (5.3)	50.3 (5.4)	1.38 (0.79, 2.41)	1.76 (1.06, 2.93)
National ADI
Quartile 1	64.6 (2.8)	38.8 (2.7)	1 (Ref.)	1 (Ref.)
Quartile 2	57.4 (3.0)	34.0 (2.8)	0.71 (0.49, 1.03)	0.80 (0.56, 1.13)
Quartile 3	61.4 (2.8)	42.8 (2.8)	0.86 (0.60, 1.24)	1.20 (0.85, 1.70)
Quartile 4	66.1 (3.6)	41.0 (4.1)	1.08 (0.67, 1.74)	1.11 (0.69, 1.78)
Diabetes status
No Diabetes	59.5 (2.4)	34.2 (2.3)	1 (Ref.)	1 (Ref.)
Pre-diabetes	62.0 (2.3)	37.6 (2.3)	1.12 (0.83, 1.52)	1.17 (0.86, 1.60)
Diabetes	66.8 (2.8)	47.7 (3.0)	1.42 (1.00, 2.03)	1.85 (1.31, 2.61)
Body mass index, kg/m2
0–24.99	60.9 (2.4)	35.1 (2.4)	1 (Ref.)	1 (Ref.)
25–29.99	61.0 (2.2)	38.1 (2.2)	1.00 (0.74, 1.36)	1.15 (0.85, 1.56)
≥30	67.4 (2.9)	47.1 (3.1)	1.38 (0.96, 1.98)	1.73 (1.21, 2.45)
Sex-specific height quartile
Quartile 1	51.4 (2.8)	27.2 (2.5)	1 (Ref.)	1 (Ref.)
Quartile 2	51.4 (2.8)	39.5 (2.9)	1.94 (1.35, 2.80)	1.78 (1.24, 2.54)
Quartile 3	63.5 (2.9)	41.2 (3.1)	1.94 (1.35, 2.80)	1.92 (1.32, 2.78)
Quartile 4	69.2 (2.7)	50.5 (3.1)	2.28 (1.57, 3.32)	2.83 (1.95, 4.09)
Frailty Measures
Slow Walking Speed	71.1 (2.9)	49.7 (3.4)	1.83 (1.28, 2.62)	1.93 (1.37, 2.72)
Unintentional Weight Loss	65.3 (3.1)	38.6 (3.3)	1.20 (0.85, 1.70)	0.92 (0.66, 1.30)
Weak Grip Strength	63.0 (2.4)	40.3 (2.3)	1.02 (0.76, 1.38)	1.05 (0.79, 1.40)
SPPB Score
Good (10–12)	56.3 (2.4)	33.8 (2.3)	1 (Ref.)	1 (Ref.)
Fair (7–9)	62.0 (2.9)	40.2 (3.0)	1.31 (0.92, 1.86)	1.35 (0.95, 1.92)
Low (0–6)	73.4 (4.1)	52.8 (4.5)	2.35 (1.41, 3.92)	2.38 (1.50, 3.78)
Drinking status
Never	63.7 (3.7)	46.6 (3.9)	1 (Ref.)	1 (Ref.)
Former	64.0 (2.6)	41.0 (2.6)	1.02 (0.67, 1.54)	0.78 (0.52, 1.16)
Current	61.5 (2.3)	37.0 (2.3)	0.90 (0.59, 1.37)	0.65 (0.43, 0.98)
Smoking status	64.1 (1.9)	38.9 (2.0)	1.15 (0.86, 1.53)	0.98 (0.74, 1.30)
Prevalent cardiovascular disease	64.8 (3.1)	37.4 (3.1)	1.16 (0.83, 1.62)	0.91 (0.66, 1.25)
Hypertension	63.8 (1.5)	40.3 (1.6)	1.56 (1.08, 2.25)	1.48 (1.02, 2.15)
Hypercholesterolemia	63.5 (1.7)	39.6 (1.8)	1.17 (0.88, 1.54)	1.08 (0.82, 1.43)
Chronic Kidney Disease	63 (1.7)	38.9 (1.7)	1.04 (0.75, 1.45)	1.10 (0.81, 1.53)
Cancer	60.7 (3.3)	42.7 (3.4)	0.91 (0.64, 1.28)	1.23 (0.88, 1.71)
Lumbosacral Stenosis	71.5 (3.0)	45.7 (3.2)	1.76 (1.24, 2.49)	1.46 (1.06, 2.01)

SE= Standard Error; CI= Confidence Interval; MNSI = Michigan Neuropathy Screening Instrument; ADI: Area Deprivation Index; SPPB: Short Physical Performance Battery

^aAdjusted prevalence estimates were derived by calculating marginal probabilities of peripheral neuropathy from logistic regression models adjusted for age, sex, and race-center

^bLogistic regression models used to evaluate the age, sex- and race-center-adjusted associations of risk factors with peripheral neuropathy

Sensitivity Analysis

In the sensitivity analysis defining PN using monofilament test, the prevalence was 38.9%, including 33.3% among participants without diabetes, 38.0% among participants with pre-diabetes, and 46.5% among participants with diabetes (P= 0.002; Figure 1). Monofilament insensitivity was present in 62.5% who screened positive for PN using MNSI (Supplementary Table 1). The risk factors associated with monofilament-defined PN were similar to those associated with MNSI-defined PN, with a few exceptions. BMI ≥30 kg/m2 (aOR 1.73), education level of less than high school (aOR 1.76), and diabetes (aOR 1.85, 95%CI 1.31–2.61), but not advanced age, were associated with PN defined by monofilament test (Table 2).

DISCUSSION:

Most prior studies estimating PN prevalence primarily relied on the monofilament test, a screening tool for advanced disease.^1,2,9 PN prevalence in very old adults using a more sensitive screening instrument has not been reported to our knowledge. Using the MNSI, 62.4% of community-dwelling adults aged 78–100 years had PN, with similar prevalence regardless of diabetes status. As expected, the PN prevalence was lower when defined using the monofilament testing, but still very high among participants both with and without diabetes (38.9% overall).

The PN prevalence in very old adults was substantially higher based on the MNSI compared to previous reports based on the monofilament test^9,26. Notably, only 62.5% of MNSI-detected PN was detected by the monofilament test. Prevalence differed likely because the monofilament test mainly detects loss of protective sensation and is less sensitive to the broader spectrum of PN presentations^1,2,27. Consistent with this notion, a meta-analysis reported the monofilament test had a pooled sensitivity of 53% for PN²⁸, while the MNSI sensitivity ranged from 65–70%.^29,30

We reported a slightly higher PN prevalence as defined by monofilament testing (38.9%) compared to prior population estimates in older adults (34.4%)⁹. The participants in the current analysis were older than those in prior studies (median age 84 vs 78 years)⁹. The association of age with PN is well established, and our data confirms the high prevalence in the aging population^9,31–34. Notably, the physical assessment captured 96.4% of PN cases in this study, underscoring the importance of incorporating this component in PN screening. Previous studies have shown that the physical assessment is sufficient to screen for diabetic PN, and combining the questionnaire and physical examination did not significantly improve detection^11,14. While only few PN cases were detected with the questionnaires, those with PN consistently reported higher scores across all questionnaire items, highlighting the relevance of this component in screening.

PN has traditionally been associated with diabetes^1,2,31, but studies have shown it’s also common in individuals without diabetes, with age as an independent risk factor^9,33,34. Using the MNSI, we reaffirmed the association between PN and age. Male sex and taller heights were associated with PN, findings consistent with limited epidemiologic studies in aging populations^6,35. Associations between slow gait and low SPPB scores with PN have been described in studies using monofilament test¹⁶. PN and lumbar stenosis commonly coexist in older adults, with stenosis potentially worsening symptoms through mechanical compression and reduced mobility^36,37. Covariates associated with loss of protective sensation, a more advanced form of PN, reflected well-established risk factors such as diabetes, obesity, and metabolic syndrome (higher BMI)^32,38. Hypertension is a known risk factor for developing PN². We showed a similar association between MNSI- and monofilament-detected PN with hypertension, which may suggest the importance of controlling hypertension regardless of neuropathy severity.

Although routine screening for diabetic PN is widely recommended by professional guidelines^2,39–41, a standardized screening approach of PN in adults without diabetes does not exist. PN is associated with significant morbidity as well as all-cause and cardiovascular mortality, even in populations without diabetes.⁶ As a result, screening for PN in high-risk individuals should be considered⁶. Our study demonstrates that PN is highly prevalent in adults both with and without diabetes, suggesting that screening may be warranted in high-risk individuals regardless of diabetes status.

There are several limitations to our study. The gold standard tests for PN are nerve conduction studies and/or electromyography, which were not performed in the ARIC study. In addition, the MNSI is validated in populations with diabetes, but not among adults without diabetes.^11,14,42 As a result, the diagnostic accuracy of MNSI among very old adults without diabetes is unclear. PN has been associated with cognitive impairment, which may limit the accuracy of the questionnaire⁴³. Given the cross-sectional design, the temporal associations of risk factors and PN could not be determined. It is also possible that some covariates may be unmeasured, including vitamin B12 deficiency. Finally, survival bias is possible as the analysis was performed on very old, healthier adults who were able to attend follow-up visits.

CONCLUSION

PN as detected by the MNSI was present in more than 60% of very old adults, both with and without diabetes. This estimate is substantially higher than the prevalence of PN reported in older adults based on the monofilament test. Given that PN is associated with significant morbidity and mortality, routine screening of older adults with a comprehensive tool such as the MNSI, regardless of diabetes status, may be warranted to improve early detection and management of PN.

Supplementary Material

Supplemental Materials

Supplementary Figure 1: Flow diagram for how participants in the Atherosclerosis Risk in Communities (ARIC) study were selected for inclusion in the study cohort.

Supplementary Figure 2: Michigan Neuropathy Screening Instrument (MNSI) Questionnaire Items

Supplementary Figure 3: Michigan Neuropathy Screening Instrument (MNSI) Questionnaire Items and Participant Responses for Peripheral Neuropathy Screening: 2022–2023, Atherosclerosis Risk in Communities Study, Visit 10

Supplementary Table 1. Results of the Michigan Neuropathy Screening Instrument (MNSI) Questionnaire and Physical Assessment Components by Participant Diabetes Status: 2022–2023, Atherosclerosis Risk in Communities Study, Visit 10

Key Points:

• Peripheral neuropathy is highly prevalent among older U.S. adults, affecting over 60% of this population, and is associated with older age.

• The condition is common regardless of diabetes status, indicating additional contributing factors beyond diabetes alone.

• Early detection and management of peripheral neuropathy is critical due to its significant association with morbidity and mortality.

Why Does this Paper Matter:

This study evaluates the prevalence of peripheral neuropathy in very old U.S. adults using the Michigan Neuropathy Screening Instrument. Previous studies on peripheral neuropathy in this population have primarily relied on the monofilament testing to detect loss of protective sensation, which identifies mostly more advanced stages of neuropathy characterized by loss of protective sensation. Understanding the full burden of peripheral neuropathy is clinically significant, as the condition is associated with increased risks of falls, functional decline, and even mortality. Early identification of peripheral neuropathy may enable timely interventions.