Neuro pal care Flashcards by Julia Newman

Sx after stroke: Depression and emotional lability

Incidence: 30%
Assessment tool: PHQ2 or 9, (HAM-D)
Management: SSRI
- emotional lability: dextromethorphan/quinidine

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Sx after stroke: Anxiety

Incidence: 20%
Assessment tool: HAM-A, GAI, HADS
Management: SSRI

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Sx after stroke: Delirium

Incidence: 10-48%
Assessment tool: CAM-ICU, DRS, 3D-CAM, 4AT
Management: behavior mod, antipsychotics for severe

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Sx after stroke: Dysphagia

Incidence: 20-50%
Assessment tool: Swallowing eval, FEES
Management: Rehab, special diet. (NG tube or PEG can improve nutrition but not stop aspiration)

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sx after stroke: Pain

Incidence:
- central poststroke pain 12%
- hemiplegic shoulder pain 48-84%
Assessment tool: Abbey pain scale, vertical VAS, FPS
Management:
- CPSP: amitriptyline, lamotrigine
- HSP: electrical stimulation, PT, NSAIDS. massage, ice/heat, botox

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Sx after stroke: Poststroke spasticity (PSS)

Incidence: 30%
Assessment tool: Modified Ashworth Scale, Tardieu scale, Carer Burden Scale
Management: Botox injection, PT, splint, antispasmotic agents

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Sx after stroke: Fatigue

Incidence: 50%
Assessment tool: FSMC, Fatigue severity scale
Management: Modafinil, amantidine, methylphenidate

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Sx after stroke: Urinary incontinence

Incidence: 50% initial
- 20% at 6mo
Assessment tool: urodynamic testing, postvoid residual, bladder stress test
Management:
-nonpharm: wt loss, diet changes, pelvic floor exercises.
- Pharm: alpha blockers, antimuscarinic drugs, SNRIs
- Surgical if unresponsive

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Sx after stroke: Fecal incontinence

Incidence: 10% at 6 mo
Assessment tool: anorectal manometry, endorectal ultrasound/MRI, defecography
Management: Supportive care, bulking agents, antidiarrheal agent, biofeedback, injectable anal bulking agent, sacral nerve stimulation, anal sphincteroplasty

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Sx after stroke: Seizures

Incidence: 5-12%
Assessment tool: EEG, MRI
Management: +/- AED

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Sx after stroke: Sexual dysfunction

Incidence: 50%
Assessment tool: hormonal labs
Management: depression screening, counseling
Controversial to start sildenafil

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Sx after stroke: sleep disordered breathing

Incidence: 50%
Assessment: Sleep study
Management: wt loss, CPAP

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Carbidopa/Levodopa

Benefit: bradykinetic sx
Side effects: nausea, somnolence, dizziness, HA, motor fluctuations, dyskinesia, dystonia, cramps

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Duopa

(enteral suspension of carbidopa/levodopa)
Improves on/off fluctuations, decreases dyskinesia

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Apomorphine

Improves “off” symptoms
SE: Chest pain drowsiness, dizziness, nausea, falls, yawning

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consequences of abruptly stopping Levodopa

neuroleptic malignant syndrome, akinetic crisis

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Consequence of abruptly stopping dopamine agents

anxiety, panic, depression, sweating, nausea, pain , fatigue, dizziness, craving

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Pamiprexole and ropinirole

Dopamine agent
Benefit: bradykinetic sx and dyskinesia
Side effects: n/v, orthostatic, confusion, sleepy, hallucinations, edema, impulse control disorder

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Rotigotine patch

Dopamine agent
Same as Pamiprexole

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Amantadine

Benefit: improves bradykinesia, rigidity and tremor

Side effects: livedo reticularis, ankle edema, hallucinations, confusion, nightmares

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Entacapone and Tolcapone

COMT inhibitors
Benefit: decrease motor fluctuations and decrease “off” symptoms
Side effects: diarrhea, discolored urine, dyskinesia, hallucinations, orthostasis

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Rasagiline and selegiline

MAO-B inhibitors
Benefit: decrease motor fluctuations and better UPDRS score
Side effects: nausea, HA, confusion, dyskinesia, psych tox

Trihexyphenidyl

Anticholinergic
Benefit: for young pt w tremor predominant PD
Side effects: Confusion, hallucinations, urinary retention, tachy

Poor prognostic factors: ALS

Dz starting with bulbar or respiratory sx
Age>65
malnutrition
Frontotemporal dementia
NIP <40
FVC <50%
impulsivity and decreased judgement

Median survival 20-48mo (die from respiratory failure in 3-5yrs)

Poor prognostic factors: MS

>1 neuro system involved at onset PPMS celebellar sx 2 attacks in 2 years high disability in 5 yrs African American >40yo at age of onset poor recovery after attack life expectancy decreased by 7-14 years

Poor prognostic factors: ICH

GCS <12 Age >80 ICH vol >30ml Intraventricular hemorrhage infratentorial origin of hemorrhage

Poor prognostic factors: parkinsons

increased age presence of dementia more severe axial sx Median survival 6-22yrs

Poor prognostic factors: stroke

coma, loss of brainstem reflexes midline shift High NIHSS score advanced age more comorbidities disabled before stroke stroke complications hemorrhagic stroke low GCS need for vent prestroke cognitive impairment

Tx of visual hallucinations and paranoid delusions in parkinsons

adjust antiparkinson meds atypical neuroleptics (clozapine, quetiapine) selective serotonin agonist (pimavabserin) NO HALDOL

Tx sialorrhea

chewing gum botox injection glycopyrrolate hyoscyamine atropine

Tx Rhinorrhea in parkinsons

ipratropium nasal spray

Tx constipation in parkinsons

lubiprostone Miralax

Tx acute exacerbation in MS

Steroids if sx impair function Methylpred 1g per day for 5 days if not responsive then plasma exchange

Tx Fatigue in MS

amantadine, methylphenidate, modafinil, fampridine, L-carnitine, SSRI, asa Rehab better than meds

Tx depression in MS

2/3 pt have depression 2x higher risk of suicide Desipramine and paroxetine (problem- many SE)

Tx pain in MS

Primarily neuropathic TCA, anticonvulsants, SNRI, PT if severe radiofrequeny rhizotomy

Tx urinary incontinence MS

timed voiding, fluid restriction ER oxybutynin and tolterodine

Tx for ALS that improve survival

Riluzole (glutamate antagonist) slows progression +83 days NPPV with BiPAP +/- on PEG

when to start NPPV in ALS

VC <50% presence of orthopnea NIF<40 MIP <60cm Nocturnal O2 <88%

When to get PEG for ALS

+/- on survival benefit 10% wt loss require >30min to finish meals symptomatic dysphagia Not option if VC <30%

Conditions to use PEG tubes

Head and neck cancer Acute stroke with dysphagia ALS Gastric decompression

Leading cause of death MS

Infection (CV, suicide, cancer)

Leading cause of death PD

aspiration PNA

Leading cause of death stroke

Early; neuro complication Late: respiratory and CV

Tx agitation in dementia

Citalopram Risperidone (effective but too many side effects: falls, stroke, infection, death)

When to use anticholinergic monotherapy for PD?

Trihexylphenidyl Pt <70yo with primarily tremor without significant bradykinesia or gait disturbance

Life expectancy after diagnosis of AD

4-8 yrs on average Effected by age of diagnosis

Mortality of advanced AD pt after admission to hospital with PNA or hip fx

6 mo mortality rate 50%

Primary side effects of donepezil

n/v, diarrhea, dizziness Wt loss (rivastigmine and galantamine)

Poor prognostic factors in dementia

Older age at onset Male gait disturbance Extrampyramidal signs hx falls wandering comorbid conditions

tools for predicting 6 mo mortality in end stage dementia

The mortality risk index (12 characteristics; limitation in generalization and not fully matching hospice requirements) Advanced dementia prognostic tool (ADEPT) - uses clinical and prognostic data related to hospice eligibility - only looked at nursing home pts - did not assess for interventions offered

Pain assessment tools for advanced dementia

- Pain assessment in advanced dementia (PAINAD) - Pain assessment checklist for seniors with limited ability to communicate (PACSLAC)

Assessing depression in pt with mild to mod dementia

Geriatric Depression scale Carroll Depression Rating Scale Cornell Depression Rating Scale

Apathy vs. depression

Apathy- loss of motivation leading to diminished initiation, lowered interest, decreased social engagement, blunted emotions, lack of insight unlike depression there is no sx of altered mood