Neurological disorders Flashcards by Lynne Saycocie

T/F: 30-40% of delirium is preventable

True

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T/F: Delirium is abrupt onset as opposed to insidious progression like dementia (alzheimers)

True

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What are some pharmacological triggers for delirium?

Agents with anticholinergic effects:
Antihistamines: H1 and H2
Antidepressants: paroxetine, TCAs
Antipsychotics: typical > atypical
Antispasmodics and muscle relaxants
Antiparkinson: tihexyphenidyl, benztropine

Benzos, meperideine, steroids
*meperidine has metabolite that can affect pts with renal impairment
Withdrawal syndromes with alcohol, sedative hypnotics, and barbituates

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T/F: There are 3 subtypes of delirium

T: hyperactive, mixed, hypoactive

Hypoactive seen more in older adults (quietly confused, disoriented, apathetic, sluggishness, lethargic)

*Often misdiagnosed as depression

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What is The CAM assessment tool?

Common Assessment Method: for screening and diagnosis and sometimes monitoring of delirium

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T/F: there is no medication to PREVENT delirium

True. Medications used to reduce delirium duration

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T/F: The approach in managing delirium is to identify cause and remove offending agent and if needed treat pharmacologically for severe agitation with low dose antipsychotics like haloperidol, olanzapine, risperidone, quetiapine

True

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T/F: Dementia is a major neurocognitive disorder

True: sig cognitive decline from a previous level of performance in one or more cognitive domains (more than just memory)

*Decline interferes with functioning in Instrumental activities of daily living (IADL): driving, managing check book AND activities of daily living (ADL): dressing, eating, etc

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What are the vitamin deficiencies associated with antiseizure medications like phenytoin, carbamazepine, phenobarbital, and primidone?

B12 and folic acid

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What vitamin deficiencies are associated with dementia?

B-12
Folic acid
B-1 (Thiamine)

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What are the assessment tools used for cognition?

MMSE: mini mental state exam
MoCA: montreal concentration assessment
BOMC: blessed orientation memory concentration
SLUMS: st louis university mental status

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What are some assessment tools for depression?

Patient health questionaire-9 (PHQ-9)

Geriatric depression scale-15 (GDS-15)

> =5: depression

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What is the pathological hallmark of Alzheimer’s disease?

extracellular beta-amyloid plaques and intracellular neurofibrillary tangles

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What are the three classes of medications used to treat dementia?

Acetylcholinesterase inhibitors
NMDA antagonist
Anti-amyloid monoclonal antibody

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What are the acetylcholinersterase inhinotors?

Donepezil, rivastigmine, galantamine

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What is the only disease modifying therapy for dementia?

Amyloid beta-directed antibody (Aduhelm: aducanumab)

*used of early disease, mild cognitive impairment

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T/F: Memantine is not used to treat mild to moderate dementia

True. Memantine used to treat only moderate to severe dementia

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What allele is associated with dementia?

APOE4

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What are the major side effects of the Ach inhibitors, NMDA antagonists like donepezil and memantine respectively?

*Opposite of Anticholinergic medications: diarrhea, nausea, vomiting, anorexia, weight loss

CNS: dizziness, headache, insomnia

Donepezil
GI side effects and insomnia.
If GI take at night
If insomnia take in morning

Rivastigmine comes in patch formulation that has less GI side effects but $$$

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Why does rivastigmine interact with anticholinergics?

Anticholinergics can cause confusion and blunt effects of acetylcholinesterase inhibtors

*acetylcholinesterase breakdown acetylcholine

*anticholinergics block the transmission of acetylcholine in the central and peripheral nervous systems

*acetylcholinerase inhibitors allow for more availability of acetylcholine transmission

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What is the only NMDA antagonist used in dementia?

Memantine

Used only in mod to severe disease
CNS side effects
Dose adjust with renal impairment

Why is Aduhelm typically not used for dementia?

Very expensive, IV admin q4 weeks, MRI monitoring

Not much data of benefit to justify expense. Clinically impact not clear for use currently.

*Patients on anticoagulants where excluded due to risk of bleeding

What is huperzine A?

Herbal supplement with MOA similar to ACHE Inhibitors

*active ingredient from chinese club moss, half compound and acts like ACHEI

*May be used to help slow cognitive decline in elderly

What is mechanism of NMDA antagonists?

Blocks Ca influx on receptors
Too much Ca excites cells too much and cell dies

Reduces excitatory state and attempt to save cells from dying

T/F: Efficacy of with ACHEIs should be assessed after 12 weeks of therapy

True. Further assessments on a 6 month basis. Monitor for AE throughout therapy

T/F: donepezil available in patch form

True. just approved, transdermal 5 or 10mg once a WEEK

T/F: verapamil, diltiazem, lancosamide, beta-blockers inc risk for bradycardia and heart block (PR interval prolongation) when used with AChEI

True

T/F: NSAIDS not recommended use with AChEI due to inc risk for dyspepsia, peptic ulcer disease, gastric bleeding

True

T/F: AChEI interact with CYP2D6 inhibitors and CYP3A4 inducers

True: CYP2D6 inhibitors: dc tolerability, buproprion, duloxetine, paroxetine, quinidine, cimetidine (dec tolerability) CYP3A4 inducers: carbamazepine, phenytoin, primidone, rifampin, st johns wort (dec efficacy)

What is NUPLAZID (pimavanserin)?

Used to treat dementia related behavior FDA indicated for hallucinations/delusions associated with parkinson/s disease related psychosis

When do you stop AChEis and memantine?

consensus lacking but: non adherence continued deterioration terminally ill or serious comorbidity patient or caregiver choice

What are some well documented risk for using benzos in older population?

*falls *cog worsening *paradoxical disinhibition, worsens behavior *modest inc in risk of development of pneumonia (sedation leading to hypoventilation, reduction in pressure in the lower esophageal sphincter leading to reflux and aspiration

T/F: FDA warning on ALL antipyscotics in AD

True. if used in AD dementia = off-label!! *primary cause of mortality with use of Antipsycotics = HF, sudden death, pneuomia black box warning of inc risk of death

T/F: Parkinson’s is diagnosed by motor symptoms

True Resting tremor Bradykinesia/akinesia Rigidity

What are medications that can cause sub-acute development of parkinsonian symptoms?

AP: haloperidol, fluphenazine Antiemetics: metoclopramide, prochlorperazine *usually bilateral onset (weeks to months from initiation)

T/F: Parkinson/s disease is shortage of dopamine in the brain

True

T/F: Selegeline IR is goes through first pass metabolism into amphetamine and methamphetamine and can cause insomnia

True. *BID dosing and recommended to take 2nd dose of the day earlier in day to prevent insomnia (by 2pm) *selegeline ODT bypasses first pass metabolism (buccal)

T/F: Safinamide only approved for management of “off” period in PD treatment

True. Cannot be used as monotherapy, adjunct only

T/F: DHIVY is newly approved formulation of carbidopa/levodopa (25mg/100mg)

True. nothing too different, IR formulation. The different is fractional tablet, can break off lil fragments if dose too high, etc.

T/F: Rytary is extended release CD/LD

True. capsule with different release or IR and ER inside Provides more consistent levels, no high peaks Can be sprinkled for pts with trouble swallowing.

T/F: intestinal gel of CD/LD is called DUOPA

True. infused during 16 hr period in daytime (J-tube), provides continuous stimulation bypassing stomach

T/F: COMT inhibitors are not to be used as monotherapy

True. Adjunct only

T/F: New medication for adjunct to CD/LD for PD istradefylline (Nourianz)

True. once daily dosing *dose adjusted to higher dose for smokers *strong 3A4 inhibitors, lower dose *strong 3A4 inducers, like carbamazepine —> avoid use *similar adverse effects as other dopaminergic meds except does NOT cause orthostatic hypotension

T/F: INbrija (Levodopa) used for rescue medications for “off period” in PD

True. Inhalation, onset 15 min, last up to 60 min *up to 5 doses per day

T/F: To manage REM sleep behavior disorder (RBD), use melatonin 3-15 mg 1 hr before sleep and if that does not work: clonazepam 0.5-2mg before sleep

True. RBD (screaming, reenacting dreams, etc)

What are the main medications in older adults that would lower the seziure threshold?

Diphenhydramine Tramadol Buproprion Meperidine Clozapine Haloperidol ___ stimulants lithium TCA theophylline Imipenem excessive PCN or Cephalosporin use

what is seizures

seizures is loss of consciousness for a brief period of time

What are common target levels of antiepileptic medications?

total PHT 10-20 free PHT 1-2 CBZ 4-12 VPA 50-100 LMT 4-18

T/F: More than 909% of PHT is bound to protein

True

T/F: Phenytoin has the ability to induce many hepatic enzymes

True CYP3A4: lurasidone, quetiapine, pimavanserin, donepezil, galantamine, apixaban, methadone, fentanyl, statins, vit D, macrolides, verapamil, diltiazem protease inhibitors, cyclopsorine, CYP2D6: codeine, morphine, tamoxifen, tramadol, haloperidol, bb blockers, TCAs, donepezil, galantamine CYP2C9: warfarin, PHT, glipizide CYP1A2: clozapine, olanzapine, rasagiline, ropinorole CYP2C19: PPIs, diazepam,PHT UGTs: LMT, VPA