Exam 2 Flashcards
stroke mimics vs stroke symptom patterns
mimics are less likely to follow predictable pattern based on blood vessels
when to initiate ASA for primary prevention
adults 50-59 who have >10% CVD risk, are not at increased risk for bleeding, and have a life expectancy of at least 10 yyears
when should adults be screened for hyperlipidemia
all adults age 40-75
who should be screened for hypertension
all adults >18
criteria for orthostatic changes
reduction of systolic or diastolic BP of at least 20 or 10 mmHg respectively. +/-increase of pulse by 20 bpm. These changes should be seen 3 minutes after a patient who was supine sits or stands up
what is TUG test
timed up and go. Pt sits in a chair and then stands up without using their arms, then walks 10 feet and back and sits down again
normal TUG score
<10 seconds
average duration of Todds paralysis
15 hours
what is a cardiogenic stroke
decrease in cerebral perfusion caused by decreased cardiac output, severe hypotension, or hypoxemia
what is a thrombotic stroke
native clot within the intracranial vasculature
most common major vessel occlusion in stroke
MCA
what percentage of strokes are ischemic
87%
what % of ischemic strokes are small vessel lacunar
25%
what % of ischemic strokes are embolic
57%
describe intracerebral hemorrhage
arterioles/small arteries bleed producing a localized hematoma that can spread along white matter pathways
etiologies of intracerebral hemorrhage
HTN, trauma, coagulopathy, stimulant use, vascular malformations
etiology of SAH
rupture of arterial berry aneurysm at base of brain (90%), or vascular malformations lying near pial surface
what % of SAH presents with sentinel bleed
30%
common sites of large artery atherothrombotic strokes
bifurcation of common carotid, MCA stem
etiology of large artery strokes
atherosclerosis, vasoconstriction, arterial dissection
ssx in large vessel atherothrombotic strokes
often fluctuate due to circle of willis collateral circulation
embolic strokes ssx
abrupt onset with early maximal ssx
multiple sites of embolic stroke indicate what source
cardiac
subcategories of embolic strokes
known cardiac or aortic source, arterial source
locations for lacunar strokes
basal ganglia, subcortical white matter (internal capsule), pons
etiology of lacunar strokes
HTN, atherosclerosis
risk factors for lacunar strokes
HTN, DM, smoking
first signs of systemic hypoperfusion CVA
cortical blindness, stupor, weakness of shoulders/thighs with sparing of face and distal limbs
what is true of fever and stroke
fever is an atypical stroke ssx, each 1 degree C increase in temp increases risk of poor outcome by 2.2
when must tPA be initiated (per laura)
within 3 hours
rate of hemorrhage after tPA
6%, about half of these are fatal
ACA stroke ssx
contralateral leg>face and arm weakness, frontal signs
MCA CVA ssx
contralateral: face and arm>leg weakness, sensory loss to all modalities, visual field cut, neglect. Ipsilateral: Gaze preference. Dominant hemisphere affected: Aphasia, alexia, agraphia
PCA CVA ssx
contralateral homonymous hemianopia. With thalamic involvement: sensory loss to all modalities
AICA CVA ssx
contralateral: hemiparesis and hemisensory loss of pain and temp. Ipsilateral: ataxia
PICA CVA ssx
contralateral: hemibody pain and temp loss.
ipsilateral: Facial pain, hemifacial pain/temp loss, ataxia, nystagmus, N/V/vertigo, horner’s syndrome, dysphagia. Hiccups
basilar artery CVA ssx
bilateral: quadriplegia, facial weakness, lateral gaze weakness with sparing of vertical gaze (locked in syndrome)
vertebral artery CVA ssx
contralateral: hemibody weakness, loss of DCML.
Ipsilateral: tongue weakness and/or atrophy, Wallenberg syndrome
vertebral artery supplies
medial and lateral medulla
basilar artery supplies
pons
PICA supplies
lateral medulla
PCA supplies
occipital lobe
intracerebral hemorrhage tx
ICU admission to maintain eunatremia, normoglycemia, normothermia, normotension, treat seizures, surgical eval. For ICP: Raise head of bed, +/-mannitol. For HTN (only if SBP>200 or MAP>150): labetalol, nicardipine, esmolol
SAH tx
early surgical clipping
subdural treatment
burr hole vs watchful waiting, extensive rehab
epidural tx
removal of clot if > 1 cm
intracerebral hemorrhage vs SAH: pressure
ICH is lower pressure bleed limited by ICP. SAH is higher pressure bleed
causes of aneurysms
genetic, gender, HTN, smoking, atherosclerosis
what is a thrombus
clot developed in place
what is an embolus
piece of clot that is free to move
what is an atheroma
plaque of thickened arterial intima occurring atherosclerosis
name of score used to assess risk of stroke after TIA
ABCD2
ABCD2 stands for
Age (>60), Blood pressure (>140/90), Clinical features (unilateral weakness=2, speech difficulty=1), Duration (>60 mins = 2, 10-59 mins = 1, <10 = 0) Diabetes
what ABCD2 score is low, moderate, high risk
3 or fewer is low risk. 4-5 moderate. 6 or greater is high risk.
components of FAST
Face, arms, speech, time
initial CVA eval
non-con CT, other studies (labs, ECG, chest xray, etc)
depression criteria mnemonic
SIG E CAPS plus either a depressed mood or loss of interest/pleasure
SIG E CAPS
Sleep (insomnia/hypersomnia), Interest (anhedonia), Guilt, Energy (fatigue), Concentration, Appetite (increased or decreased), Psychomotor (agitation or retardation), Suicidal ideation
risk factors for suicide
Family and/or personal history of suicide attempt, mental illness, substance abuse, recent hardship
what is dysthymia
depressed mood for most days during the past 2 years
what is bipolar II
one or more hypomanic episodes and at least one major depressive episode
what is cyclothymia
2 year period of cycling hypomanic ssx and depressive ssx that fail to meet criteria for MDD
what is a mixed state
meets criteria for both manic episode and major depressive episode almost every day for at least one week
length of time for hypomanic episode
4 days
what types of anxiety disorders prevalent in older adults
OCD, panic disorder, PTSD
what is psychosis
a break with reality, involving hallucinations, delusions, disorganized thinking, bizarre behavior, or catatonia
important diagnostic consideration in psychosis
can be primary or secondary, must rule out delirium
what are hallucinations
apparent sensory perceptions in the absence of sensory stimuli
what are delusions
firmly held, false beliefs
types of delusions
persecutory, grandiose, religious, somatic, thought control
delusions/hallucinations and Alzheimers
50% of AD patients experience them in the first 3 years
what is disorganized behavior/thought
behavior that is chaotic, poorly directed, without a clear goal or purpose, or directed toward some bizarre end. Thought lacks logical connection
what is catatonia
state of immobility, resistance to attempts to be moved, mutism
steps in psychosis eval
r/o physical illness, family history, mental status exam, medical eval, psychological tests
what is the most common type of psychosis in dementia
paranoid delusions
what to know about treating psychosis in dementia
antipsychotics carry a black-box warning for increased mortality in dementia patients
what are cluster A personality disorders and examples
odd/eccentric: paranoid, schizoid, schizotypical
what are cluster B personality disorders and examples
dramatic/emotional/erratic: Antisocial, borderline, histrionic, narcissistic
what are cluster C personality disorders
anxious/fearful: avoidant, dependent, obsessive compulsive
which types of personality disorders are most common in elderly
clusters A and C
what is true about aging and personality disorders
most have been present but undiagnosed throughout life, but age can worsen them
diagnosis consideration of personality disorders in elderly
must r/o reversible causes
hoarding aka
disposophobia
what is palliative care
interdisciplinary approach to relieve suffering and obtain the best quality of life possible
who is approved for hospice
terminally ill with life expectancy less than 6 months as certified by 2 MDs
criteria for admission to hospice
physiologic impairment of functional status per palliative performance score, dependence on assistance for 2 or more ADLs, co-morbidities that may lead to less than 6 months to live, specific disease states (cancer, COPD, liver failure, HIV)
what is most common symptom of critical illness
pain
other ssx of critical illness
dyspnea, anorexia, cachexia, constipation, nausea, anxiety, delirium, depression, fatigue
how to treat pain on hospice
avoid NSAIDs and methadone, use the same drug for breakthrough pain (ie oxycontin with oxycodone immediate release)
considerations for pain management on hospice
consider declining renal and hepatic function, manage constipation, discuss tolerance
treatment strategies for dyspnea on hospice
add O2 if possible, use a fan, opioids, roxanol (liquid morphine), +/-benzos
treatment strategies for GI discomfort on hospice
assess for fecal impaction before using laxatives, fiber does not help, consider risks/benefits of artificial nutrition/hydration
how to treat death rattle
liquid glycopyrolate
what is capacity
situation-specific ability of a patient to consent to or refuse care
4 elements of decision making
understanding (comprehend relationship of intervention/outcome), appreciation (risks vs benefits), reasoning (compare alternatives and consequences), expressing choice
highest risk group for suicide
men >85 y/o
what is reduplicative paramnesia
the belief that the present environment is duplicated or moved from another location
what is the most frequent complication of hospitalization
delirium
delirium criteria
disturbance of consciousness with reduced ability to focus, sustain, or shift attention/ A change in cognition or the development of a perceptual disturbance that develops over a short period of time and fluctuates and is believed to be caused by an underlying organic condition or is iatrogenic.
features of delirium
acute onset, fluctuating course, inattention, disorganized thinking, altered level of consciousness
what to rule out when considering delirium
dementia, depression, mania, acute psychosis
pharmacological management for delirium ssx (only for safety concerns)
haldol
components of initial eval for delirium
history/physical with neuro exam, vital signs, labs (thyroid panel, B12, drug levels, tox screen, ammonia, cortisol, ABG), search for occult infection, review meds. +/-brain imaging, LP, EEG
nonpharm strategies for management of delirium
reorientation, encourage family involvement, use of sitters, eyeglasses/hearing aids, sleep hygiene, encourage fluids, maintain mobility/self care
hallmark of delirium
impaired attention (attention is preserved in dementia until final stages)
character of hallucinations in delerium vs acute psychosis
delirium: usually visual. Acute psychosis: usually auditory and more complex
geriatric depression scale 4 or less
absence of significant depression
geriatric depression scale 5-7
borderline depression
geriatric depression scale 7 or more
probable depression
what is encephalopathy
syndrome of global brain dysfunction with a spectrum of disturbances ranging from subtle confusion to stupor, coma, and death
types of progressive encephalopathy
intrinsic, extrinsic, metabolic
types of nonprogressive encephalopathy
trauma, acute hypoxia
greatest risk factor for dementia
age
additional risk factors for dementia
HTN, head trauma, hyperlipidemia, hypoxia, smoking, stroke, depression, ETOH, hypothyroidism
Alzheimer’s areas of difficulty
learning new info, finances, visio-spatial impairment, lost in surroundings
fronto-temporal dementia etiology
loss of spindle neurons
fronto-temporal dementia aka
Pick’s disease
fronto-temporal dementia ssx
loss of social awareness, inhibition. compulsive behaviors, loss of executive function and insight into deficits. Frontal release signs
what are frontal release signs
palmomental reflex, palmar grasp reflex, rooting reflex (later signs)
what is the palmomental reflex
chin twitches if you stroke the thenar emanence
causes of vascular dementia
untreated HTN, DM, hyperlipidemia, CAD
vascular dementia ssx
confusion, agitation, depression, unsteady gait, memory disturbances, urinary ssx, night wandering, difficulty planning and organizing, poor attention/concentration
1st and 2nd most common forms of dementia
AD and vascular
vascular dementia tx
prevent future CVAs
lewy body dementia ssx
visual hallucinations, cognitive dysfunction, fluctuating levels of attention, REM sleep behavior disorder, autonomic dysfunction, parkinsonism
what is progressive multifocal leukoencephalopathy
rapidly progressive lesions gradually demyelinate white matter, due to infection, chemo, other drugs (usually seen in immunosuppressed)
characteristics of Creutzfeldt-Jakob
prion disease causing encephalopathy that is rapidly progressive and usually fatal within one year of onset
alcoholic encephalopathy areas affected
cortical and cerebellar (frontal, limbic or both)
what is wernicke’s
acute medial cortical amnestic syndrome with coma, ocular palsies, irregular pupils, ataxia
what is Korsakoff
profound amnesia (retrograde and anterograde) with clearing of aphasia, spatial disorientation, and apraxia
labs when evaluating dementia
CBC, chemistries, TSH, vitamin B12, folate, RPR, MRI head, LFTs, UA
what is executive function
planning, attention, memory, motor skills
what are ADLs
care of self (bathe, groom, feed, toilet)
what are IADLs
care of close environment (use phone, pay bills, drive, shopping, cleaning)
when to refer dementia patients to neuro
combination of psychosis and dementia, patients with early ssx for accurate diagnosis, whenever the diagnosis is in doubt
what is true of behavioral ssx in vascular dementia
they can be hard to control
how to delay or prevent need for psychotropic drugs in dementia
environmental control
functional scale for dementia
FAST
when to initiate hospice for dementia patients
be at least FAST 7c and have all features of stages 6a-7c
genes associated with alzheimers
PS-1, PS-2 (early-onset), various polymorphisms of APO-E
postmortem pathology findings of Alzheimers
accumulation of extracellular amyloid and intraneuronal neurofibrillary tangles
late onset alzheimers initial presentation
confusion, depression, delusions, visual hallucinations
pathology subtypes of fronto-temporal dementia
ubiquitin-positive inclusions and tau inclusion
what % of strokes occur >65 y/o
75%
who under the age of 75 is more likely to have a stroke
women
typical stroke presentation
facial droop, speech, motor, mental status, depending on location
common stroke mimics
hypoglycemia, infection, syncope, migraine, drugs, acute MI, trauma
how to rule out bacterial endocarditis as cause of stroke
ESR
what is amaurosis fugaz
transient monocular vision loss
most common presentation of lacunar stroke
pure motor deficit
appearance of lacunar infarct on CT
small, punched out hypodense areas
what is the scale used to predict Pt’s recovery following stroke
NIH stroke scale
what NIH score predicts high probability of death/disability vs good outcome in stroke
> 16 is bad, <6 is good
what is true of advanced age and tPA
age alone is not a cause for the risk outweighing benefit
when does stroke recovery reach a plateau
3 months
secondary prevention after stroke due to intracranial atherosclerosis
dual antiplatelet x 90 days, then ASA
what does ACA supply
medial surface of frontal lobe to anterior parietal lobe, including medial somatosensory cortex
what does MCA supply
lateral convexity of cerebral cortex, including lateral portion of primary motor and somatosensory cortex. Lateral temporal lobe and some parietal lobe
what does PCA supply
inferior and medial portions of temporal and occipital lobes
most common cause of nontraumatic intracerebral hemorrhage in elderly
amyloid angiopathy
what is the most common overall cause of intracerebral hemorrhage
HTN
intracerebral hemorrhage ssx
slower onset (minutes-hours) of HA, N/V, focal neuro ssx, AMS
subdural etiology
tearing of bridging veins 2/2 trauma
subdural ssx
gradual increase in neuro ssx including AMS and pupil abnormalities
subdural imaging
concave bleed that can cross suture lines
subdural tx
surgical evacuation of >5 mm of midline shift
3 classic phases of epidural
brief LOC, lucid interval, neurologic deterioration
epidural ssx
HA, vomiting, aphasia, hemiparesis, seizure, uncal herniation (CN III palsy)
epidural imaging
lens/lemon shaped bleed that does not cross suture lines
epidural tx
evacuation of hematoma or craniotomy
ssx of unruptured aneurysm
pain above and behind eye, numbness, weakness, paralysis on one side of face, vision changes. May be transient
examples of intrinsic encephalopathy
degeneration, chronic HTN, changes in brain matter due to changes in blood supply
examples of extrinsic encephalopathy
hydrocephalus, tumors
risk factors for delirium
elderly, polypharmacy, changes in environment, prior episode of delirium, underlying cognitive impairment, comorbidities, male, low activity levels
causes of delirium
use of indwelling catheters, physical restrains, malnutrition, dehydration, iatrogenic events, infection, depression, pain, sleep deprivation, critical illness
most common cause of creutzfeldt-jakob
sporadic mutation
creutzfeldt jakob imaging, EEG
cortical ribboning, hockey stick sign, cortical cytotoxic edema. Spike wave complexes on EEG
alzheimers imaging
medial temporal lobe atrophy, can be generalized
what is the most sensitive exam for alzheimers
MOCA, can use SLUMS if not certified
clock test is an assessment of _____
visuospatial impairment
which syphilis test can be used on CSF
VDRL
what is FTA-ABS test
confirmatory testing for syphilis after positive VDRL/RPR
what is amyloid beta protein precursor test
test done on CSF which will be low in Alzheimers
what is APOE4 test
a test done a CSF that will likely be low in high-risk for Alzheimers disease
what palliative performance score indicates eligibility for hospice
70% or less
obsessive compulsive personality disorder ssx
ego-syntonic, preoccupation with orders and details without obsessions or compulsions, rigid, stubborn, serious
obsessive compulsive personality disorder is most common in _____
men
dependent personality disorder ssx
inability to assume responsibility, dependent or submissive behavior, fear of being alone, difficulty making decisions
what is avoidant personality disorder ssx
intense fear of rejection leading to social inhibition, shy, isolated
narcissistic personality disorder ssx
grandiose, excessive sense of self-importance, superiority, lack of empathy
histrionic personality disorder ssx
attention seeking, overly emotional, temper tantrums, inappropriate sexual behavior, needs praise, relationships feel closer than they are
borderline personality disorder ssx
unstable self-image and relationships, mood swings, black and white thinking, intense reactions, fear of abandonment, impulsivity
antisocial personality disorder ssx
failure to conform to social norms, disregard of rights of others, aggression toward others, exploitation for personal gain, recklessness, lack of remorse
schizotypal personal disorder ssx
odd, eccentric, bizarre behavior and thought pattern, magical thinking
schizoid personality disorder ssx
anhedonia, social withdrawal, odd appearance
paranoid personality disorder ssx
distrust and suspiciousness of others, interprets motives as malevolent, thinks benign remarks are threatening
drug for PTSD nightmares
prazosin, must start low and titrate slow
most common phobia in elderly
fear of falling
what is the screening test for elder abuse
elder abuse suspicion index
risk factors for elder abuse
functional disability, cognitive impairment, abuser substance abuse/mental health problems, abuser dependence, social isolation, history of violence
