Neuro pal care Flashcards
Sx after stroke: Depression and emotional lability
Incidence: 30%
Assessment tool: PHQ2 or 9, (HAM-D)
Management: SSRI
- emotional lability: dextromethorphan/quinidine
Sx after stroke: Anxiety
Incidence: 20%
Assessment tool: HAM-A, GAI, HADS
Management: SSRI
Sx after stroke: Delirium
Incidence: 10-48%
Assessment tool: CAM-ICU, DRS, 3D-CAM, 4AT
Management: behavior mod, antipsychotics for severe
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)
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
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
Sx after stroke: Fatigue
Incidence: 50%
Assessment tool: FSMC, Fatigue severity scale
Management: Modafinil, amantidine, methylphenidate
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
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
Sx after stroke: Seizures
Incidence: 5-12%
Assessment tool: EEG, MRI
Management: +/- AED
Sx after stroke: Sexual dysfunction
Incidence: 50%
Assessment tool: hormonal labs
Management: depression screening, counseling
Controversial to start sildenafil
Sx after stroke: sleep disordered breathing
Incidence: 50%
Assessment: Sleep study
Management: wt loss, CPAP
Carbidopa/Levodopa
Benefit: bradykinetic sx
Side effects: nausea, somnolence, dizziness, HA, motor fluctuations, dyskinesia, dystonia, cramps
Duopa
(enteral suspension of carbidopa/levodopa)
Improves on/off fluctuations, decreases dyskinesia
Apomorphine
Improves “off” symptoms
SE: Chest pain drowsiness, dizziness, nausea, falls, yawning
consequences of abruptly stopping Levodopa
neuroleptic malignant syndrome, akinetic crisis
Consequence of abruptly stopping dopamine agents
anxiety, panic, depression, sweating, nausea, pain , fatigue, dizziness, craving
Pamiprexole and ropinirole
Dopamine agent
Benefit: bradykinetic sx and dyskinesia
Side effects: n/v, orthostatic, confusion, sleepy, hallucinations, edema, impulse control disorder
Rotigotine patch
Dopamine agent
Same as Pamiprexole
Amantadine
Benefit: improves bradykinesia, rigidity and tremor
Side effects: livedo reticularis, ankle edema, hallucinations, confusion, nightmares
Entacapone and Tolcapone
COMT inhibitors
Benefit: decrease motor fluctuations and decrease “off” symptoms
Side effects: diarrhea, discolored urine, dyskinesia, hallucinations, orthostasis
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
