Neuro Flashcards
12 modifiable risk factors for dementia
education to a maximum of 11-12 years of age,
social isolation,
late-life depression,
mid-life obesity,
physical inactivity,
Alcohol consumption (>21 units/ week)
hearing loss,
diabetes,
smoking
mid-life hypertension
Air pollution
TBI
Responsive behaviors to dementia are behavioural and psychological manifestations of dementia (delusions, hallucinations, anxiety, depression, agitation, apathy) what is first line?
Non pharm options #1
Depression/ anxiety = structured psychological interventions ( CBT/ counseling)
Agitation = rec therapy, exercise, outdoor activity, sensory stimulation (massage, therapeutic touch, music)
Insufficient evidence = light therapy, aromatherapy,
What are pharmacological options for responsive behaviors to dementia?
For anxiety
For depression
For agitation
Sleep disturbances
Severe agitation
Always include family in decision making when pharm starts
Anxiety = psychomotor agitation, pacing, chanting
#1 SSRI ( citalopram, sertraline)
Depression
#1 SSRI ( except paroxetine)
Antipsychotics (reserve meds for agitation, psychosis when symptoms severe and dangerous)
#1 SGA (risperidone, olanzapine)
Sleep disturbances
#1 trazodone
If all else fails, benzos in severe agitation (LOT/ lorazepam, oxazepam, temazepam)
Prevention of dementia / non pharm approaches
Addressing known modifiable risk factors
Exercise 30min rigorous 3x weekly = minimal
Moderate intensity aerobic and resistance training, along with dance and mind body exercises (tai chi) = improves cognitive function
Mentally stimulating activities( games, computer use, social activity)
Diet = meditarranean
Identifying sleep apnea
Prevention of dementia pharm approaches
Deprescribing of sedative meds with high anticholinergic burden (can improve cognitive function)
HTN meds = to treat baseline HTN
Statins ( prevention remains controversial)
Vitamin E= not recommended
Vitamin B = beneficial only in those with elevated baseline levels of homocysteine
Alzheimer disease tx
cholinesterase inhibitors
mainstay of tx for cognitive and functional symptoms
Donepezil, rivastigmine and galantamine = different modes of actions but same efficacy when used as mono tx
Donepezil #1 (used for all severities)
Mild-mod severities (rivastigmine, galantamine)
CI = with sick sinus syndrome, profound Bradycardia, prolonged QT interval (cholinesterase inhibitor small risk of QT prolongation)
Which med can you add to Alzheimer’s disease if intolerant to cholinesterase inhibitors ?
no cure.
NMDA receptor antagonists (memantine 5mg po OD)
Only if intolerant to above or to augment response of AChI
Treatment for vascular dementia (stepwise decline in cognition after CVA with cognitive deficits involving memory, executive function, language and attention)
1 donepezil
Cholinesterase inhibitors
(Others: rivastigmine, galantamine)
Pharm treatment for Lewy body dementia (early onset visual hallucinations, Daytime drowsiness, napping, fluctuating consciousness, disorganized speech, parkinsonian symptom, antipsychotic sensitivity
1 donepezil
Cholinesterase inhibitors
(Others: rivastigmine, galantamine)
Could consider NMDA if intolerant or want to augment (memantine 5mg)
Treatment for frontotemporal dementia? (Disinhibition, socially inappropriate behaviors, compulsive behaviors, lack of apathy, change in habits or beliefs, prominent language deficitss
Nonpharm is #1
Managing symptoms with emphasis on family and caregiver support = mainstay for treatment
Should you use antipsychotics for Lewy body dementia?
NO
Can worsen LBD
If needed quetiapine ***
Should you use cholinesterase inhibitors for frontotemporal dementia?
NO do not use or mementine
Tips for prescribing
Start at lowest dose and increase every 4 weeks as tolerated
Avoid treating the side effects of it, instead consider reducing the dose or switching to CI once the side effects have fully resolved after discontinuation of the initial agent
Side effects of CI
AE= GI, anorexia, wt loss, vivid dreams, tremors, vertigo, cholinergic effect (rhinnorhea, urinary frequency)
Very good at watching CTV
V-vivid dreams
G-GI
W-wt loss
C-cholinergic effect
T-tremors
V-vertigo
When to stop a cholinesterase inhibitor ?
Pt or caregiver decided due to non adherence to
Cognitive function or behavioral
Decline is more rapid on treatment that without
Intolerable side effects
Has progressed / terminally
Tapering of cholinesterase inhibitors?
Reduce by half of previous dose or stepping down through available dose formulations
- decrease dose every 4 weeks
If ++ a/e = abrupt discontinue
Monitor:
Severe symptoms l, agitation, aggression, hallucination within 1 week-> restart previous dose
Worsened cognition, behavior or psychological or function ( 2-6 wk)-> consider restarting previous dose
If 6wk-3mo, symptoms resurgence likely progression or re emergence
Cholinesterase inhibitors side effects
Think GI: nausea, vomiting, and diarrhea >10%
<10%: bradycardia, syncope, dizziness, headache, sleep disturbance, fatigue, abdominal pain, weight loss, UTI, urinary incontinence, rhinitis.
Heart block (rare), seizures (rare), delirium (rare).
Cholinesterase drug interactions
Toxicity may be increased by paroxetine, erythromycin, prednisone, grapefruit juice
PEPG
Effectiveness may be reduced by inducers of CYP2D6 or CYP3A4, such as carbamazepine, phenytoin, rifampin.
Mainstay of tx in responsive behaviors in dementia?
Nonpharm approaches
When to re-assess antipsychotics prescription for response behaviors to dementia
Q3-6months if symptoms subside then taper
What drug can also be used to decrease RBD
Cholinesterase inhibitors and memantine
They have less risk of serious adverse events compared to antipsychotics
** overall benefit on behaviors appears to be small suggesting questionable evidence***
What is first line for anxiety symptoms in RBD
Non pharm first
Then SSRI (citalopram or sertraline)
What is first line for depressive/ sex inappropriate behaviors in RBD
Nonpharm #1
SSRI ( exception paroxetine)
Needs 6-8 weeks of tx to see improvement
What is first line sleep disturbances symptoms in RBD
Trazodone
Helps with sleep and sun downing
When to use antipsychotics for RBD?
Reserve with severe responsive behaviors, particularly aggression that poses a risk to harm self or others, if Nonpharm is ineffective
Nonpharm #1
Pharm #1 SGA (risperidone / olanzapine)
DO NOT GIVE IF LBD , use quietiapine if antipsychotic required
Benzos and RBD
Can sometimes be used for severe agitation when other agents fail and worsening condition
Low dose LOT
Lorazepam, oxazepam, temazepam
In acute situation to mana severe agitation Ativan + haldol can be given IM
What increases your risk of Bell’s palsy
PHIL D
Pregnancy
HTN
Immunizations
Lyme disease
Diabetes
What is classic presentation of Bell’s palsy?
acute onset
Unilateral facial weakness (involving upper and lower face)
Ear pain
Altered taste
Nonpharm options for Bell’s palsy
Exercise for early stages by physio (low evidence but not a bad thing to do)
Greatest benefit is seen with Bell’s palsy treatment when treatment is initiated when?
Up to 48 hours after symptom onset
Not a good benefit if treatment started 7 days after onset of symptoms
Early treatment (initiated within 48–72 hours of symptom onset) provides maximal benefit; evidence of benefit is less clear for treatment initiated 4–7 days after onset.[16][17] Although several guidelines recommend treatment within 72 hours of onset, a 48-hour window appears to confer greater benefit.
Bell’s palsy treatment // mild weakness <7 days , not progressing
No treatment
Analgesics - ibuprofen Tylenol required for first 1-2 days to alleviate pain and edema
Eye care - to prevent corneal abrasion in any eye that cannot close, lubricate with ophthalmic drops, gels or ointments BID up to Q1h while awake
** tape eyelid closed at night and protect with glasses during the day **
Early treatment (48-72 hours of symptom onset) provides maximal benefit, evidence of benefit is less clear for treatment initiated 4-7 days after onset. A 48 hour window is of greater benefit.
Partial (still progressing) or complete paralysis duration <7 days
PO prednisone 60mg x 5 days
Can discontinue without tapering if <2 weeks duration
THINK palsy=5 = 5 days
With complete paralysis, corticosteroids started within 7 days of onset of paralysis showed clinically and statistically improvement in recovery of function
Analgesics - ibuprofen Tylenol required for first 1-2 days to alleviate pain and edema
Eye care - to prevent corneal abrasion in any eye that cannot close, lubricate with ophthalmic drops, gels or ointments BID up to Q1h while awake
** tape eyelid closed at night and protect with glasses during the day **
Complete or stable, partial paralysis, duration >7 days
No treatment (meds will not help)
Urgent referral to neuro for opinion
Children with Bell’s palsy
No demonstrated benefit from corticosteroid therapy
Risk of incomplete recovery is very small
When do you add antivirals to bell palsy
Consider adding antivirals to corticosteroids for severe facial paralysis, suspect Ramsay hunt syndrome or immunocompromised
Acyclovir 400mg daily x 10 d
Famciclovir 500 mg TID x 1 week
Valacyclovir 1000mg TID x 1 week
Pregnancy and bell palsy
Tends to occur in third trimester or first few weeks PP, prognosis is worse for satisfactory recovery than general population what is the treatment ?
1 supportive care
Analgesics - Tylenol required for first 1-2 days to alleviate pain and edema
Eye care - to prevent corneal abrasion in any eye that cannot close, lubricate with ophthalmic drops, gels or ointments BID up to Q1h while awake
** tape eyelid closed at night and protect with glasses during the day **
Effects of corticosteroids on fetus is unclear / will recover spontaneously
To use antivirals VAC may be considered
Different types of seizures
Atonic: Loss of muscle tone
Tonic: Muscle stiffness, rigidity
Clonic: Repetitive, jerking movements
Myoclonic: Sporadic (isolated), jerking movements
Absence: brief loss of consciousness
Grand Mal: Unconsciousness, convulsions, muscle rigidity
if someone is having a seizure move all near objects out of the way and depending on seizure hold patient still.
Nonpharm for seizures ?
Encourage good sleep
Keep alcohol consumption to a minimum
Decrease stress / anxiety
Cocaine and amphetamines must be avoided due to proconvulsant properties
Review herbal supplements some are proconvulsant
Ketogenic diet, modified Atkins, low glycemic index = decreases seizures // RD should be involved
discuss seizure precautions with family
Referral for epilepsy surgery or neuromodualtion should be considered with medically refractory epilepsy or resistant to > 2 anti seizure meds (not include intolerant to s/e)
Yoga, mindfulness, increase QOL
Limited evidence in meditation, relaxation, acupuncture
Should you treat the first seizure ?
First Investigate causes
many pts will NOT require ASM
Decision should be guided by history and other clinical indicators
no role for ASMs in patients with acute symptomatic (provoked) seizures, such as those provoked by metabolic derangements (e.g., hypoglycemia, hyponatremia) or withdrawal from drugs or alcohol.
in TBIs ASMs prevent seizures in the 7 days post seizure no effect on the development or later seizures
-> could benefit from short term use <7 days of ASM but long term use does not prevent progression to epilepsy
ASM (anti seizure meds) basic principles
start low, titrate up - minimize the risk of dose-dependent AEs *lamotigrine ALWAYS requires slow titration
inform pt of risks - life-threatening hypersnesitivity reaction
anyone of child-bearing age - 1mg of folic acid to prevent neural tube defects
Make a small dosage reduction if dose-related adverse effects are problematic
Principles of adding second ASM
Add a second ASM if the max tolerated dose of the first ASM has failed to achieve satisfactory seizure control. Gradually withdraw the first ASM after maintenance dose has been achieve with second drug
Focal seizure treatment ?
1 Lamotrigine 25mg daily po
After 2 week increase to 25mg BID then increase by 25-50 mg/day at 2 week intervals
Maintenance: 100-400mg/ day BID
Carbamazepine also an option
Side effects of lamotrigine
Rash which rarely can be very serious
Insomnia
Absence seizure treatment
1 ethosuximide (drug of choice)
Valproic acid = equally effective
Generalized seizures first line
Valproic acid 250mg BID
Increase by 250mg q3-4 days
Maintenance: 750-1000mg/ day in 2 divided doses
Should not be used in women of childbearing potential **
Valproic acid side effects
Nausea, weight gain, tremor, hair loss, blood dyscrasias, hepatotoxicity (rare), edema (rare), menstrual irregularities, teratogenicity.
V- vomiting
A-alopecia (hair loss)
L-liver toxicity
P-pancreatitis / decrease platelets
R- risk of neural tube defects
O- obesity (weight gain)
A-anorexia
T-tremor/ teratogenic
E-edema
Ethosuximibe side effects
GI upset
** absence seizure only / won’t work if you have multiple different kind of seizures**
Dose related effects for ASM
Different categories
dose-related
skin rash - (more likely to happen w/ phenytoin, carbamazepine and lamotrigine/ PCL) more likely to occur within the first 6 weeks of tx
-DC immediately
* titrate very slow to avoid*
Blood and/or hepatic dyscrasias
Mild elevations (<2-3 times the upper limit of normal) in liver enzymes and/or modest reductions in blood counts (e.g., neutropenia with carbamazepine, thrombocytopenia with valproic acid) are relatively common.
Enzyme-inducing ASMs increase the risk of hyperlidiemia
-Obtain a baseline CBC and serum liver aminotransferases if treating with an ASM that may cause a hypersensitivity syndrome involving blood or liver; repeat in 4-6 wk. - do not need to be DC’d with minor changes, keep following and if enzymes remain stable then can he monitored yearly
Osteoporosis
Long-term use of valproic acid and enzyme-inducing ASMs ( CBZ, clobazam, phenytoin, phenobarbital)
- monitor bone density carefully, supplement calcium and vitamin D
Discontinuing ASM
Consult with neuro
Usually 2-5 years seizure freedom (adult)
18-24 months + normal EEG (child)
Contraceptive and ASM
There is an increased risk of combined oral contraceptive (COC) failure in patients taking enzyme-inducing ASMs
Ideally the COC should contain ≥50 mcg ethinyl estradiol - does not exist in canada
Considering taking 2 COCs/ day
*barrier methods also recommended
(Condoms)
Intrauterine devices (hormonal and nonhormonal) and progestin depot injection formulations may be reasonable alternatives for patients with epilepsy.
Lamotrigine metabolism is profoundly affected by concomitant use of COCs - reduced levels by 50% - measure levels before and after initiation of COC - consider doubling Lamotrigine dose
Which Contraceptive less likely to be effective with ASM
Combined contraceptive patch
Combined oral contraceptive
Progestin implant
Progestin-only oral contraceptive
Vaginal ring
ASM during pregnancy
Pre pregnancy- assess if ASM still required, if >2 years free of seizures , consider d/c. If at risk = keep
AVOID: Valproic acid + topiramate
PREFERRED: Lamotrigine, levetiracetam and oxcarbazepine safe with low rates of teratogenicity.
- Remember to take folic acid supplement**
- Do not switch AEDs during pregnancy to avoid teratogenesis
- Measure serum levels of AEDs q monthly during pregnancy as they can drop d/t increased clearance
-May need dose adjustments
-afte delivery , levels rise quickly 1-2 weeks dose
Will need to be adjusted early after delivery to avoid toxicity // slowly titrate back to pre pregnancy dose // might be slight higher 3 months PP due to lack of sleep
If taking Valproic acid =
Take 4mg/ day folic acid
