Neurological conditions Flashcards
What is a neurological disorder?
any disorder of the nervous system, both centrally (brain and spinal cord) and peripherally (nerves)
What are the four main types of neurological disorders?
sudden-onset conditions
intermittent and unpredictable conditions
progressive conditions
stable conditions
List some examples of sudden-onset conditions.
acquired brain injury
spinal cord injury
List some examples of intermittent and unpredictable conditions.
epilepsy
chronic fatigue syndrome (CFS/ME)
certain types of headache
early stages of multiple sclerosis
List some examples of progressive conditions.
motor neurone disease
Parkinson’s disease
later stages of multiple sclerosis
List some examples of stable conditions.
post-polio syndrome
cerebral palsy in adults
What are some of the symptoms of Parkinson’s disease other than tremor?
balance and falls stress and anxiety dementia mild thinking problems sleep problems dexterity issues urinary problems
What is the biggest risk factor for dementia?
age
What is the cost of delivering services for people with neurological conditions?
£3.3 billion
What percentage of the social care budget is spent on supporting people with neurological conditions?
14%
What is the cost of delivering urgent and emergency care for people with neurological conditions?
£750 million
What percentage of people diagnosed with a neurological condition will die prematurely due to complications?
35%
What is the prevalence of dementia in the UK?
850,000
What is the prevalence of acquired brain injury in the UK?
348,453 admissions to hospital in 2016/17
What is the prevalence of epilepsy in England?
362,000-415,000
What is the prevalence of multiple sclerosis in England?
190 cases per 100,000
105,800
What is the prevalence of motor neurone disease in England and Wales?
4,000 at any one time
What is the prevalence of Parkinson’s disease in the UK?
up to 160 per 100,000
annual incidence of 15-20 per 100,000
What is the prevalence of cerebral palsy in the UK?
2-2.5 cases per 1,000 live births
What is the prevalence of cerebrovascular accident (CVA) in the UK and worldwide?
150,000 per year
20,000 occur in people <65 yrs
the second biggest cause of death in the UK
up to 22% of people die within 30 days
1.2 million CVA survivors in the UK
15 million cases and 5 million deaths per year worldwide
List ten risk factors of CVA.
diabetes high blood pressure, high cholesterol obesity, smoking, alcohol congenital heart defects coronary heart disease ethnic origin gender
What percentage of CVA cases are caused by modifiable factors?
90%
poor diet increases risk by 11%
smoking doubles risk of ischaemic stroke
How many times more likely are people with diabetes to develop a CVA?
2-6 times
What percentage of CVA cases are associated with high blood pressure?
50%
People from which ethnicities are more likely to develop conditions associated with CVA?
caucasian - increased risk of AF
black - increased risk of sickle cell disease and its complications, hypertension, diabetes
South Asian - increased risk of hypertension, hyperlipidaemia, diabetes
What is the definition of CVA according to Tadi and Lui (2020, p. 1)?
“Acute stroke is defined as the acute onset of focal neurological findings in a vascular territory as a result of underlying cerebrovascular disease.”
What is the definition of a transient ischaemic attack (TIA) according to Khare (2016, p. 1)?
”..transient episode of neurological dysfunction caused due to loss of blood flow to the brain or spinal cord without acute infarction.”
How can you compare a CVA and TIA without further investigation?
the time period of recovery
TIAs last <1 hr or up to 24 hrs
there is debate as to whether the 24 hr period is a useful indicator
Why was the FAST acronym developed?
to educate the public and healthcare professionals in early detection of CVA
What does FAST stand for?
Face - facial weakness and drooping, which may include the mouth, eyes or both
Arms - inability to lift one or both arms, due to weakness or numbness
Speech - inability to talk, or understand what is being said, with or without slurred speech
Time - a factor in accessing treatment for a suspected CVA or TIA
What is the ROSIER (Recognition of Stroke in the Emergency Room) assessment?
a test to distinguish between CVA and TIA: loss of consciousness or syncope seizure activity asymmetric facial weakness asymmetric arm weakness asymmetric leg weakness speech disturbance visual field defect
What happens if there is a suspected CVA following the ROSIER assessment?
CT imaging
this must be undertaken as soon as possible, due to the time limit for administering medication to patients with suspected ischaemic CVA
What percentages of CVAs are ischaemic compared with haemorrhagic?
ischaemic - 85%
haemorrhagic - 15% (10% intracerebral and 5% subarachnoid)
What is a TIA?
the same as a CVA, except symptoms last <24 hrs
almost a third of patients with TIA develop a disabling stroke within 5 years
the majority of strokes occur within 18 months (highest risk in the first few days/weeks post-TIA)
5% of TIAs lead to a CVA within 48hrs
15% of ischaemic CVAs precede a TIA
What is a carotid assessment?
required to detect carotid stenosis
50% requiring endarterectomy (removal of atheroma)
What is the initial course of action in the treatment of a CVA?
to determine whether the CVA is ischaemic or haemorrhagic
What is thrombolysis?
treatment which aims to break down the thombosis in ischaemic CVA
Which drug is recommended by NICE in the management of thrombosis?
alteplase
What is the time period for the administration of alteplase for the treatment of ischaemic CVA?
within 4.5 hours of onset of symptoms
it can be administered up to 6 hours, but is less beneficial with reduced patient outcomes
What proportion of patients are eligible to receive thrombolysis?
around 8 in 10
What percentage of patients do not receive thrombolysis due to staff availability and competency?
15%
What other reasons for not receiving thrombolysis relate to not meeting the necessary criteria?
haemorrhagic CVA
patient is unable to recall when symptoms began
delay in reaching a hospital in time and lack of resources
bleeding disorder (e.g. haemophilia)
recent major surgery
CVA or head injury within the past three months
current medication interacts with alteplase
What is a thrombectomy?
alternative to thrombolysis
this needs to be assessed for suitability and patient health
this can occur within 6 hours of onset of symptoms, and in certain cases up to 24 hours with the entry point being the femoral artery
What is a carotid endarterectomy?
a surgical procedure to remove plaques from a carotid artery with the goal of preventing strokes
it is carried out by separating the plaque from the arterial wall
the operation may last between 1-2 hours depending on the complexity of the operation and the patient’s medical history
Patients with suspected TIA who have undergone carotid imaging have to meet which criteria before being determined as suitable for carotid endarterectomy?
patients with stable neurological symptoms from acute non-disabling stroke or TIA and symptomatic carotid stenosis of 50 to 99% - urgent referral for carotid endarterectomy
patients with symptomatic carotid stenosis <50% do not receive surgery
review and commence treatment for BP, antiplatelet agents, cholesterol-lowering through diet and drugs, and lifestyle advice in both cases
What is the recommended pharmacological treatment for TIA or ischaemic CVA?
aspirin 300 mg PO within 24 hours if patient does not have dysphagia, OR
aspirin 300 mg rectally or by enteral tube within 24 hours if patient has dysphagia
this is continued for 2 weeks after the onset of CVA symptoms, which then leads to a long-term antithrombotic treatment
PLASMINOGEN ACTIVATORS
Alteplase, duteplase, reteplase, streptokinase - actions & MOA
enzymically activate plasminogen to give plasmin which digests fibrin and fibrinogen, lysing the clot
PLASMINOGEN ACTIVATORS
Alteplase, duteplase, reteplase, streptokinase - abs/distrib/elim
given by IV injection or infusion
short half-life (except for reteplase)
PLASMINOGEN ACTIVATORS
Alteplase, duteplase, reteplase, streptokinase - clinical use
myocardial infarction, acute ischaemic stroke and other arterial thrombosis
ideally given as soon as possible after onset of thrombosis
occasionally used in severe cases of deep vein thrombosis and pulmonary embolism
PLASMINOGEN ACTIVATORS
Alteplase, duteplase, reteplase, streptokinase - adverse effects
bleeding (most important), reperfusion dysrhythmias, nausea and vomiting, hypersensitivity reactions
PLASMINOGEN ACTIVATORS
Alteplase, duteplase, reteplase, streptokinase - special points
streptokinase is a plasminogen-activating protein extracted from cultures of streptococci
alteplase and duteplase are single- and double-chain recombinant tissue plasminogen activators (tPA)
more active on the fibrin-bound plasminogen than on the plasma plasminogen (‘clot selective’)
action blocked by antibodies which appear about 4 days after initial dose - use of either agents should not be repeated after this time has elapsed
IRREVERSIBLE COX-1 INHIBITOR
Aspirin - actions
antiplatelet (also analgesic and anti-inflammatory)
IRREVERSIBLE COX-1 INHIBITOR
Aspirin - MOA
irreversibly inactivates cyclo-oxygenase (COX)-1
alters balance between thromboxane A2 (TXA2) and prostacyclin (PGI2) in the platelet/vascular endothelium axis
IRREVERSIBLE COX-1 INHIBITOR
Aspirin - abs/distrib/elim
given orally in small doses
excretion in urine, increased if urine is alkalinized
IRREVERSIBLE COX-1 INHIBITOR
Aspirin - clinical use
acute treatment of acute coronary syndrome and stroke
secondary prevention of arterial thrombosis after cardiovascular and cerebrovascular events, including after arterial stents
prevention of pre-eclampsia in pregnancy
IRREVERSIBLE COX-1 INHIBITOR
Aspirin - adverse effects
GI bleeding because the cytoprotective action of PGs (namely ↓acid secretion, ↑mucus and bicarbonate) is decreased
bronchospasm in some individuals
toxic doses cause respiratory alkalosis followed by acidosis
IRREVERSIBLE COX-1 INHIBITOR
Aspirin - special points
interactions: effects increased by anticoagulants and thrombolytic drugs
ANTICOAGULANTS
Vitamin K antagonist: warfarin - actions
inhibit blood coagulation
ANTICOAGULANTS
Vitamin K antagonist: warfarin - MOA
inhibits the reduction of vitamin K and thus prevents the γ-carboxylation of the glutamate residues in factors II, VII, IX, and X
ANTICOAGULANTS
Vitamin K antagonist: warfarin - abs/distrib/elim
given orally
onset slow because the circulating γ-carboxylated factors have to be degraded
ANTICOAGULANTS
Vitamin K antagonist: warfarin - clinical use
to treat deep vein thrombosis, pulmonary embolism
to prevent embolization in atrial fibrillation
ANTICOAGULANTS
Vitamin K antagonist: warfarin - adverse effects
bleeding - treated by giving natural vitamin K or fresh plasma or prothrombin complex concentrates
ANTICOAGULANTS
Vitamin K antagonist: warfarin - special points
prothrombin time must be monitored action increased (with ↑risk of bleeding) by many drugs e.g. ciprofloxacin, aspirin action decreased (with ↓risk of clotting) by many drugs e.g. rifampicin
DIRECT ORAL ANTICOAGULANTS
Dabigatran, apixaban, rivaroxaban - actions
reduce clot formation
DIRECT ORAL ANTICOAGULANTS
Dabigatran, apixaban, rivaroxaban - MOA
dabigatran is a direct inhibitor of clot-bound and free thrombin (factor IIa)
apixaban and rivaroxaban are direct inhibitors of factor Xa
DIRECT ORAL ANTICOAGULANTS
Dabigatran, apixaban, rivaroxaban - abs/distrib/elim
given orally
half-lives: dabigatran 14-17h, apixaban 8-13h, rivaroxaban 5-9h
dabigatran is a prodrug and has a low bioavailability
apixaban and rivaroxaban are around 50% renally excreted
dabigatran is 80% renally excreted
DIRECT ORAL ANTICOAGULANTS
Dabigatran, apixaban, rivaroxaban - clinical use
prevention of deep vein thrombosis/pulmonary embolism in orthopaedic surgery
treatment of venous thromboembolism
prevention of stroke in atrial fibrillation
DIRECT ORAL ANTICOAGULANTS
Dabigatran, apixaban, rivaroxaban - adverse effects
bleeding, which can be treated with specific reversal agents: idarucizumab for dabigatran, andexanet alfa for factor Xa inhibitors
DIRECT ORAL ANTICOAGULANTS
Dabigatran, apixaban, rivaroxaban - special points
these drugs are administered in standard doses without monitoring
dabigatran can be removed via haemodialysis rivaroxaban and apixaban are highly protein bound - limits dialysis
Approximately what percentage of patients could be fully independent within three weeks of their stroke (SIGN)?
up to 30%
Approximately what percentage of patients could be fully independent within six months of their stroke (SIGN)?
nearly 50%
What variables can make recovery time from a stroke difficult to predict?
type of stroke experienced
how soon treatment was administered
pre-stroke health including comorbidities
rehabilitation programmes and facilities
What is the pathway for patients receiving treatment for a stroke in hospital?
(1) HASU - hyper acute stroke unit
(2) CVA ward - continue rehabilitation
(3) discharge - early supported discharge/community rehab team
What are the twelve activities of daily living (ADLs) as developed by the Roper-Logan-Tierney model of nursing?
maintaining a safe environment communication breathing eating and drinking elimination washing and dressing controlling temperature mobilising working and playing expressing sexuality sleeping death and dying
What percentage of stroke survivors have difficulty with memory/orientation/language/attention?
3% at 3-12 months post CVA
falls occur in 23-37%
What percentage of stroke survivors have visual problems?
up to 66%
What percentage of stroke survivors have aphasia/dysarthria?
33%
aphasia expressive - words
aphasia receptive - understanding or muscle control
What is the prevalence of pneumonia in patients who have suffered a CVA?
10-40%
Stroke survivors with dysphagia are how many times more likely to develop pneumonia than stroke survivors without dysphagia?
3 times
Stroke survivors with aspiration of food and drink into the lung, as a link to the dysphagia, are how many times more likely to develop pneumonia than stroke survivors with no aspiration?
11 times
What percentage of stroke survivors have dysphagia?
40-65%
up to 50% can be asymptomatic
Of stroke survivors with dysphagia, what percentage will be able to swallow safely within two weeks post-CVA?
up to 90%
What percentage of stroke survivors can regain arm movement post-CVA?
up to 70%
What percentage of stroke survivors have issues of urinary incontinence due to bladder control post-CVA?
up to 50%
What percentage of stroke survivors have issues of faecal incontinence due to bowel control post-CVA?
33%
What percentage of stroke survivors will continue to suffer with incontinence after one year post-CVA?
15%
What percentage of stroke survivors have reduced ability to regulate body temperature due to reduced general mobility and movement?
80%
this can cause similar complications in washing and dressing independently
What percentage of stroke survivors have reduced ability to regulate body temperature due to reduced arm mobility and movement?
70%
this can cause similar complications in washing and dressing independently
What percentage of stroke survivors have an inability to use one arm?
40%
What percentage of stroke survivors suffer from spasticity?
19-38%
this increases their risk of developing pressure ulcers at pressure points (e.g. sacrum, heels, occipital locations)
Why does the impact of poor mobility continue in many stroke survivors?
due to hemiparesis (one-sided weakness)
Why can limited arm movement and strength cause shoulder damage?
due to the weight of the arm
this leads to pain caused by tendons overstretching, and even dislocation
What percentage of stroke survivors suffer from depression?
up to 29%
What percentage of stroke survivors continue with altered emotional states for up to 6 months post-CVA?
20%
What percentage of stroke survivors continue with altered emotional states beyond 6 months post-CVA?
10%
What percentage of stroke survivors suffer with altered sensation?
80%
Why do many stroke survivors struggle to engage in intimacy (e.g. hugging) or more intimate actions (e.g. intercourse)?
due to poor mobility, strength, cognition, mental health
Why do many stroke survivors struggle to remain comfortable while sleeping?
due to reduced general and arm movement
the presence of altered sensations
5-20% experience pain
What percentage of stroke survivors will die within 30 days post-CVA?
up to 22%
What percentage of stroke patients may experience a continued disability and death as a result of the CVA?
up to 70%
Why is a multidiscplinary approach important for stroke rehabilitation?
to utilise all the skills, knowledge and expertise of each member to improve patient outcomes
How are goals devised in stroke rehabilitation?
goals have to take into account both their relevance and meaning
set against the evidence-base that exists
the activity is suitable and requires participation but remains challenging and achievable
these are part of both short- and long-term goals
Who are the seven members of an MDT for stroke rehabilitation?
physician nurse occupational therapist physiotherapist speech and language therapist social worker rehabilitation assistant
What is the role of the physician in stroke rehabilitation?
to engage with the patient and significant others in the care of patients and their medical health
What is the role of the nurse in stroke rehabilitation?
to engage with the patient and significant others within the design of care plans to address issues related to ADLs
What is the role of the occupational therapist in stroke rehabilitation?
to engage with the patient and significant others to undertake their occupation
this is alongside ADLs and whether adaptations of strategies can be employed
What is the role of the physiotherapist in stroke rehabilitation?
to engage with the patient and significant others
offer initially at least 45 mins of stroke rehabilitation therapy for a minimum of 5 days per week in patients able to participate and where functional goals can be achieved
What is the role of the speech and language therapist in stroke rehabilitation?
to engage with the patient and significant others and the nursing team with areas such as dysphagia
this may result in recommendations for a soft diet or the short-term use of a nasogastric tube (4 weeks)
consideration of a percutaneous endoscopic gastronomy for long-term use if needed
What is the role of the social worker in stroke rehabilitation?
to engage with the patient and significant others in the planning of discharge into the home
this may contain a package of care, or training that may be short- to long-term
What is the role of the rehabilitation assistant in stroke rehabilitation?
to support rehabilitation that has been designed and devised by the healthcare professionals
What did Lloyd (2018) conclude about the experiences of stroke survivors, and their families and unpaid carers, regarding goal setting in stroke rehabilitation?
person-centred goal setting is possible but often does not occur
health professionals shape the context of goal setting
health professionals need to listen to the person and know “who they are” - need for an individualised approach to goal setting
recovery is ongoing and unpredictable
