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
2
Q
True/False
Older age increases risk of secondary headaches
A
True
3
Q
Which location of strokes are more likely to cause headache, anterior or posterior circulation?
A
Posterior circulation
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
5
Q
Diagnostic test for cardiac cephalagia
A
Stress test, improves with nitroglycerin
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
7
Q
True/False
Tryptans are contraindicated for cerebrovascular and cardiovascular disease
A
True
8
Q
For prophylactic treatment of migraines, how long at the goal dose should people expect the full benefit?
A
2-3 months
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
10
Q
SNRI starting dose for migraine and titration
A
Venlafaxine 37.5mg daily, goal 150mg daily (fewer SE than TCA)
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)
12
Q
Chronic migraine definition requiring preventative treatment
A
15 or more headaches per month, 1/2 with migraine features
13
Q
BPPV, Vestibular neuritis, herpes zoster, Ménière’s disease, acoustic neuroma are causes of what type of vertigo?
A
Peripheral
14
Q
Vestibular migraine, brainstem ischemia, cerebral vascular accident, multiple sclerosis, are all examples of what type of vertigo
A
Central
15
Q
The triad of Ménière’s disease
A
Vertigo, tinitis, hearing loss - aural fulness
16
Q
Vertigo aggravated by movement
A
BPPV
17
Q
HINTS test components
A
Head impulse, nystagmus, test of SKew
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!
19
Q
Timing of vertigo in Ménière’s disease
A
20 minutes - days
20
Q
Timing of vertigo in BPPV
A
Seconds to minutes
21
Q
Timing of vertigo in vestibular neuritis versus migraine
A
VN- persistent
VM- Episodic, minutes to hours
22
Q
T/F Vertical nystagmus is a normal finding
A
False! Indicates Possib;e CVS
23
Q
Five diagnostic criteria required for restless leg syndrome- URGES
A
- Urge to move legs
- Symptoms worsen with inactivity/rest
- Sensations relieved with movement
- Symptoms worse or only at night
- Symptoms not accounted for by other medical or behavioural condition
Urge to move, Rest induced, Gets better with activity, and Evening and night accentuation
24
Q
First line pharm treatment for restless leg syndrome
A
Pramipexole
25
First line treatment for periodic limb movement in sleep - PLMD
Clonazepam
26
T/F - Depression in older adults may be prodrome for dementia
True
27
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.
True
28
Non-modifiable high risk factors for suicide in older adults
Old age, male gender, widowed/divorced, previous self harm attempt, losses (health status or people)
29
Minor depressive disorder symptom timeframe-
| 1st line tx-
<4wks
Psychotherapy
30
Doxepin, amitriptyline - med class?
| Considerations for prescribing TCAs-
Tricyclic antidepressant
Don’t use in patients with conduction abnormalities on ECG or postural hypotension
31
Class of Antidepressant medication most likely to cause hyponatraemia
SSRI’s
32
Venlafaxine, duloxetine - med class?
SNRI
33
Med class-
Trazodone-
Bupropion-
Mirtazapine-
1. Serotonin receptor agonist and reuptake inhibitors
2. Dopamine reuptake inhibitor
3. Alpha-2 antagonist
34
Remission of symptoms must take place for how long before considering stopping antidepressant therapy
1 year
35
At risk drinking criteria male and female
5+/ day in Males
4+/ day in Females
In last year
36
What percentage of alcohol dependent drinkers require medically managed detox
20%
37
When to start out pt detox-
How lften to follow-up-
Pharmacotherapy for outpatient alcohol detox
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
38
Initial pharmacological treatment for alcohol dependence should be how long?
6 months- can be 1-2 years
39
First line pharmacoltherapy older adults depression
Onset of action time-
Trial time-
SSRIs-
3-4 wks
6-8 wks
40
Vertigo red flags
1. Any neuro deficit
2. Total ipsilateral hearing loss
3. Inability to walk without support
4. Direction changing nystagmus
41
Purpose lf the HINTS exam
Diff vestibular neuritis and stroke
42
Reassuring HINTS exam components x 3
1. Unidirectional nystagmus
2. No vertical skew
3. Abnormal head impulse test
43
Abnormal head impulse test vs normal
Catch up saccade- reassuring- vestibular neuritis
| Fixed gaze- worrisome- cerebral pathology
44
Alexander’s law- nystagmus
Horizontal nystagmus is accentuated when looking away from hypoactive/ affected ear
45
Can unilateral nystagmus be used to rule out cerebellar infarct
Not in isolstion!
| 46% cerebellar infarct pts have unilat nystagmus.
46
What does the vesitbulo-ocular reflex do?
Hinges eye movement to head mvmt
| Ie. reader can turn head side to side and continue to read.
47
“Catch up Saccade” - via head thrust test/ head impulse test (do both sides)
Reassuring finding- indicates periph vestibular pathology
| Happens when head is turned rapidly toward affected side- disrupted
48
Diploplia, dysarthria, limb ataxia, dysphagiad and weakness/ numbness-
Cerebellar infarct- large!- brain stem
49
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
- ETOH
| - Male
50
Condition strongly associated with PMR
Giant Cell Arteritis
51
Giant cell arteritis is ___ vasculitis:
A) medium vessel
B) small vessel
C) large vessel
C) Large vessel vasculitis, can involve medium and small arteries
52
List common S&S for GCA
- Visual disturbances painless, permanent visual impairment (20%) (secondary to anterior ischemic optic neuropathy)
- Headache
- Jaw claudication
- Neck pain
- Scalp tenderness
+/- constitutional symptoms
53
Diagnostic tests for GCA
Temporal artery biopsy (if negative biopsy contralateral side)
Increased CRP/ESR
54
Treatment for GCA
High dose corticosteroid trial (up to 2-5 years)
55
True/False
| Treatment of GCA can be initiated before biopsy is performed
True
56
GCA is associated with all except:
- Increases risk for AA, MI, stroke, PVD
- PMR
- painful visual disturbances
- constitutional symptoms
Visual disturbances, painless
57
4 significant indicators for stroke (in evaluation of vertigo)
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
Subjective S&S of normal aging
-Delayed retrieval (forgetting names) and slower processing
59
Apathy, euphoria, contralateral hemiperesis, legs > arms, impaired bladder control
Anterior circulation stroke
60
Diploplia, vertigo, nausea, vomitting, slurred speech, trunchal ataxia, crossed sign- opposite side involvement
Posterior circulation stroke
61
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
Middle circulation
62
Five most
common
medications likely
to disrupt sleep7
1. Levodopa
2. Prednisone
3. Venlafaxine
4. Fluvoxamine
5. Rotigotine
63
STOP BANG, and what it is used for
```
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
Surgical referral for head and neck pain is warranted if no improvement with conservative therapy for how long?
12 weeks
65
TRAP for parkinsons
Tremor - resting
Rigidity
Akinesia/Bradykinesia
Postural instability
66
Parkinsons dementia occurance
Up to 40%
67
Early S&S of parkinsons
pill rolling tremor with difficulty initiating voluntary movements, recent falls, muscular rigidity, mood disorders, excessive daytime sleepiness, altered executive function
68
Skin findings of parkinsons
Worsening seborrheic dermatitis
69
Treatment of parkinsons
1st line - carbidopa/levodopa TID, start low doses 25/100 BID-TID with meals (to avoid nausea)
Titrate up slowly
70
Withdrawal of dopamine agonists
Akinetic crisis
| Parkinson hyperpyrexia syndrome (fever, autonomic disturbance, muscular rigidity and altered LOC)
71
Adverse effects of carbidopa/levodopa
```
motor fluctuations (wearing off)
dyskinesia
dystonia
dizziness
somnolence
nausea
headache
tardive dyskinesia or EPS (treat with benztropine/amantidine - anticholinergics)
```
72
Is tremor in parkinsons symmetrical or asymmetrical?
asymmetrical
73
What is the confirmatory test for parkinsons disease?
Definite response to levadopa
74
Suggest alternative diagnosis if which of the following are present in the first 3 years in suspected Parkinson's?
```
hallucinations
freezing
postural instability
dementia
eye movement (limited upward gaze)
autonomic dysfunction
neuroleptic use in previous 6 months
```
75
Which is the most common presenting symptom for PD?
resting tremor
76
How long will someone conventionally have parkinsons before the development of lewy body dementia?
1 year
77
Normal pressure hydrocephalus characteristic symptoms
Gait dysfunction - wide based shuffling gait
Urinary incontinence
Progressive dementia
78
4Cs of addiction
loss of Control over substance use WITH Cravings &/or Compulsive use which is Continued despite harm
79
CAGE
Cut down
Annoyed
Guilty
Eye opener
80
```
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
```
Anticholinergics
81
T/F- fluctuations in cognition in a 24 hour period is a characteristic of Dementia
True
82
Agnosia
Inability to interpret sensory and inability to recognize things
83
Neurotransmitters involved in Alzheimer’s pathophysiology
Acetylcholine
84
Most common form of hallucinations in dementia
Visual
85
Dementia gait disturbance in urinary incontinence –
Normal pressure hydrocephalus
86
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- 3
B- 1
C- 2
87
Recent memory loss is associated with what Alzheimer stage
1
88
What is a catastrophic reaction
Over exaggerated negative emotional response usually due to perceived failure at a task or changing environment.
Present in stage two of Alzheimer’s
89
Amyloid protein deposits in the brain are proposed ideologies of what disease
Alzheimers
90
T/F- A patient with Alzheimer’s stage one is given Donepezil- NP should expect to see improvement in ability to remember recent events.
True- cholenisterase inhibitor
91
Failure to identify objects despite intact sensory function
Agnosia
92
Inability to carry out purposeful complex movements and use objects properly
Apraxia
93
Inability to speak or comprehend what I said or written
Aphasia
94
```
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- weight gain
| B- decreased sexual function
95
All of the following are examples of what type of vertigo:
| BPPV, menieres, labrynthitis, acoustic neuroma, cerebellar ataxia
Episodic vertigo
96
What to suspect with spontaneous/not-triggered and acute vertigo < 12 hours?
Posterior circulation stroke
97
Meclizine is used as treatment for dizziness in what 2 conditions?
What is the maximum duration of use?
Vestibular neuritis and meniieres
| Max use for 3 days
98
If HINTS exam and Dix-hallpike negative, what to do next?
Refer
99
T/F?
| Essential tremor are not symmetrical and occur at rest.
False, essential tremors are action tremors and are often symmetrical
100
Parkinsons tremor is higher frequnecy than essential tremor. T/F?
False, essential tremor is higher frequency
101
T/F? Parkinson's disease patients present with weakness.
False
102
List the 4 characteristic signs of PD
Bradykinesia
Tremor
Postural instability
Rigidity
103
T/F? Cerebellar diseases have an action tremor which differentiates it from PD?
True
104
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.
True
105
What is the STOP-BANG questionnaire used for and what does each letter stand for?
OSA
```
Snoring
Tired
Observed stop breathing/gasping
Pressure (HTN)
BMI >35
Age > 50
Neck circumference
Gender male
```
106
What do all these medications have in common?
1. Levodopa
2. Prednisone
3. Venlafaxine
4. Fluvoxamine
5. Rotigotine
Most likely medications to distrupt sleep
107
Max dose of zoplicone in older adults
5mg/day
108
T/F?
| the safest and best studied sleep medication for use inthe elderly is doxepin (≤ 6mg/day
True
109
Zoplicone treatment should not exceed _____ days
7-10 days
110
Zoplicone requires taking >/= ___ hours before driving
12 hours
111
Zoplidem requires taking >/= ___ hours before driving
8
112
SE of SSRI (10)
```
Mania/hypomania in Bipolar dx
Increase bleeding risk
Fragility #
Hyponatremia
Acute angle closure glaucoma
Prolonged QT
Serotonin syndrome
Withdrawal symptoms
SI
Sexual dysfunction
```
113
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
True
114
Duration of onset for SSRI and peak action
1-2 wks
| 6-8 wks
115
SE sumatriptan
```
QT prolongation
CV events
HTN
CVA
Reynauds
Serotonin syndrome
Ocular effects
```
116
'SHIVERS' mneumonic for serotonin syndrome
```
Shivering
Hyperreflexia/myoclonus
Increased temperature
VS instability
Encephalopathy (altered LOC)
Restlessness
Sweating
```
117
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
MCI
118
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
Dementia
119
MMSE is best for MCI?
False, MoCA is best for MCI
120
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).
MRI
121
Delerium is worse in the morning and depression worse at night. T/F?
False, the opposite is true
122
Poor insight into defecits is characteristics of dementia. T/F?
True
123
Tests to consider with cognitive impairement to rule out organic causes
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
mMSE
- Mild =
- Moderate =
- Severe =
- Mild = 20-26
- Moderate = 12-19
- Severe = <12
125
What brief cognitive test(s) to
administer if Patients with cognitive complaints
and functional impairments
Consider administering MMSE
or Mini-Cog.*
ABN --> dementia
