Neurological and neuromuscular Flashcards
How does Parkinson’s cognitive function differ from Alzheimer’s dementia?
The executive dysfunction and visuospatial impairment are usually present, the initial memory impairment is less prominent
Are cholinesterase inhibitors used in parkinsons associated dementia?
Yes, with moderate success.
i.e. Donepezil (Aricept), Galantamine- block the breakdwon of acetylcholine
What medications are used to treat motor symptoms in parkinsons disease?
Dopaminergic agents are effective in PD, at least for some time, but are less useful in atypical parkinsonian disorders.
Carbidopa/levodopa; amantadine; and selegiline (monoamine oxidase inhibitor MAO)
Amyotrophic lateral sclerosis
What 2 variants of ALS exist?
-** 1) Spinal variant-** characterized by early, often asymmetric tetraparesis, and late onset of deficits in cranial nerve function
2) Bulbar variant- 20% of cases- presents with predominant deficits in speech & swallowing, followed by progressive muscle weakness
ALS
Why should supplemental oxygen not be used in ALS?
Can lead to CO2 retention and should not be routinely used.
ALS
How is respiratory insufficiency treated in ALS?
Non invasive positive pressure ventilation
Has been shown to prolong survival and improve QOL
ALS
What are symptoms of ALS patients who are experiencing nocturnal hypoventilation.
1) morning headaches
2) increased daytime sleepiness
ALS
Management of mucous congestion in ALS
Nebulized beta receptor antagonists, saline and furosemide
CoughAssit
High frequency chest wall oscillation
Home suction device
Txt with mucolytics (ambroxol or N-acetylcysteine is of limited benefit)
ALS
Malnutrition- how is it managed in ALS?
It results from dysphagia and hypermetabolism; management starts with SLP to reduce swallowing deficits & referral to dietician.
Patients may wish to proceed with gastrostomy.
A positive effect of artificial nutrition on survival has not been confirmed in studies.
ALS
What are treatment options for sialorrhoea?
Commonly associated with swallowing deficits.
Non pharmacological management includes: sage tea and consultaiton with SLP to improve swallowing.
Pharmacological: amitriptyline or hyoscine hydrobromdide; atropine or glycopyrolate.
Injections of botulinum A or B in the salivary glands or salivary gland radiotherapy may need to be considered.
ALS
Spasticity in ALS: Non pharmacological and pharmacological options.
PT to maintain a full ROM and avoid contractures
Pharmacological txt: **alpha 2 adrenergic agonists like Tizanidine & baclofen **(side effects: muscle weakness, somnolence, xerostomia)
Nabiximols (sativex) - synthetic cannabinoid is approved for MS spasms
Nabiximols (sativex)- could be considered for ALS spasticity off label
ALS
**What is the recommended treatment for muslce cramps in ALS?
Levetiracetam (Keppra)
ALS
How to manage pseudobulbar affect.
Manifests in inappropriate laughter or crying incongruent to the patient’s mood.
Combination of detromethorphan & quinidine.
Or Antidepressants i.e. amitriptyline or citalopram
Parkinson’s disease
Parkinson’s disease
What are some atypical parkinsonian disorders? What makes them atypical?
Progressive Supranuclear palsy (PSP)
Corticobasal degeneration
Dementia with lewy bodies (DLB)
Multi system atrophy (MSA
Atypical: do not respond to antiparkinsonian drugs like PD
…normal life expectancy of PD…’ Pg: 999 Oxford
Atypical Parkinson’s disease
The use of what medication may reduce the frequency of falls in the early stages of PSP.
Amitriptyline
Atypical PD
How is myoclonus treated in pts with PSP, corticobasal degeneration and MSA?
benzodiazepines (clonazepam)
or
levetiracetam
Atypical PD
Dysautonomic symptoms are hallmark of MSA, but could occur in other parkinsonian syndromes, What are some of the symptoms and how would you treat?
Ortostatic dysfunction: reduction of levlodopa, use of compression stockings, inc sodium intkae, improve hydration. Consider fludrocortisone (0.1-0.2mg/day); midodrine 2.5=10mg TID.
Urgency and urinary incontinence: oxybutynin, botulinum toxin, supra pubic catheterization
Drug treatment options in symptoms in neurodegenerative disorders
Constipation
Dyspnea
Dyspnea related anxiety
Fatigue
Muscle Cramps
Pain
Pseudobulbar affect
Pseudo-hypersalivation
Psychosis, agitation, irritability, dysphoria
REM sleep behavior disorder
Respiratory failure
Rigidity, brady/akinesia
Sleeplessness
Spasticity
Thick secretions
Constipation: ensure sufficient hydration, osmotic laxatives (ie. PEG or lactulose); stimulant laxatives i.e. senna
Dyspnea: opioids
Dyspnea related anxiety: benzos i.e. sublingual lorazepam q4 hours as needed
Fatigue: SSRI (citalopram) or a psychostimulant (modafinil 100mg daily or methylphenidate 5mg BID)
Muscle Cramps: quinidine 200mg daily
Pain: PT, pure opioid agonist, SNRI; Tricyclic antidepressant
Pseudobulbar affect: dextromethorphan/quinidine 20mg/10mg daily, or an SSRI
Pseudo-hypersalivation: sage tea, amitriptyline 25mg once daily, Hyoscine hydrobromide TD patch, Botulinum toxin A in salivary glands; salivary gland radiotherapy
Psychosis, agitation, irritability, dysphoria: calm & stable environment, Quetiapine 25-50mg /day)
REM sleep behavior disorder: clonazepam 0.25-1.25mg QHS, melatonin 3-12mg
Respiratory failure: NIPPV, tracheostomy, opioids
Rigidity, brady/akinesia: midazolam, amantadine, rotigotine patch
Sleeplessness: zopiclone, mirtazapine, Quetiapine 25mg QHS
Spasticity: PT, baclofen 5mg bid), tizanidine 2mg QHS; botulinum toxin A
Thick secretions: Ensure sufficient hydration, mucolytics (N-Acetylcysteine), supportive measures i.e. neb saline, manually assisted coughing techniques, humidification, high-frequency chest wall oscillation
