Module 2 Flashcards
Types of cephalalgia
-migraines
-cluster
-tension
-subdural hematoma
-SAH
-viral or bacterial meningitis
-tumor
-temporal arteritis
-rebound HA
With elderly patients, what can cause altered mental status other than dementia/delirium?
B12 deficiency
infection
polypharmacy
ETOH/drug abuse
When concerned about a patient’s altered mental status, what labs would you order? What other diagnostic tests would be ordered?
-UA, CBC, BMP (CMP), B12, RPR, ESR, TSH
-CXR, MRI vs CT, Cognitive testing
Is delirium chronic or acute?
Is dementia chronic or acute?
acute
chronic
Generalized treatments used for Alzheimer’s disease?
-cholinesterase inhibitors
-Memantine (Namenda)
-antidepressants
Alzheimer’s Disease
-what type of medications should be limited?
-labs to be drawn to dx, imaging for dx?
-how do you confirm dx?
-antipsychotic
-CBC, CMP, TSH, B12, RPR; CT head
-spinal tap
Alzheimer’s Disease
-cognitive testing
*types
-SLUMS - comparable to MoCa; scores: >26 = normal (27-30), 21-26 = mild decline, <21 = dementia; comparable specificity and sensitivity as MoCa
-MoCa - 30 point test, expensive ($125), greater specificity and sensitivity than MMSE
-MMSE
-Mini-cog test: word recall (0-3pts), clock drawing (2 or 0pts) = 5 points total; 0 points = positive test, 1-2 points = positive test, 3-4 points = negative test, 5 points = negative test.
Normal Pressure Hydrocephalus (NPH)
-def
-what type of imaging is initially needed for dx?
-age usually diagnosed
-more common in men or women?
-enlargement of ventricles without increased ICP (HA, N/V, etc.); extra fluid is fairly well distributed between four ventricles
-CT or MRI
->=60
-equal (minimally men)
Normal Pressure Hydrocephalus (NPH)
-Triad of Sx
-Tx (and what should you NOT treat?)
-Gait changes, altered thought processes, urinary incontinence
-Shunt, anticholinesterase inhibitors (helpful for memory loss), therapy for gait
*do not treat overactive bladder with medications
Stroke
-sx
-what impacts sx?
-preferred imaging for dx?
-Abrupt change in neurological status, often accompanied by hemiparesis or hemiplegia
-location and severity of stroke
-CT
Stroke
-TX
*ischemic stroke
*hemorrhagic stroke
-needs to be initiated within 4.5 hours onset of S/S (IV); ASA given by mouth, TPA to dissolve clot
-focus on controlling the bleeding; clipping of aneurysm; evacuation of hematoma
Stroke
-what kind of evaluation must take place via US?
-anticoagulation therapy (what anticoagulation therapy would patient be put on?)
-non-valvular afib (what meds could patient be put on to manage?)
-carotid US to check for carotid stenosis
-ASA 325mg; plavix; aggrenox; coumadin (INR goal 2-3)
-Pradaxa, Zarelto, Eliquis
Treatment with ASA
-what disease/issue does this help with?
-dose?
-Stroke, anticoagulation therapy
-325mg
Treatment with Plavix
-what disease/issue does this help with?
Anticoagulation therapy –> stroke
Treatment with Aggrenox
-what disease/issue does this help with?
Anticoagulation therapy –> stroke
Treatment with Coumadin
-what disease/issue does this help with?
Anticoagulation therapy –> stroke
Treatment with Pradaxa
-what disease/issue does this help with?
-non-valvular afib –> stroke
Treatment with Zarelto
-what disease/issue does this help with?
-non-valvular afib –> stroke
Treatment with Eliquis
-what disease/issue does this help with?
-non-valvular afib –> stroke
Parkinson’s Disease
-Sx
-more common in males or females?
-when is onset common?
-tremor, rigidity (cog-wheeling), bradykinesia, postural instability
-equal
-45-65yrs
Parkinson’s Disease
-HALLMARK SX
tremor, rigidity (cog-wheeling), bradykinesia, postural instability
Parkinson’s Disease
-what is the first sign noticed?
*is this sign present all the time?
-are symptoms present when active or at rest?
-what do sx do with intention?
-pill-rolling tremor; initially unilateral
*absent during sleep
-maximum sx at REST
-decrease with intention
Parkinson’s Disease
-what medications cause pseudo-Parkinson’s?
-metoclopramide
-reserpine
-anti-psychotics
Parkinson’s Disease
-what labs need to be collected for dx?
-TX
*what should be considered if <50yrs old?
*what type of consult?
*Medication therapy
-CBC, CMP, TSH, B12, RPR
-Huntington’s chorea; Wilson’s Disease (copper)
-Neurology (esp with younger onset <60yrs)
-Sinemet (Levadopa); Amantadine, Sinemet (ER)
What disease does Sinemet (Levadopa) treat?
-Parkinson’s
What disease does Amantadine treat?
-Parkinson’s
What disease does Sinemet (ER) treat?
-Parkinson’s
Essential Tremor
-what areas of the body are impacted?
-what exacerbates?
-dx
-hands, head voice
-exacerbated by stress, fatigue, stimulants (amphetamines)
-extend hands; Archimedes spiral
Essential Tremor
-present or absent at rest?
-present or absent with intention?
-age of onset?
-bilateral or unilateral? where is tremor mostly located?
-absent
-present
-20-60yrs
-Bilateral, distal upper extremities (fingers, hands) –> may be unilateral on presentation
Essential Tremor
-pill-rolling sx?
-what happens when sx progress?
-NO
-can progress and be present at rest
Essential Tremor
-TX
-Therapy
-Wrist weights
-Exercises
-Rest
-Beta blocker
Myasthenia Gravis
-at what age does this tend to occur?
-what may this be associated with?
-patho
-any age, any time
-autoimmune disease???
-decrease in number of acetylcholine receptors and their effectiveness
Myasthenia Gravis
-Sx
nonspecific
-asymmetric limb weakness, muscle fatigue, cranial nerves effected
*motor nerves of face and neck
*Diplopia (double vision), ptosis (lid lag), dysphagia (difficulty swallowing)
*possible respiratory difficulties
Myasthenia Gravis
-dx
*test
*labs
*imaging
-Tensilon Testing: administered IV –> improvement in strength of affected muscles = + test
-RA ANA, ESR
-CT
Dizziness
-def
-differential dx
-what must be ruled out?
-what should be considered with continuous unrelenting dizziness?
-sensation of motion even when being still
-vertigo (episodic), sinus infection complication
-orthostatic hypotension
-underlying psychological disorder(s)
Benign Paroxysmal Positional Vertigo
-what kind of trauma can cause this?
-Def
-Tx
-ear trauma, possibly
-displacement of otoliths into gelatinous capsule of semicircular canals
-particle repositioning therapy (PT) with Epley Maneuver
Seizures: generalized Epilepsy
-Nonmotor types
-absence seizures
-atypical absence seizures
Seizures: generalized epilepsy
-Absence seizure
*another name for absence seizure
*what age is this common among?
*does it go away? If so, when?
*unilateral or bilateral brain activity on EEG?
-Petit mal
-5-18yrs
-by age 20, but can be replaced by another type of seizure
-Bilateral brain activity on EEG
Seizures: generalized Epilepsy
-Motor types
-Tonic clonic seizure
Seizures: generalized epilepsy
-Tonic-clonic seizure
*another name for this seizure
*parts of the seizure progression
-gran mal
-possible aura –> sudden LOC (rigid, falls to ground, respiration arrested = tonic) –> jerking (clonic) –> flaccid coma (loss of postural tone and DTR; unconscious, apnea, cyanosis, urinary/fecal incontinence when awakening)
Seizures: generalized epilepsy
-Tonic-clonic seizure
*how long does tonic portion of seizure tend to occur?
*how long does clonic portion of seizure tend to occur?
-<1min
-2-3min
Seizures: tonic clonic seizure
-management
*prophylaxis
*intractable seizures
-dilantin, tegretol, phenobarbital, primidone, depakote
-surgery
Dilantin
Tonic clonic seizure
Tegretol
Tonic clonic seizure
Phenobarbital
Tonic clonic seizure
Primidone
Tonic clonic seizure
Depakote
Tonic clonic seizure
Focal Seizures
-also known as?
-same as generalized seizures?
-are both hemispheres of brain activated?
-types (2)
-partial seizure
-NO
-one hemisphere
-Simple Partial Seizure; Complex Partial Seizure
Focal Seizure: simple partial seizure
-awake or unconscious?
-types of simple partial seizures
-involves large or small area of brain?
-awake
-motor and nonmotor
-focal area of brain (smaller portion)
Focal Seizures: complex partial seizure
-def
-does seizure stay in one hemisphere of the brain?
-how long does this type of seizure last?
-impaired awareness or awareness; may be preceded, accompanied, followed by various motor and nonmotor sx
-starts in one hemisphere but travels
-30sec - 2min
What is the most common type of seizure in adults?
Complex partial seizure
What type of focal seizure has sx of LOC impaired?
What type of focal seizure has sx of LOC not impaired?
-Complex partial seizure
-Simple partial seizures
Rolandic Epilepsy
-onset; stops by?
-When is onset? Where does it begin on the body?
-what can it progress to? What may present with this type of epilepsy?
-after how many years are these patients typically seizure free?
-tx
-mid childhood (peaks 8-9yrs); stops by age 18yrs
-nocturnal onset; begins in face
-tonic clonic seizure; status epilepticus
-5yrs
-NONE (seldom treated)
Febrile Convulsions:
-at what age do these occur?
-more common in men or women?
-6MO-5YR
-men
most common type of epilepsy in childhood?
Rolandic epilepsy
most common type of seizure in childhood?
Febrile convulsions
Dysautonomia:
-def
-type of acute Dysautonomia
-autonomic NS dysfunction; acute or chronic
-Guillain-barre (self-limiting)
Dysautonomia:
-types
- orthostatic hypotension
- primary chronic autonomic failure
- Postural orthostatic intolerance (POTS)
- Panic disorder
- Neurologic essential HTN
- CHF
- Chronic fatigue syndrome
Dysautonomia: Chronic orthostatic intolerance
-Postural orthostatic tachycardia syndrome (POTS)
*link between POTS and what disease?
*sx
*triggers
*relation to anxiety?
*TX
-COVID
-fatigue, lightheadedness, brain fog, forceful heart beat or palpitations, N/V, HA, excessive sweating, shakiness, intolerance to exercise
-warm environments, standing for long periods, low fluid/low salt intake, can get worse when fighting infection
-increase fluids, inc salt, caffeine; beta blockers to control HR; Midodrine to constrict blood vessels and raise BP
Midodrine
constricts blood vessels and raises BP for POTS patients
Multiple Sclerosis:
-sx
-DTRs and Babinski reflex
-DX by what imaging?
-types
-tx
-nonspecific/vague; blurred vision, diplopia, loss of balance, weakness, paresthesias, vertigo, slurred speech
-DTR brisk; + Babinski reflex
-MRI –> requires 2 episodes involving 2 CNS areas/sx or progression of sx over a 6MO period
-Relapsing-remitting; primary progressive; secondary progressive; progressive relapsing
-No cure; manage sx
What is the #1 disability in young adults?
MS
Neuralgias:
-what are the most common types?
-Trigeminal
-Post herpetic (post shingles) PHN
Neuralgias:
-Trigeminal
*females vs males occurrence?
*sx
*onset (age)
-females
-sharp, electric, lancing, stabbing pain
->40yrs
Neuralgias:
-post herpetic (post shingles) PHN
*females vs males occurrence?
*sx
*onset
*what type of pain occurs?
-females 2:1
-severe pain or severe rash; painful bursts that may lead to chronic prolonged episodes
->80yrs; peak onset 60-70yrs
-prodromal pain BEFORE rash
Dementia: Alzheimer’s Disease
-cause
-women vs men
-Blacks vs Whites
-can it be prevented?
-can it be cured?
-can it be halted?
-generalized degeneration of the brain; middle or older age
-women
-blacks
-NO
-NO
-NO
Dementia: Alzheimer’s Disease
-65yo life expectancy with this dx?
-when do you consider familial connection?
-R/F
-4-8 years, as much as 20yrs
-if dx before age 60yrs
-age, fam hx, APOE4 genotype, CAD R/F, education, social and cognitive engagement, traumatic brain injury, down syndrome
Dementia: Alzheimer’s Disease
-APOE4
*how common in those dx with Alzheimer’s disease?
*where is this marker seen? (in what type of testing?)
*how many alleles in this gene?
-20-25%
-specialized cholesterol testing
-3 alleles
Dementia: Alzheimer’s Disease
-APOE4
*how to treat if patient has allele E4 (or E3)?
*what allele is associated with inc risk of developing Alzheimer’s disease?
-Ezetimibe (zetia); not fishoil!!!
-E4
Delirium
-is this seen in acute or chronic medical problems?
-what other factors can cause delirium?
-both
-substance abuse; medications can cause delirium
Depression (and dementia)
-how common (%)?
-how is it diagnosed?
-25%
-5 or more sx present w/i 2 week period and are change from baseline:
*depressed mood
*decreased interest/pleasure in activities
*5% or greater wt change
*insomnia/hypersomnia
*psychomotor agitation
*fatigue
*Feelings of worthlessness or excessive/inappropriate guilt
*Diminished ability to concentrate or think
*Recurrent thoughts of death/suicide
Beers Criteria
-what age do these criteria apply to the population?
> 65yrs
Beers Criteria: antihistamines
-NOT to be prescribed
*but when can this be prescribed?
-SX
-Diphenhydramine/chlorpheniramine (Benadryl)**
*OAB
-dry mouth, confusion, blurred vision
Beers Criteria: Phenergan
-SE
sedation, dry mouth, etc.
Beers Criteria: Antidepressants
-what type of antidepressant should be avoided in patients with hx of falls w/ fracture?
*SE
*Drugs
-SNRI**
-dizziness
-Cymbalta, effexor
Beers Criteria: Antiparkinson’s meds
-Drugs
-Benztropine**
Can use sinemet (carbidoba-levadopa)
Beers Criteria: Antispasmodic
-drugs
-belladonna (hot flashes)
-Clidinium-chlordiazepoxide (Librax)
-Hyoscyamine (IBS)**
-Propantheline
-Scopolamine
Beers Criteria: Short-acting dipyridamole
-SE
hypotension
Beers Criteria: Macrobid (Nitrofurantoin)**
-what can long-term use cause?
-how should we do UTI tx?
-renal insufficiency
-culture driven UTI tx (unless running fever)**
Beers Criteria: Alpha blockers**
-avoid in tx of what?**
-can use in tx of what?**
-HTN
-BPH
Beers Criteria: Alpha agonist
-Drugs
- Clonidine**
- Guanabenz
- Guanfacine
- Methyldopa
- Reserpine (>0.1mg daily)
Beers Criteria: Cardiac drugs
-antiarrhythmics (drugs - 5 drugs that we should not manage)
-antiarrhythmics (7 other drugs)
-amiodarone, flecainide, procainamide, sotalol, quinidine
-Disopyramide; rivaroxaban; dabigatran; dronedarone; digoxin; nifedipine, spironolactone
Beers Criteria: Neurological drugs
-Tricyclic antidepressants
*drugs; SE
-Elavil, Tofranil, librax
-dizziness, dry mouth, inc risk of falls
Beers Criteria: what five cardiac drugs should we as the NP not manage?
amiodarone, flecainide, procainamide, sotalol, quinidine**
Beers Criteria: anti-psychotics
-Drugs
ALL - increased lethargy, AMS (altered mental status), and risk of stroke (esp dementia)**
Beers Criteria: Hypnotics
-after how many days of consistent use, should hypnotics be stopped?
-sx
-what hypnotic is acceptable (off label use)?
-Drugs
-avoid using >90 days**
-hypersomnia, confusion, dry mouth, inc risk for falls**
-Trazadone** (acceptable; also used for anti-depressant)
-ambien, sonata, lunesta**
Beers Criteria: Neurologic drugs
-other drugs
-benzodiazepines**
*avoid as much as possible
-chloral hydrate
-meprobamate (tranquilizer)
-Ergot mesylates
Beers Criteria: Opioids
-what should be avoided when taking opioids?
-what opioid increases risk for SIADH if used a lot?
-avoid using opioids with benzodiazepines an gabapentin/Neurontin (includes pregabalin/Lyrica)**
-Tramadol/ultram
Beers Criteria: hormones
-androgens
*who should androgens be avoided in (what sex, what hx)?
*what may androgens exacerbate?
*what androgen can increase risk of heart disease?
*androgens increase risk of what type of cancer?
-males, prostate CA**
-heart problems or prostate CA**
-testosterone**
-prostate CA**
Beers Criteria: hormones
-estrogens with or w/o progestins
*increase risk of what types of CA?
*lntra-vaginal cream in what type of dose is okay?**
-endometrial and breast
-low
Beers Criteria: hormones
-growth hormones
*what patients can received growth hormones?
Only those with pituitary removed**
Beers Criteria: Desiccated thyroid
-may need armor thyroid (for pts who need extreme management of TSH)**
Beers Criteria: sliding scale insulin
-risk for?
-what is best type of regimen for insulin?
-hypoglycemia**
-basal insulin**
Beers Criteria: Megestrol (Megace)
-off label use
-increases risk of what?
-appetite stimulants** in CA pts.
-blood clots
Beers Criteria: Gastro/muscle/pain meds
-Metoclopramide (reglan)**
*Med should be avoided in all pts except those with what?
*what is the max amount of time pt can use this med?
*can cause what Sx?
-gastroparesis
-4-6 weeks
-tardive dyskinesia
Beers Criteria: proton pump inhibitors**
-longest amount of days can use?
-can try H2 blocker?**
-90
-yes!!
Beers Criteria: Mineral oil**
-SE
increased risk for aspiration**
Beers Criteria: Trimethobenzamide
-Promethazine (Phenergan)**
-Sx
-?
-confusion, dizziness, inc fall risk, dry mouth**
Beers Criteria: NSAIDS**
-SX
GI bleeds**
Beers Criteria: Meperidine (demorol**)
-Not effective pain reliever
-can cause what?
-seizures
AD 8 Dementia Screening Tool
-def
-scoring
-what does this test determine?
-Informant interviews, helps to distinguish btw signs of normal aging and mild dementia
*tests memory, orientation, judgment, function
-0-1 normal
->=2 cognitive impairment likely
Treatment for dementia: 4 types listed
- cholinesterase inhibitors
- Memantine
- Leqembi/Lecranemab
- Antipsychotics
Dementia Tx: Cholinesterase inhibitors
-patho
-med (2)
*best dosed at what time of day?
-slows breakdown of neurotransmitters
-Donepezil (5 or 10mg)
*Dose at night
-Exelon patch (rivastigmine); works well (4.6, then 9.5, then 13.3mg dosed every 30d)
Dementia Tx: Memantine
-patho
-what allows more cell damage?
-regulates activity of glutamate by blocking some of the NMDA receptor sites
-Glutamate is released in larger quantities by damaged cells, creating overload that allows for more cell damage
Dementia Tx: Antiamyloid medication
-Leqembi/Lecranemab
*patho
*what type of antibody?
*common SE
*important EXTRAS
-amyloid beta plaque reduction
-monoclonal antibody
-HA, dizziness, vision changes, N, diarrhea, seizures, confusion
-BBW
Dementia Tx: Antiamyloid medication
-at what point can this med be prescribed?
-need beta amyloid plaques in order to prescribe
ARIA –> amyloid related imaging abnormalities
-asymptomatic or symptomatic?
-Sx
-Def
-asymptomatic
-higher mortality rates, diabetes, sedation (esp haldol)
-life threatening brain swelling and fatal brain hemorrhage
ARIA
-population at highest risk
-occurs spontaneously or with antiamyloid therapy?
-POE4 genotype, blood thinners, previous hx of microscopic brain bleeds
Dementia Tx: psychotics
-Rexulti
*consider…
-agitation associated with Alzheimer’s disease, MDD, , schizophrenia
*BBW: inc mortality in elderly pts with dementia; inc risk of hyperglycemia, stroke, tardive dyskinesia.
