2 - Neurologic Disorders Flashcards
Neurologic method - how to assess
-where is the lesion (CNS, PNS, both)
CNS - cortex, midbrain, spinal cord, meninges
PNS - motor/sensory nerves, NMJ/muscle
Neurologic method - how to assess -what is the lesion —grey matter —white matter —metabolic/degenerative
Grey = primary neuronal
-early cognitive disturbances, movement disorders, seizures
White
-motor, sensory, VISUAL, cerebellar
Met/degen
-symptoms are progressive and symmetric
Neurologic method - how to assess
-lab assessment (3)
Blood and CSF tests
Focused neuroimaging
Electrophysiologic studies
Seizures and epilepsy -seizure —define —what —who
Transient sign/symptom of abnormal excessive or synchronous neuronal activity in the brain
Not a disease, but a symptom
5-10% of the population will have at least one
Seizures and epilepsy -epilepsy —define —what —process
Condition in which a person has a risk of recurrent seizures
(“Chronic seizure disorder”)
Not a specific disease, but a condition
Chronic, underlying process
Seizures
-determining type of seizure is essential for (3)
Determining cause
Treatment
Long-term prognosis
Seizures
-focal vs generalized onset
Focal
- limited to one brain region
- usually structural abnormalities of the brain
Generalized
- distributed across both hemispheres
- cellular, biochemical, or widespread structural abnormalities
Seizures -factors —endogenous —epileptogenic —precipitating
Genetic
Severe penetrating head trauma (also stroke, etc.)
Stress, exposure to toxins, certain meds, etc.
Seizures -predominance —childhood —adolescence and early adulthood —older adults
Well-defined epileptic syndromes present (idiopathic or genetic)
Developmental disorders, CNS infection (esp viral encephalitis)
Secondary to acquired CNS lesions
Head trauma, brain tumor, illicit drug use, alcohol withdrawal
Cerebrovascular and degenerative diseases
Seizures - general medical approach
-shortly after a seizure, priorites are
Attention to vital signs
Respiratory and cardiovascular support
Recognize and manage life-threatening condns such as CNS infection, metabolic derangement, drug toxicity
Seizures - general medical approach
-when pt is not acutely ill
—no hx of seizures
—prior seizures or known epileptic
Determine if episode was actually a seizure
Determine cause
Decide if anticonvulsant therapy is required, treat any underlying illness
ID underlying cause and precipitating factors
Determine adequacy of current therapy
Seizures and epilepsy - diagnosis
- history
- exam
- labs
- EEG
Truly a seizure?
- syncope more likely if provoked by emotional stress
- greater than 15 seconds more characteristic of a seizure
All pts require complete neurological exam
Routine blood studies, toxin screen, lumbar puncture (if suspicious of meningitis/encephalitis)
ASAP
Seizures and epilepsy - treatment
- underlying condns
- avoiding precipitating factors
- anti-epileptic meds
- surgery
Metabolic, drugs/meds, structural
SLEEP DEPRIVATION, alcohol, etc
50%+ can eventually discontinue
1/3 need multiple meds
20-30% cannot be controlled with meds alone
Managing pts during a seizure
-calling 911
Usually do not require emergency medical attention
Call if:
- first time
- difficulty breathing/waking after
- lasts >5 min
- has another soon after
- person is hurt or in water
- pt has DM, heart disease, is pregnant
Managing pts during a seizure
-first aid for tonic-clonic/grand mal
—what to do
Ease to the floor Turn gently onto one side Clear area to prevent injury Put something soft/flat under head Remove glasses Loosen necktie/anything around neck
Managing pts during a seizure
-first aid for tonic-clonic/grand mal
—what NOT to do
Do NOT:
- hold them down/try to stop movements
- put anything in their mouth
- attempt mouth-to-mouth
- offer food/water until fully alert
Dementia
-define
Acquired degeneration in cognitive abilities that impairs the successful performance of activities of daily living
Dementia
- cognitive ability most commonly lost/main thing noticed with dementia pts
- strongest risk factor
- causes
Episodic memory
Increasing age
Alzheimer’s is most common cause in Western countries
Vascular disease (atherosclerosis) 2nd most
Also assoc with Parkinson’s, alcoholism, drugs/meds
Alzheimer’s
- who
- vs dementia
~5% over age 70, over half of those with significant memory loss
A causes D (Alzheimer’s is a disease, dementia is a group of symptoms)
Alzheimer’s - clinical manifestations
-cognitive changes
Tend to follow characteristic pattern: beginning with memory loss and progressing
~20% present with other problems, such as visual processing dysfunction
Alzheimer’s - clinical manifestations
- early stages
- middle stages
Early - memory loss may go unnoticed, be ascribed to benign forgetfulness, eventually interfere with daily living
Middle - unable to work, easily lost/confused, require daily supervision
Alzheimer’s - clinical manifestations
- late stages
- end stages
Late - some remain ambulatory, wandering aimlessly
-loss of judgement and reasoning inevitable
-delusions prevalent
—common themes = theft, infidelity, misidentification
End - rigid, mute, incontinent, bed-ridden
-death most commonly from aspiration > malnutrition, secondary infections, pulmonary emboli, heart disease
Alzheimer’s - differentials
- imaging
- simple, useful clinical cues
To R/O other disorders
Slowly progressive
-vs tumor: early onset of focal seizure
Alzheimer’s - epidemiology
- age
- genetics
- sex
- history
- systemic
> 70 (prevalence 20-40% of pop >85)
Positive family history
Females
Hx of head trauma
DM incr risk 3x
Alzheimer’s - pathology and genetics
- brain atrophy
- microscopically
- genetics
Begins in medial temporal lobe and spreads
Widespread neural plaque containing amyloid beta
Neurofibrillary tangles/tau filaments
Several genes play important role - APP gene on xsome 21
Alzheimer’s - treatment
-focus
On long-term amelioration of assoc behavioral/neurological problems and providing caregiver support
Alzheimer’s - treatment -meds —mild efficacy with SE —unsuccessful so far —black box warning, sometimes necessary —vigilantly avoid
Cholinesterase inhibitors, memantine, etc.
Estrogen replacement, ginkgo biloba, vaccination
All antipsychotics
Anticholinergics (sleep aids, incontinence tx - even OTC)
Neurological disease
-implications for ODs (3, not meds)
What we do regularly covers a large part of standard neuro exam
Neuro disorders are common, will affect how we care for our pts
We will be co-managing
Neurological disease
-implications for ODs (2 meds examples)
Bigabitrin/sabril = VF restrictions
Topiramate = AC narrowing -> bilateral angle closure -> pressure spike (40s/50s)
-secondary to choroidal effusion
