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NUNP 547 - Older Adult > Neuro/MH > Flashcards

Neuro/MH Flashcards

1
Q

SNOOP4

A 
S - systemic symptoms (fever, chills, myalgia, weight loss)
N - neurological symptoms, focal
O - older age > 50 years
O - onset, rapid/thunderclap
P - Papilledema
P - Positional
P - precipitated by valsalva
P - progressive/pattern change
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2
Q

True/False

Older age increases risk of secondary headaches

A

True

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3
Q

Which location of strokes are more likely to cause headache, anterior or posterior circulation?

A

Posterior circulation

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4
Q

Link type of headache to description:
A) sudden onset focal neurological deficits
B) thunderclap, presence of anticoagulation
C) subacute onset, papilledema, neurological defecits
D) systemic symptoms, scalp tenderness, visual changes
E) Headache precipitated by exertion
F) morning headache, daytime sleepiness
G) Headache in dimly lit conditions
H) headache exacerbated by neck mvmt
I) polypharmacy

A 
A) CVA
B) ICH
C) Neoplasm
D) GCA
E) cardiac cephalagia
F) headache attributed to OSA
G) subacute glaucoma headache
H) cervicogenic headache
I) medication overuse
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5
Q

Diagnostic test for cardiac cephalagia

A

Stress test, improves with nitroglycerin

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6
Q

Migraine symptoms that differ with older adults

A

Increased autonomic S&S (bilateral tearing and rhinnorrhea)
Decrease N/V & photophobia
Migraine aura without headache - visual, sensory or speech < 60 minutes (pathognomic - sequential, marching parttern that increase over minutes)
Increase neck pain

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7
Q

True/False

Tryptans are contraindicated for cerebrovascular and cardiovascular disease

A

True

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8
Q

For prophylactic treatment of migraines, how long at the goal dose should people expect the full benefit?

A

2-3 months

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9
Q

Which TCA has less side effects and indicated for treatment of migraines for older adults?
Starting dose and max dose/titration

A

Nortryptilline (less side effects) compared to amitryptilline
10mg OD at HS, titrating up 10mg per week for max 50-70 mg

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10
Q

SNRI starting dose for migraine and titration

A

Venlafaxine 37.5mg daily, goal 150mg daily (fewer SE than TCA)

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11
Q

Anti-epileptic medications for migraine, starting dose and titration

A

Valproate 250 mg starting, 250 mg titration weekly, max dose 1000mg (CBC, LFTs required)
Topirimate 12.5 mg, increase by 12.5 mg weekly to max 100-200mg daily in divided doses (high risk of cognitive SE)

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12
Q

Chronic migraine definition requiring preventative treatment

A

15 or more headaches per month, 1/2 with migraine features

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13
Q

BPPV, Vestibular neuritis, herpes zoster, Ménière’s disease, acoustic neuroma are causes of what type of vertigo?

A

Peripheral

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14
Q

Vestibular migraine, brainstem ischemia, cerebral vascular accident, multiple sclerosis, are all examples of what type of vertigo

A

Central

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15
Q

The triad of Ménière’s disease

A

Vertigo, tinitis, hearing loss - aural fulness

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16
Q

Vertigo aggravated by movement

A

BPPV

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17
Q

HINTS test components

A

Head impulse, nystagmus, test of SKew

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18
Q

Dizziness precipitated by exertion, Palpitations, known history of structural heart disease, family history of sudden death, abnormal ECG

A

Cardiac etiology! Red Flags!

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19
Q

Timing of vertigo in Ménière’s disease

A

20 minutes - days

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20
Q

Timing of vertigo in BPPV

A

Seconds to minutes

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21
Q

Timing of vertigo in vestibular neuritis versus migraine

A

VN- persistent

VM- Episodic, minutes to hours

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22
Q

T/F Vertical nystagmus is a normal finding

A

False! Indicates Possib;e CVS

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23
Q

Five diagnostic criteria required for restless leg syndrome- URGES

A
  1. Urge to move legs
  2. Symptoms worsen with inactivity/rest
  3. Sensations relieved with movement
  4. Symptoms worse or only at night
  5. Symptoms not accounted for by other medical or behavioural condition

Urge to move, Rest induced, Gets better with activity, and Evening and night accentuation

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24
Q

First line pharm treatment for restless leg syndrome

A

Pramipexole

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25
Q

First line treatment for periodic limb movement in sleep - PLMD

A

Clonazepam

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26
Q

T/F - Depression in older adults may be prodrome for dementia

A

True

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27
Q

T/F- Older adults are more likely to present with somatic complaints such as G.I., less guilt or low self-esteem, with underlying depression.

A

True

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28
Q

Non-modifiable high risk factors for suicide in older adults

A

Old age, male gender, widowed/divorced, previous self harm attempt, losses (health status or people)

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29
Q

Minor depressive disorder symptom timeframe-

1st line tx-

A

<4wks

Psychotherapy

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30
Q

Doxepin, amitriptyline - med class?

Considerations for prescribing TCAs-

A

Tricyclic antidepressant

Don’t use in patients with conduction abnormalities on ECG or postural hypotension

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31
Q

Class of Antidepressant medication most likely to cause hyponatraemia

A

SSRI’s

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32
Q

Venlafaxine, duloxetine - med class?

A

SNRI

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33
Q

Med class-

Trazodone-
Bupropion-
Mirtazapine-

A
  1. Serotonin receptor agonist and reuptake inhibitors
  2. Dopamine reuptake inhibitor
  3. Alpha-2 antagonist
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34
Q

Remission of symptoms must take place for how long before considering stopping antidepressant therapy

A

1 year

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35
Q

At risk drinking criteria male and female

A

5+/ day in Males
4+/ day in Females

In last year

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36
Q

What percentage of alcohol dependent drinkers require medically managed detox

A

20%

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37
Q

When to start out pt detox-

How lften to follow-up-

Pharmacotherapy for outpatient alcohol detox

A

Mon/tues unless weekend coverage
Daily for first 3-4days
Thiamine x 5 days
Diazepam- 10mg q 4-6h (day 1) titrate as time goes on

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38
Q

Initial pharmacological treatment for alcohol dependence should be how long?

A

6 months- can be 1-2 years

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39
Q

First line pharmacoltherapy older adults depression
Onset of action time-
Trial time-

A

SSRIs-
3-4 wks
6-8 wks

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40
Q

Vertigo red flags

A
  1. Any neuro deficit
  2. Total ipsilateral hearing loss
  3. Inability to walk without support
  4. Direction changing nystagmus
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41
Q

Purpose lf the HINTS exam

A

Diff vestibular neuritis and stroke

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42
Q

Reassuring HINTS exam components x 3

A
  1. Unidirectional nystagmus
  2. No vertical skew
  3. Abnormal head impulse test
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43
Q

Abnormal head impulse test vs normal

A

Catch up saccade- reassuring- vestibular neuritis

Fixed gaze- worrisome- cerebral pathology

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44
Q

Alexander’s law- nystagmus

A

Horizontal nystagmus is accentuated when looking away from hypoactive/ affected ear

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45
Q

Can unilateral nystagmus be used to rule out cerebellar infarct

A

Not in isolstion!

46% cerebellar infarct pts have unilat nystagmus.

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46
Q

What does the vesitbulo-ocular reflex do?

A

Hinges eye movement to head mvmt

Ie. reader can turn head side to side and continue to read.

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47
Q

“Catch up Saccade” - via head thrust test/ head impulse test (do both sides)

A

Reassuring finding- indicates periph vestibular pathology

Happens when head is turned rapidly toward affected side- disrupted

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48
Q

Diploplia, dysarthria, limb ataxia, dysphagiad and weakness/ numbness-

A

Cerebellar infarct- large!- brain stem

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49
Q

All of the following are RF for giant cell arteritis except: (may have multiple answers)

  • Advanced age (mean age 75, suspect if >50)
  • Female
  • Family hx
  • Male
  • EtOH
  • Smoking
  • Infection
A
  • ETOH

- Male

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50
Q

Condition strongly associated with PMR

A

Giant Cell Arteritis

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51
Q

Giant cell arteritis is ___ vasculitis:
A) medium vessel
B) small vessel
C) large vessel

A

C) Large vessel vasculitis, can involve medium and small arteries

52
Q

List common S&S for GCA

A
  • Visual disturbances painless, permanent visual impairment (20%) (secondary to anterior ischemic optic neuropathy)
  • Headache
  • Jaw claudication
  • Neck pain
  • Scalp tenderness
    +/- constitutional symptoms
53
Q

Diagnostic tests for GCA

A

Temporal artery biopsy (if negative biopsy contralateral side)
Increased CRP/ESR

54
Q

Treatment for GCA

A

High dose corticosteroid trial (up to 2-5 years)

55
Q

True/False

Treatment of GCA can be initiated before biopsy is performed

A

True

56
Q

GCA is associated with all except:

  • Increases risk for AA, MI, stroke, PVD
  • PMR
  • painful visual disturbances
  • constitutional symptoms
A

Visual disturbances, painless

57
Q

4 significant indicators for stroke (in evaluation of vertigo)

A
  1. Rapid onset with max intensity all at once
  2. Hx of vascular disease increased risk- hypertension, cardioaortic dx
  3. Ataxia- inability to walk withiut supports- 71%
  4. Direction changing nystagmus- 56%
58
Q

Subjective S&S of normal aging

A

-Delayed retrieval (forgetting names) and slower processing

59
Q

Apathy, euphoria, contralateral hemiperesis, legs > arms, impaired bladder control

A

Anterior circulation stroke

60
Q

Diploplia, vertigo, nausea, vomitting, slurred speech, trunchal ataxia, crossed sign- opposite side involvement

A

Posterior circulation stroke

61
Q

Contralateral gaze deviation, only seeing half visual field with both eyes,
R= dyspraxia- inability to coordinate voluntary movements effectively
L= aphasia- understanding words vs inability to speak words

A

Middle circulation

62
Q

Five most
common
medications likely
to disrupt sleep7

A
  1. Levodopa
  2. Prednisone
  3. Venlafaxine
  4. Fluvoxamine
  5. Rotigotine
63
Q

STOP BANG, and what it is used for

A 
S - snoring
T - tired
O - observed apnea/choking
P - High BP
B - BMI > 35
A - age > 50 years
N - neck size > 16 inches
G - gender male
64
Q

Surgical referral for head and neck pain is warranted if no improvement with conservative therapy for how long?

A

12 weeks

65
Q

TRAP for parkinsons

A

Tremor - resting
Rigidity
Akinesia/Bradykinesia
Postural instability

66
Q

Parkinsons dementia occurance

A

Up to 40%

67
Q

Early S&S of parkinsons

A

pill rolling tremor with difficulty initiating voluntary movements, recent falls, muscular rigidity, mood disorders, excessive daytime sleepiness, altered executive function

68
Q

Skin findings of parkinsons

A

Worsening seborrheic dermatitis

69
Q

Treatment of parkinsons

A

1st line - carbidopa/levodopa TID, start low doses 25/100 BID-TID with meals (to avoid nausea)
Titrate up slowly

70
Q

Withdrawal of dopamine agonists

A

Akinetic crisis

Parkinson hyperpyrexia syndrome (fever, autonomic disturbance, muscular rigidity and altered LOC)

71
Q

Adverse effects of carbidopa/levodopa

A 
motor fluctuations (wearing off)
dyskinesia
dystonia
dizziness
somnolence
nausea
headache
tardive dyskinesia or EPS (treat with benztropine/amantidine - anticholinergics)
72
Q

Is tremor in parkinsons symmetrical or asymmetrical?

A

asymmetrical

73
Q

What is the confirmatory test for parkinsons disease?

A

Definite response to levadopa

74
Q

Suggest alternative diagnosis if which of the following are present in the first 3 years in suspected Parkinson’s?

A 
hallucinations
freezing
postural instability
dementia
eye movement (limited upward gaze)
autonomic dysfunction
neuroleptic use in previous 6 months
75
Q

Which is the most common presenting symptom for PD?

A

resting tremor

76
Q

How long will someone conventionally have parkinsons before the development of lewy body dementia?

A

1 year

77
Q

Normal pressure hydrocephalus characteristic symptoms

A

Gait dysfunction - wide based shuffling gait
Urinary incontinence
Progressive dementia

78
Q

4Cs of addiction

A

loss of Control over substance use WITH Cravings &/or Compulsive use which is Continued despite harm

79
Q

CAGE

A

Cut down
Annoyed
Guilty
Eye opener

80
Q 
Hey patient with dementia related to Parkinson’s disease is being treated for a fracture from a recent fall. The NP should assess the clients history for what type of medication
A. Anti-cholinergics 
B. dopamine agonists 
C. anxiolytics 
D. benzodiazepines
A

Anticholinergics

81
Q

T/F- fluctuations in cognition in a 24 hour period is a characteristic of Dementia

A

True

82
Q

Agnosia

A

Inability to interpret sensory and inability to recognize things

83
Q

Neurotransmitters involved in Alzheimer’s pathophysiology

A

Acetylcholine

84
Q

Most common form of hallucinations in dementia

A

Visual

85
Q

Dementia gait disturbance in urinary incontinence –

A

Normal pressure hydrocephalus

86
Q

Identify the stage of alzheimers associated with-
A- Unable to communicate meaningfully
B- Absence of delusions
C- Makes faulty interpretations i.e. paranoid delusions

A

A- 3
B- 1
C- 2

87
Q

Recent memory loss is associated with what Alzheimer stage

A

1

88
Q

What is a catastrophic reaction

A

Over exaggerated negative emotional response usually due to perceived failure at a task or changing environment.
Present in stage two of Alzheimer’s

89
Q

Amyloid protein deposits in the brain are proposed ideologies of what disease

A

Alzheimers

90
Q

T/F- A patient with Alzheimer’s stage one is given Donepezil- NP should expect to see improvement in ability to remember recent events.

A

True- cholenisterase inhibitor

91
Q

Failure to identify objects despite intact sensory function

A

Agnosia

92
Q

Inability to carry out purposeful complex movements and use objects properly

A

Apraxia

93
Q

Inability to speak or comprehend what I said or written

A

Aphasia

94
Q 
Which of the following are side effects of escitalopram
A- weight gain
B- decreased sexual function
C- sedation
D- blurred vision
E- urinary retention
F- dry mouth
A

A- weight gain

B- decreased sexual function

95
Q

All of the following are examples of what type of vertigo:

BPPV, menieres, labrynthitis, acoustic neuroma, cerebellar ataxia

A

Episodic vertigo

96
Q

What to suspect with spontaneous/not-triggered and acute vertigo < 12 hours?

A

Posterior circulation stroke

97
Q

Meclizine is used as treatment for dizziness in what 2 conditions?
What is the maximum duration of use?

A

Vestibular neuritis and meniieres

Max use for 3 days

98
Q

If HINTS exam and Dix-hallpike negative, what to do next?

A

Refer

99
Q

T/F?

Essential tremor are not symmetrical and occur at rest.

A

False, essential tremors are action tremors and are often symmetrical

100
Q

Parkinsons tremor is higher frequnecy than essential tremor. T/F?

A

False, essential tremor is higher frequency

101
Q

T/F? Parkinson’s disease patients present with weakness.

A

False

102
Q

List the 4 characteristic signs of PD

A

Bradykinesia
Tremor
Postural instability
Rigidity

103
Q

T/F? Cerebellar diseases have an action tremor which differentiates it from PD?

A

True

104
Q

T/F?
Sedative medications for insomnia more than double the risk of falls and hip fractures. These are common causes of hospitalization and death in older people and increase the risk of car accidents.

A

True

105
Q

What is the STOP-BANG questionnaire used for and what does each letter stand for?

A

OSA

Snoring
Tired
Observed stop breathing/gasping
Pressure (HTN)
BMI >35
Age > 50
Neck circumference
Gender male
106
Q

What do all these medications have in common?

  1. Levodopa
  2. Prednisone
  3. Venlafaxine
  4. Fluvoxamine
  5. Rotigotine
A

Most likely medications to distrupt sleep

107
Q

Max dose of zoplicone in older adults

A

5mg/day

108
Q

T/F?

the safest and best studied sleep medication for use inthe elderly is doxepin (≤ 6mg/day

A

True

109
Q

Zoplicone treatment should not exceed _____ days

A

7-10 days

110
Q

Zoplicone requires taking >/= ___ hours before driving

A

12 hours

111
Q

Zoplidem requires taking >/= ___ hours before driving

A

8

112
Q

SE of SSRI (10)

A 
Mania/hypomania in Bipolar dx
Increase bleeding risk
Fragility #
Hyponatremia
Acute angle closure glaucoma 
Prolonged QT
Serotonin syndrome
Withdrawal symptoms
SI
Sexual dysfunction
113
Q

T/F?
REM sleep is usually preserved into very old age, while Non -REM sleep (Stages 3 and 4 particularly) decrease significantly and even disappear

A

True

114
Q

Duration of onset for SSRI and peak action

A

1-2 wks

6-8 wks

115
Q

SE sumatriptan

A 
QT prolongation
CV events
HTN
CVA
Reynauds
Serotonin syndrome
Ocular effects
116
Q

‘SHIVERS’ mneumonic for serotonin syndrome

A 
Shivering
Hyperreflexia/myoclonus
Increased temperature
VS instability
Encephalopathy (altered LOC)
Restlessness
Sweating
117
Q

in 1 of the following cognitive domains: memory, language,
visuospatial, executive function and behaviour
ii. that does not significantly affect their usual activities or work
iii. that is not explained by delirium or other major psychiatric
disorder

A

MCI

118
Q

impairment in at least 2 of the following cognitive domains: memory,
language, visuospatial, executive function, and behaviour*
ii. that causes a functional decline in usual activities or work
iii. that is not explained by delirium or other major psychiatric
disorder

A

Dementia

119
Q

MMSE is best for MCI?

A

False, MoCA is best for MCI

120
Q

All of the following are indications of what?
The patient is less than 60 years old;
The onset has been abrupt or the course of progression rapid;
There is a history of significant recent head injury;
The presentation is atypical or the diagnosis is uncertain;
There is a history of cancer;
There are new localizing neurological signs or symptoms;
There is a suspicion of cerebrovascular disease;
The patient is on anticoagulants or has a bleeding disorder; or
The patient has a combination of early cognitive impairment with urinary incontinence and gait disorder (to exclude normal pressure hydrocephalus).

A

MRI

121
Q

Delerium is worse in the morning and depression worse at night. T/F?

A

False, the opposite is true

122
Q

Poor insight into defecits is characteristics of dementia. T/F?

A

True

123
Q

Tests to consider with cognitive impairement to rule out organic causes

A

1) Complete Blood Count (CBC)
2) B12
3) Urinalysis
4) Glucose - fasting
5) Hemoglobin A1c
6) TSH
7) Sodium
8) Albumin/Calcium***
9) Creatinine/eGFR
10) ECG

ii. In patients with risk factors, check:
1) Liver enzymes
2) Syphilis
3) HIV
4) Drug levels (e.g.: digoxin, phenytoin)

124
Q

mMSE

  • Mild =
  • Moderate =
  • Severe =
A
  • Mild = 20-26
  • Moderate = 12-19
  • Severe = <12
125
Q

What brief cognitive test(s) to
administer if Patients with cognitive complaints
and functional impairments

A

Consider administering MMSE
or Mini-Cog.*
ABN –> dementia

NUNP 547 - Older Adult (19 decks)

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