6a. Approach to Neuro Cases II Flashcards
1
Q
What is a tremor?
A
involuntary, rhymic, oscilatory movement of body part
most common mvmt disorder seen in primary care
2
Q
How are tremors classified?
A
- resting
- action
- enhanced physiogic tremor
- essential tremor
- parkinsonism
- cerebellar tremor
- psychogenic
- other: dystonic and wilson disease
3
Q
- occurs in body part that is relaxed and completely supported vs. gravity
- enhanced by mental stress or movement of another body part (walking)
- diminished by voluntary movement of that body part
A
resting tremor
4
Q
What are the tyes of action tremors?
A
- postural
- isometric
- kinetic
5
Q
type of tremor: maintain a position against gravity
A
postural tremor
[ex: arm elevation]
6
Q
type of tremor: musce contraction vs. rigid stationary object
A
isometric tremor
[ex: making a fist]
7
Q
type of tremor: voluntary movement, including intention tremor (prduced with target-directed movement)
A
kinetic tremor
[ex: reaching for a pen]
8
Q
- low amplitude, high frequency at rest and during activity
- enhanced by anxiety, stress, certain medications, and metabolic conditions
A
enhanced physiologic tremor
[note: everybody has an asymptomatic physiologic tremor]
9
Q
When do patients with tremor not need any further testing?
A
“If a patient has a tremor that comes and goes with anxiety, medication use, caffeine intake, or fatigue, they do not need further testing.”
10
Q
- most common pathological tremor
- 95% of patients have primarily kinetic rather than postural
- most common in hands and wrists (also head, LE, voice)
- bilateral and present w/ different tasks/interefers w/ many activities
- can be inherited & progresses with age
- 25% of those affected retire early or modify career path (can cause social embarassment)
- can be exacerbated by caffeine and fatigue; can be helped by alcohol
A
essential tremors
11
Q
How do medications cause Parkinsonism tremor?
A
blocking or depleting dopamine
12
Q
Describe Parkinson’s Disease.
A
- chronic neurodegenerative disease
- most common form is idiopathic PD
- 70% of PD pt w/ resting tremors
- classic tremor = “pill rolling mtion”
- bradykinesia = difficulty rising from seated position, reduced arm swing while walking, micrographia
13
Q
- low ferquency, slow-intension or postural tremor
- typically caused by MS w/ cerebellar plaques, strokes, or brainstem tumors
A
cerebellar tremors
14
Q
Cerebellar tremors are typically caused by ___.
A
- MS w/ cerebellar plaques
- strokes
- brainstem tumors
15
Q
- can be difficult to differentiate from organic tremor
- some features that are consistent include:
- abrupt obset
- spontaneous remission
- changing tremor characteristics (location and freq)
- increase with attention and extinction w/ distraction
- more frequently seen in pt employed in allied health professions, involved in litigation
A
psychogenic tremors
16
Q
What history should you obtain for tremor?
A
- Fam hx of neuro disease or tremor = genetic component (esp essential tremor)
- Age = tremor in older pt more likely PD or essential tremor
- Onset = sudden onset more likely pschogenic (related to med use or toxin exposure or brain tumor - rare)
17
Q
Distinguish between Parkinson’s Disease Tremor vs. Essential Tremor.
A
18
Q
Name history/signs consistent with Parkinson’s Disease.
A
19
Q
Name that tremor.
A
essential tremor
[large, tremulous, illegible]
20
Q
Name that tremor.
A
Parkinson’s Disease tremor
[small, can be ilegible]
21
Q
Define dementia.
A
- loss of cognitive functioning (thinking, remembering, reasoning)
- loss of behavioral abilities (interferes w/ daily life & activities)
- functions lost: memory, language, visual perception, problem solving, self management, ability to focus and pay attn
22
Q
In what demographic is dementia more prevalent?
A
females (~82+ y/o)
23
Q
Name some etiologies of dementia.
A
24
Q
Which cognitive domain is affected based on these symptoms:
- apathy
- increase in inappropriate behaviors
- loss of empathy
- impaired judgment
A
social cognition
25
Which cognitive domain is affected based on these symptoms:
* difficulty in using familiar technology, tools, or kitchen appliances
* getting lost in familiar environments
perceptual-motor
26
Which cognitive domain is affected based on these symptoms:
* forgetting ot buy items or buying same items multiple times at store
* repetition in conversation
* difficulty in recalling events
* relying on lists of tasks to complete
* forgetting to pay bills
learning and memory
27
Which cognitive domain is affected based on these symptoms:
* difficulty finding correct words
* using general pronouns regularly instead of names
* mispronunciation of words
* problems w/ understanding verbal and written communication
language
28
Which cognitive domain is affected based on these symptoms:
* difficulty in completing previously familiar multistep tasks (preparing meals)
* no longer wanting to participate in home activities
* difficulty in completing activities or tasks b/c of easy distractablity
* social outings become more taxing and less enjoyable
executive function
29
Which cognitive domain is affected based on these symptoms:
* normal routine tasks take longer
* difficulty in completing tasks when multiple stimuli present
* dfificulty in maintaining info while completing tasks (mental math, remember phone number to dial, etc.)
* work requires more overview/rechecking than before
complex attention
30
What is a **major neurocognitive disorder**?
(based on DSM-5)
significant cognitive decline in at least one domain interfering with activities of daily living
31
What is a **minor** **neurocognitive disorder**?
(based on DSM-5)
modest cognitive decline that **does not** interere with daily living
32
What should be included in history for dementia patient?
* education (timeline of sx presentation and speed of progression)
* med review (Beers criteria)
* recent hospitalization (hx infection; delirium; cardiometabolic risk factors)
33
What is important about the physical examination of a dementia patient?
* exam is typically nrmal
* exam **intent** is to look for reversible causes:
* hypothyroidism
* vitamin deficiencies
* intracranial tumors
* normal pressure hydrocephalus
* depression
* hypoperfusion from CHF
34
Describe the brief initial screening test for cognitive impairment.
1. mini-Cog
2. ascertain dementia 8 item informant questionnaire
3. general practitioner assessment of cognition
35
Describe the **mini-cog**.
* Pt asked to repeat 3 unrelated words, perform clock drawing test, then recall 3 works.
* Sensitivity: (76-100%)
* Specificity: (54-85%)
* Scoring: 1 pt for each word remembered, 2 pt for good clock, 3-5 is lower likelihood for dementia but does not excluse some cognitive impairment
36
* screens for major and minor neurocognitive disorders
* sensitivity 85%
* specificty 86%
* scoring: count # of "yes"
* 0-1 = normal
* 2+ = cognitive impairment likely
ascertain 8-item informant questionnaire
37
* patient and informant component
* validation in primary care settng, little to no education bias, available in multiple languages
* limitation: only in Australian populations
* tests patient recall, clock drawng, information components
* sensitivity 85%, specificty 86%
general practitioner assessment of cognition
38
If the brief initial screening test for cognitive impairment is positive, what are the next steps?
Screening for **Degree**
* MMSE
* MOCA
* St. Louis University Mental Status Exam
39
* most comonly used DEGREE screening
* score. 0-30
* sensitivity 81%, specificity 81% for dementia
* nomograms for normal vs. impaired based on age
mini-mental state examination (MMSE)
40
* DEGREE screen designed for persons scoring 24 + on MMSE
* accurate in patients with Parkinson's disease
Montreal cognitive assessment (MOCA)
41
If DEGREE screening is positive, what are the next steps?
* geriatric depression scale to r/o pseudodementia
* lab evaluation and neuroimaing for reversible causes of dementia
