6B. Neurologic Disorders Flashcards
Parkinson’s Disease
► Degenerative CNS disorder characterized by ____ deficiency
► Affects approximately 500,000 people
► 1 % over age 50 have the disease
►2.5 % over the age of 70 have the disease
► ____x increase in frequency is predicted in the next 50 years
dopamine
3-4
Etiology / Pathophysiology
► Primary
– Degeneration of dopaminergic neurons of the
____
► Secondary
– Loss of or interference with the action of ____ 20 to other CNS diseases
► Associated factors – \_\_\_\_ mutation – Stroke – \_\_\_\_ tumor – Head injury – Exposure to \_\_\_\_
substantia nigra dopamine genetic brain chemicals
Signs / Symptoms
►Resting tremors
– ____
– Seen in extremities at ____ – “Pill – rolling“
►Muscle rigidity
– ____ arm swing with walking
– ____ posture
– ____ instability
►Pain
►\_\_\_\_ dysfunction ►Slow movements ►Facial \_\_\_\_ ►“Restlessness” ►Impairment of \_\_\_\_ and concentration ►Mood disturbances ►\_\_\_\_
rhythmic rest decreased bent gait
bladder/bowel
impassiveness
memory
dementia
Diagnosis ►Physical signs and symptoms ►No reliable \_\_\_\_ or biochemical markers for PD ►Neuroimaging – Evaluate \_\_\_\_ production – Rule out other CNS pathology ►Positive clinical response to \_\_\_\_
Rest means more acitivity, ____ is less activity.
This is substantia nigra section of the brain translating to dopramine activity
histological
dopamine
carbidopa/levodopa
blue
Medical Management ►Mainstay of treatment has been replacement of \_\_\_\_ ►Sinemet® (Carbidopa / Levodopa) – Levodopa (L-dopa) ►Metabolic precursor of \_\_\_\_ ►Crosses \_\_\_\_
– Carbidopa
►Inhibits ____ of peripheral levodopa
– May induce ____
– Medication must be ____ carefully to diminish dyskinesia
dopamine
dopamine
BBB
decarboxylation
dyskinesia
titrated
Oral considerations ►Oral motor and sensory impairment ►\_\_\_\_ ►Xerostomia ►\_\_\_\_ ►Burning mouth syndrome
dysphagia
candidiasis
►Preventive strategies ►Consider patient’s physical and cognitive deficiencies – Electric toothbrushes – Modification of oral hygiene aids – \_\_\_\_ rinses – Topical fluoride – \_\_\_\_
►Therapeutic strategies – Venue for dental treatment – Orthostatic \_\_\_\_ – Facial / oral muscle tremor – Increased salivation – Basic vs. complex dental treatment – Choice of dental restorative \_\_\_\_ – Drug interactions
chlorhexidine
sialogogues
hypotension
materials
Alzheimer’s Disease
►Neurodegenerative disease characterized by ____
►Gradual ____ in cognitive processes
►May lead to total ____ disability
dementia
decline
mental and physical
Epidemiology (AD)
►> 5 million people in the U.S. affected by dementia / AD
– 18.5 million cases in the U.S. by the year 2050
►Incidence
– 11% over age 65
– 50% over age 85
►____ are at greater risk than men for development of AD
►Genetic predisposition
– Early onset AD
►More ____
►Progresses more ____
women
severe
rapidly
Etiology (AD)
►Primary pathophysiologic mechanism of AD – Excessive \_\_\_\_ deposition – \_\_\_\_ plaques – \_\_\_\_ tangles
►Loss of ____ input into the cortex
►Age ►\_\_\_\_ sex ►Prior head injury ►Family history ►\_\_\_\_ genotype ►\_\_\_\_ mutation ►Trisomy \_\_\_\_
beta amyloid
neuritic
neurofibrillary
cholinergic
female
ApoE4
SORL1
21
AD Brain
Macro and both micro changes in brain. This picture is for macro changes:
• Decrease in amount of brain tissue in areas
• ____ of ventricles
• ____ of sulcus
• Pronounced ____ in language and memory cortices.
widening
deepening
decrease
Signs / Symptoms (AD) ►Gradual deterioration – \_\_\_\_ – Orientation – \_\_\_\_ stability – Language capacity – \_\_\_\_ thinking – Motor skills – Self \_\_\_\_
memory
emotional
abstract
care
Diagnosis (AD)
► Dementia established by clinical examination and documented with testing (MMSE)
► Deficits in two or more areas of ____
► Progressive worsening of memory and other cognitive functions
► No disturbance of ____
► Onset between ages 40 and 90
► Absence of systemic disorders or other brain diseases that could account for the progressive memory and cognitive changes
cognition
consciousness
►Three stages of disease – Progress though stages variable ►\_\_\_\_ AD ►Mild cognitive impairment (MCI) – \_\_\_\_ loss (most prominent feature) – Time disorientation – \_\_\_\_ errors – Notable decline in personal appearance / hygiene
preclinical
memory
judgement
►Dementia due to AD – Rapid decline in \_\_\_\_ capacity – Inability to ►Recognize \_\_\_\_ ►Understand speech ►Recognize \_\_\_\_ objects
►Dementia due to AD – Advanced disease ►\_\_\_\_ ►Unable to walk ►Body \_\_\_\_ ►Seizures ►Hyperorality ►\_\_\_\_ behavior
• Death from ____, secondary infection, or ____ disease
intellectual
self
familiar
disoriented
wasting
aggressive
malnutrition
Medical Management (AD)
►No definitive cure
►Use of acetylcholinesterase
inhibitors
– ____ (Aricept®)
►Use of NMDA receptor antagonist
►____ (Namenda®)
►Improve cognition – NSAID’s – Antioxidants (\_\_\_\_ – \_\_\_\_ biloba ►\_\_\_\_ ►Symptom-specific medication
donepezil memnatine vitamin E ginkgo antipsychotics
Dental Management
► Dental treatment planning, oral care, and behavioral management for persons with AD must be designed with consideration of the severity of the disease and must involve family members
►AD patients at increased risk for: – Coronal and root \_\_\_\_ – Periodontal diseases – \_\_\_\_ disorders – Orofacial pain
caries
TMJ
AD
►Aggressive preventive measures – Topical \_\_\_\_ – Chlorhexidine – Frequent recall visits ►Maintain updated medical and medication records ►Dental appointments / instructions may be \_\_\_\_ ►Dentures are frequently \_\_\_\_ / lost
fluoride
forgotten
broken
AD
►Oral dysfunction limit dental treatment
– ____ function
– Involuntary oral movements
►Changes in oral environment may be ____ for AD patients
►Progressive neglect of oral health
– ____ plaque / calculus
►Consider IV ____ / GA for advanced AD patients ►Avoid complex / time – consuming treatment
reflexive
disturbing
increased
sedation
Multiple Sclerosis
►Most common ____ disease of nervous system
►Chronic, intermittent ____ of neurons within the CNS
autoimmune
demyelination
Epidemiology (MS) ►Incidence – 1 / 1,000 in the U.K. – 1 / 10,000 in the \_\_\_\_ ►\_\_\_\_ adults – Between 20 and 45 years old ►\_\_\_\_ affected more than men – 3:2
US
young
women
Etiology (MS)
►Autoimmune disease triggered by infectious agent – \_\_\_\_ – Mumps – \_\_\_\_ – Chlamydia pneumoniae – \_\_\_\_ – Epstein – Barr virus – \_\_\_\_
►____ factors
– 20 – 40x greater chance of child developing MS if parent has MS
►Geographical distribution
– Countries at greater distance from the ____ have higher incidence of MS
rabies
measles
HSV-1 and -2
HHV-6
genetic
equator
Pathophysiology (MS)
►____ of axons
►Impaired ____
demyelination
axonal conduction
MS
►Affected regions are called “plaques” – \_\_\_\_ – B / T lymphocytes – \_\_\_\_ cells – Inflammatory cytokines – \_\_\_\_
►Most common demyelinated regions
– ____ nerve
– Periventricular cerebral white matter
– ____ cord
macrophages
plasma
immunoglobulins
optic
cervical spinal
Signs/symptoms (MS)
► Clinical signs are ____ of CNS location involved
► Most common symptoms
– Disturbance in ____ acuity
– Abnormal ____ movements
– ____ sign
► Motor disturbances
– ____
– Spasticity
– Tremor/paralysis
► Sensory disturbances
– Loss of ____, pain, temperature, proprioception
► Fatigue
► Attack / relapse pattern over several years
► Course is unpredictable
– 50% of patients will need help walking within ____ years of onset of disease
dependent
visual
eye
uhthoff’s
incoordination
touch
15
Laboratory Findings (MS)
►Evaluation of CSF
– Shows elevated ____ levels in 80% - 90% of patients
– ____ protein
►MRI
– Visualize ____ demyelinated regions
immunoglobulin
myelin
hypodense
Medical Management (MS)
►Anti-inflammatories – IV \_\_\_\_ – Interferon – β drugs – \_\_\_\_ – Natalizumab
►Complications managed via medications
– Spasticity – ____, BDZ’s
– Poor bladder control – ____ – Fatigue
– ____
corticosteroids chemotherapeutics baclofen anticholinergics stimulants
Oral / dental considerations (MS)
►Facial pain symptoms can mimic ____
– V2 and V3 sensory neuropathy
– Facial paralysis
► Higher incidence of ____ and headache
► Oral symptoms ►Myokymia
►Dysarthria
►“____ Speech”
► Patients undergoing relapse – \_\_\_\_ dental treatment only ► Optimal time for treatment is during \_\_\_\_ ► Evaluate level of motor impairment ► Drug interactions / ADR’s
trigeminal neuralgia TMD scanning emergency remission
Anxiety Disorders
• anxiety • Sense of psychological distress that may not have a focus • Foci may include: – Internal \_\_\_\_ conflict – Environmental stress – Physical disease state – Medicine / drug effect • May be purely \_\_\_\_ or physical experience
Physical effects are widespread
Very often ____ upset
Muscle tightness that feels like ____ pain
psychological
psychological
GI
chest
Epidemiology (Anxiety)
• Most frequently found psychiatric problem in the general population
• ____ disorder is the most common anxiety disorder in people seeking medical treatment
– Sudden, unexpected, overwhelming feeling of ____ accompanied by physical symptoms
– Peaks in ____ minutes, may last 20 to 30 minutes
panic
terror
10
Etiology (Anxiety)
• Combination of psychosocial and biological processes
– May be associated with dysregulated firing of neurons in ____ in the brainstem
– Dysfunction of ____ receptors
locus coeruleus
benzodiazepine
Post-traumatic Stress Disorder (PTSD) • Syndrome of psychophysiologic signs / symptoms that develop after exposure to a traumatic event outside the range of human experience • Men – \_\_\_\_-induced PTSD • Women – \_\_\_\_-induced PTSD
combat
sexual/physical
3 cardinal features of PTSD •
• \_\_\_\_ – Startle responses, inability to sleep • \_\_\_\_ of the initial trauma • Psychic \_\_\_\_ – Detachment from others, reduced capacity for intimacy
• Acute and chronic forms
– Based on ____ of symptoms
• ____ – onset PTSD
hyperarousal
flashbacks
numbing
duration
delayed
Treatment • Psychological treatment – \_\_\_\_ • Behavioral treatment – \_\_\_\_, desensitization • Drugtreatment – \_\_\_\_, SSRI’s, BDZ’s
psychotherapy
hypnosis
TCAs
Mood Disorders
• ____ group of disorders characterized by extreme exaggeration and disturbance of mood and affect
heterogeneous
Depression
Depression is a common but serious affect
Affect all areas of life, there are lots of types,
Persistent depressive disorder, post partum depression, psychotic, seasonal, major depressive disorder
Bipolar disorder
Bipolar is shift in mood, energy and ability to ____ normal task
fulfill
Epidemiology (mood disorders)
• 5% of adults in the U.S.
• More common among ____
• Major depression may begin at any ____ – 20 – 25% of adult women
– 7 – 12% of adult men
• Bipolar disorder – 0.4 – 1.6%
– Equal frequency between ____
women
age
sexes
Etiology (mood disorders)
• Decreased levels of neurotransmitters
• Depression
– ____
– Serotonin
– ____
• Bipolar Disorder
– ____
– Norepinephrine
– ____
norepinephrine
dopamine
GABA
dopamine
Pathogenesis (mood disorders)
• Abnormality in function / quantity of receptors
• Chronic release of ____
– “Long term stress reaction
• Genetic studies
– Family hx of depression
– Stronger genetic link with ____ disorder
• Psychosocial theory
– Focuses on ____ stressor as the
cause for depression
• Cognitive hypothesis
– ____ thinking which leads to pessimistic / negative views of self and others
TSH and cortisol
bipolar
emotional
distorted
Clinical Presentation
• Major depressive disorder
– Feeling ____ / blue / helpless / hopeless most of the day (dysphoria)
– Decrease in ____ / pleasure from most activities (anhedonia) – Impaired cognition
– ____
– Psychomotor retardation
– Marked ____ change (+/- 5%)
– Sleep disorders
– Symptoms must be present for at least ____ weeks
sad interest agitation weight 2
Bipolar Disorder
• AKA Manic – Depressive Disorder • Manic episodes – Distinct period in which mood is either markedly \_\_\_\_ or irritable / anger – Excessive \_\_\_\_ in multiple activities – Little to no \_\_\_\_ for days • Depressive episodes • Extreme \_\_\_\_ of moods – Unpredictable – Variable duration
elevated
participation
sleep
cycling
MDD Treatment • Anti – depressants – \_\_\_\_ antidepressants – \_\_\_\_ inhibitors – \_\_\_\_ inhibitors
• ____ behavioral therapy – Psychotherapy
tricyclic
selective serotonin re-uptake
monoamine oxidase
cognitive
MDD Treatment
• Electroconvulsive therapy (ECT) – \_\_\_\_ cases of depression – Non-responsive to medication – Refusal to eat – Multiple \_\_\_\_ attempts
• Massive neuronal electrical discharge
– Akin to ____ / convulsion
- Neuronal membranes become more responsive to ____
- Medical complications rare
severe
suicide
seizure
serotonin
BD Treatment
• Rapid control of acute manic episodes
– ____ (Lithium) +
– ____ (Risperidone) +
– ____ (Lorazepam)
• Prevention and / or reduction of severity of future episodes
– ____(+/- antipsychotic, benzodiazepine)
- Psychotherapy
- ECT
mood-stabilizer
anti-psychotic
benzodiazepine
lithium + SSRI
Medical History
• Provide empathy and reassurance
• HPI
– ____ each patient-reported complaint
– Physical or psychological causes of complaint?
• Past psychiatric hx
– Utilization of ____ services?
– Treatment received?
• Family hx
– ____ of psychiatric illness?
• Social hx
– ____?
– Relationships?
– Substance use / abuse?
clarify
psychiatric
FH
employment
Dental / Oral Findings
- Dental caries
- Periodontal disease
- Tooth loss
- Facial pain complaints
• Medication – induced effects – \_\_\_\_ –Candidiasis – \_\_\_\_ –Stomatitis – \_\_\_\_ –Sialadenitis – \_\_\_\_
xerostomia
dysgeusia
glossitis
bruxism
Provision of Dental Care
• Assess ____ of condition
• Ensure compliance with medications
• Medical ____, if appropriate
• Laboratory evaluation(s), if appropriate
• Determine appropriate ____ for dental care
• Aggressive preventive measures
• ____ education
• Drug interactions
• ____ substitutes
• Surveillance for oral and maxillofacial pathology
stability consultation environment/venue oral hygiene salivary
