Dementia, headaches, head injury - ERIC Flashcards
what is delirium
acute change
causes confusion and short term memory loss
decreased level of alertness
resolves within one week
what is dementia
progressively worsening impairment of intellectual functioning:
language
memory
visuospatial
executive functioning
emotional behavior
what is the PINCHME mneumonic for
to help identify potential causes of delirium
what is the PINCHME mneumonic
Pain
Infection
Nutrition
Constipation
Hydration
Medication
Environment
What is MOCA
Montreal Cognitive Assessment
how many area’s are assessed during MOCA
8 areas of cognition assessed
what cognitive test do we use when there is concern for cognitive impairment or dementia
MOCA
how is Dementia worked up by lab work
CBC
CMP
THS
B12, folate, thiamine
Drug screen
Ammonia levels
Syphillis screen
?heavy metal screens
how is dementia worked up with imaging
acute mental status change - CT of the brain without contrast
Progressive - MRI w/o contrast
what is alzheimers dementia
progressive dementia caused by intracellular neurofibrillary tangles and extracellular plaques
what is the most common type of dementia
Alzheimers dementia
what are risk factors for Alzheimers dementia
Age and family history
occurs in 3-50% of people at age 80
how is Alzheimers dementia treated
Acetylcholinesterase inhibitors
NMDA receptor agonists
Aducanumab - newly FDA approve and controversial
how do Acetylcholinesterase inhibitors treat Alzheimers dementa
delays disease progression and may improve memory
Ex. Donepezil, Rivastigmine, Galantamine
how do NMDA receptor agonist treat Alzheimers dementia
regulates glutamate. too much glutamate triggers NDMA which increase dementia risk
used in conjunction with acetylcholinesterase inhibitors in mod-severe disease
ex. memantine
how are aducanumab used to treat Alzheimers dementia
newly FDA approved and very controversial
only USED ONLY IN MILD DEMENTIA with MOCA
thought to reduce amyloid plaques
what are non-medication treatments for Dementia
room-by-room safety (garage, basement, workroom, kitchen, bathroom)
Locks
Alarms
Preventing Falls
Living Partners
what is vascular dementia
second most common type of dementia
M>W
ischemia of the brain and lacunar infarcts - occurs both with and without hx of TIA/stroke
what conditions are vascular dementia associated wtih
hypertension and high cholesterol
what are the subtypes of vascular dementia
cortical vascular dementia
Subcortical vascular dementia
what is cortical vascular dementia
speech difficulty, loss of ADLs, confusion, Amnesia and poor executive function
what is subcortical vascular dementia
motor deficit, gait changes, urinary incontinence, personality changes
what does the progression of vascular dementia lead to
loss of ADLs, decreased concentration, disorientation, social withdrawal
labs on patients with vascular dementia may show
underlying hyperlipidemia
what is seen on brain CT or MRI on a patient wtih ascular dementia
small vessel infacts
what is the treatment for vascular dementia
treat underlying hyperlipidemia and hypertension (consider statins and anti-platelet)
Treat symptoms of insomnia, depression and agitation
what is Lewy Body Demenia caused by
deposits in nerve cells known as Lew bodies in the midbrain, brain stem and olfactory bulb
what does Lewy Body Dementia cause
delusions and visual hallucinations, anxiety, with or without motor symptoms
what is Histologically similar to Parkinsons diesase
Lewy Body Dementia- dementia starts before motor symptoms
what type of medications are used to treat Lewy Body dementia
Cholinesterase help with the delirium, but dopamine medications are not effective
what is the cause of frontotemporal dementia
caused by degeneration of the frontal and temporal lobes
what does frontotemporal dementia present with
euphoria, apathy, disinhibition or compulsions
MRI shows degeneration of frontal lobe on what type of dementia
frontotemporal dementia
what is the treatment for frontotemporal dementia
no curative treatment
what is pseudodementia
perceived memory loss - usually due to uncontrolled depression or anxiety
what condition presents with perceived memory loss with normal MOCA, MRI and labs?
psudodementia
how is pseudodementia treated
with SSRIs and counseling for uncontrolled depression or anxiety
how are dementia symptoms managed
Depression - SSRI or antipsychotics
Hallucinations/agitation - Zyprexia, Seroquel, Risperdal
Weight loss/lack of appetite - antipsychotics, cyproheptadine, Remeron
Acute head trauma exam includes
CSF or blood in external acoustic canal, nostril
bruising at base of skull or around the eyes
obvious head/trauma/skull depressions
Hemotympanum
priapism
pupils, Glasgow coma scale, blood glucose, tox screen, CT of brain without contrast
a patient presents with bilateral raccoon eyes what tests needs to be run
CT scan
what is priapism
erection (can happen s/p brain injury)
What is the glasgow coma scale scoring
15 is the best response
8 or less the patient is comatose
3 is totally unresponsive
what are the components of Glasgow coma scale
Eye opening response
Best verbal response
Best Motor response
what responses are assessed in the eye opening response portion of the Glasgow coma scale
spontaneously -4
to speech -3
to pain - 2
no response - 1
what responses are assessed in the best verbal response portion of the Glasgow coma scale
oriented to time, place and person -5
confused - 4
inappropriate words - 3
incomprehensible sounds -2
No response - 1
what responses are assessed during the best motor response portion of the Glasgow coma scale
obeys commands - 6
moves to localized pain - 5
flexion withdrawal from pain - 4
abnormal flexion (decorticate) - 3
abnormal extension (decerebrate) - 2
no response - 1
what is the Glasgow Coma Scale on a deceased patient
3
what is the cause of a singular pupil dilation
brain bleed on the dilated pupils side
what duration of loss of consciousness has the worst prognosis
> 2 minutes
what is a countra-coup injury
happen on the opposite site of impact
if a child 2 years or older has a GCS of 15 or less what is the plan of care
CT scan
where do intracerebral hemorrhages occur
intraparenchymal space
what is the cause of intracerebral hemmorhages?
trauma, arterio venous malformation or hypotension
what is a key CT finding for Intracerebral hemorrhages
bleed will not touch the skull
what are the symptoms of intracerebral hemorrhage
headache, N/V, hemiplegia, hemiparesis
what can a lumbar puncture cause in a patient with a intracerebral hemorrhage
herniation of the brain
that is the treatment for intracerebral hemorrhage
steroids to decrease edema, anti-epileptics and possible surgical intervention
what is a subarachnoid hemorrhage
arterial bleed in the space between the arachnoid and pia matter
what is the cause of subarachnoid hemorrhage
caused by trauma, AVN, or chery aneurysm
what is a “thunderclap” headache associated with
subarachnoid hemorrhage
what are the symptoms for subarachnoid hemorrhage
thunderclap headache, usually unilateral, N/V
photophobia, confusion, neck stiffness
what is the treatment of subarachnoid hemorrhage
stool softeners, antieleptic (phenytoin), Nimodipine (BP control)
what is the shape of epidural hematoma
I or lemon shape
what is a epidural hematoma
arterial bleed between the skull and dura mater
usually due to skull fracture damaging the middle meningeal artery
what is associated with a skull fracture of the middle meningeal artery
epidural hematoma
what are the common symptoms with epidural hematom
loss of consciousness, and regain of consciousness
Headache, N/V, CSF fluid leak, focal neuro changes, coma
what is the treatment of epidural hematoma
EMERGENT NEUROSURGERY CONSULT
what is a subdural hematoma
venous bleeding between dura and arachnoid from torn bridging veins
along the skull line but not lemon shaped
what is the most common location of damage during subdural hematomas
torn bridging
what population are at higher risk for subdural hematoma
elderly, alcoholics
what is damaged during a concussion
axonal rupture from shear or tensile forces causing axonal swelling and release of neurotransmitters
what should be seen on a concussion CT scan
normal - there should be no bleeding
what is a patient with a concussions common GCS score
15
what can make concussion symptoms worse
focusing eyes, mental strain and physical strain
what are redflags of headaches
thunderclap headache
worse headache of life
recent head trauma
anticoagulation use
decreased level of consciousness
suspicion of meningitis
what is a Romberg exam
balance test with eyes closed and arms up to assess for balance
what is a migraine
unilateral headache with pulsating/throbbing moderate-severe pain
what are the subtypes of migraines
migraine with aura and migraine without aura
what is likely cause a migraine
intracranial vasospasm
what are migraine triggers
alcohol
caffeine
skipped meals
physical exertion
bright light
excessive noise
smells
lack of sleep
stress
weather
what should be avoided in patients with migraine with aura
estrogen medications because increase risk of stroke
how much Triptan medications can be prescribed at once
no more than 10 days a month
what types of drug classes are used to prevent migraines
Antihypertensives
antidepressant
anticonvulsants
CGRP antagonists
What are the common antihypertensives used to prevent migraines
propranolol, metropolol, atenolol - beta blockers
Lisinopril - ACEi
Candesartan - ARB
what are the common Antidepressant medications used to prevent migraines
Amitriptyline - TCA
Venlafazine - SNRI
what are the common anticonvulsants used to prevent migraines
Topiramate
Valproate
Gabapentin
what are the common CGRP antagonists used to prevent Migraines
Rimegepant (Nurtec)
Aimovig
what are tension headaches thought to be caused by
thought to be due to muscle spasms, but more evidence showing it is due to increased neuronal sensitivity
what are tension headaches induced by
stress, anxiety and minor trauma
what is the treatment of tension headaches
NSAIDs, acetaminophen
IM/IV Toradol (ketorolac)
Muscle relaxers
migraine abortive medications
what is the presentation of cluster headaches
severe, unilateral periorbitalpain - conjunctival injection, ptosis, tearing and nasal congestion
very short duration and can occur several times a day
what is the first line of treatment for cluster headaches
100% O2
other treatment : subcutatneous sumatriptan
what medications can prevent cluster headaches
verapamil titration or prednisone 60mg taper (only if new onset)
what is the cause of sinus headaches
due to underling sinusitis (chronic or acute)
these are usually migraines with superimposed sinus symptoms
what signs are not indicative of sinus headaches
photophobia, phonophobia or nausea
what is the cause of exertional headaches
thought to be due to intrathoracic/abdominal pressure causing pain in sensitive vascular and meningeal structure
what are exertional headaches often associated with
past trauma
space occupying lesion
AVM/aneurysm
intracranial hemorrhage
how do you rule out vascular anomaly and lesion in exertional headaches
MRI and MRA
what are the types of sexual activity headaches
pre-orgasmic headaches and orgasmic headaches
what are the symptoms of pre-orgasmic headaches
occurs as a bilateral occipital pain (pressure/aching)
what are the symptoms of orgasmic headaches
due to increase in blood pressure and HR
sudden onset severe throbbing pain over the whole head
what is a menstrual headache
fluctuations in estrogen level can trigger both headaches and migraines
menstrual migraines occur from 2 days prior to 2 days after menstruation
what can be used to treat migraines without aura
OCP to regulate estrogen levels - continuous regimens may decrease further
