Neurological Disorders Flashcards
Alzheimer’s Disease: What is it?
A degenerative brain disease that causes progressive decline in neurocognitive functioning that is severe enough to compromise social and occupational functioning
Alzheimer’s Disease: General Considerations
- most common form of dementia
- after age 60, the prevalence doubles every 5 years
- half of patients with AD have a family history
Alzheimer’s Disease: Risk Factors
- aging
- smoking
- family history
- Down’s syndrome
Alzheimer’s Disease: Assessment Findings
- gradual worsening ability to remember new information (most common)
- decline in memory, cognition, language, personality, and mobility
- impaired judgement, abstract thinking, memory, reasoning, orientation, and attention
- difficulty with speech and other forms of communication
- inability to interpret sounds, speech, and use of objects
- insomnia, daytime sleepiness
- hyperactivity, wandering, restlessness
- mood disturbances and emotional outbursts
- urinary and/or fecal incontinence
- paranoia, hallucinations, delusions (late findings)
Alzheimer’s Disease: Diagnostic Studies
- Medical and family history
- APOE 34 presence increases risk
- Mini mental status exam
- Rule out reversible causes: CBC, CMP, UA, LFTs, thyroid function tests, B12, and folate levels, consider CT or MRI, syphilis serology, PET scan to rule out Lewy Body Dementia
Alzheimer’s Disease: Prevention
- Regular physical exercise
- Healthy diet
- Management of risk factors (control of DM and HTN)
Alzheimer’s Disease: Nonpharmacological Management
- Maintain routines and familiar environment
- Supportive care
- Display calendar and clocks in prominent places
- Display family pictures
- Promote socialization
- Fall precautions
- Wandering and exiting precautions
- Emotional support from family
- Respite care for caregivers
- Maintain healthy nutritional status
Alzheimer’s Disease: Pharmacological Management
- Cholinesterase inhibitors
- NMDA receptor antagonists
Cholinesterase Inhibitors
** For treatment of Alzheimer’s
- Donepezil
- Galantamine
- Rivastigmine
NMDA Receptor Antagonist
** For treatment of Alzheimer’s Disease
- Memantine
Alzheimer’s Disease: Referral/Consultation
- consult neurologist for new onset dementia
- consult social services as needed for family
** 33% of patients develop depression
Bell’s Palsy: What is it?
An acute, unilateral, peripheral paralysis of cranial nerve 7, which controls the lower motor neurons of the face
Bell’s Palsy: Etiology
- Inflammation
- Idiopathic
- Herpes simplex or zoster virus
Bell’s Palsy: General Considerations
- most common cause of unilateral facial paralysis
- peak age of occurrence is 20-40 years of age
- affects people with DM or upper respiratory infections more commonly and those who are pregnant
Bell’s Palsy: Risk Factors
- Lyme disease
- Pregnancy
- DM
- Family history
- HTN
Bell’s Palsy: Assessment Findings
- Acute onset of unilateral upper and lower facial paralysis
- Loss of nasolabial fold on affected side
- Otalgia
- Poor eye closure with decreased/excessive tearing, and blurred vision
- Taste disturbances
- Drooling, dysphagia
Bell’s Palsy: Diagnostic Studies
- Usually diagnosed on clinical presentation
- CT to rule out stroke or neoplasm
- Lyme disease titer if history of tick bite
- Serologic studies for syphilis and HIV
- CBC, TSH, ESR, glucose
- EMG testing (determines severity and extent of nerve involvement)
- Hearing/vestibular testing (is cochlear or vestibular nerve affected)
Bell’s Palsy: Nonpharmacological Management
- Patient education
- Warm, moist heat to affected side of face
- Close and cover affected eye, especially at night
- Active and passive ROM of eye and facial muscles
- Majority of cases will recover without treatment
Bell’s Palsy: Pharmacologic Management
- Corticosteroids
- Antivirals (valacyclovir, acyclovir)
- Pain relief (ASA, ibuprofen, tylenol)
Bell’s Palsy: Consultation/Referral
- Obstetrician for pregnant patients
- Neurologist for serious comorbid conditions
- Ophthalmologist for actual or suspected corneal abrasions
- Occupational and/or speech therapy
Bell’s Palsy: Follow Up
- 2 weeks after onset to monitor treatment safety and condition of eye
- 3 months
- 6 months
Bell’s Palsy: Expected Course (Resolution of Symptoms)
** Varies
- complete recovery of facial nerve function (majority)
- incomplete recovery of facial nerve function with no obvious cosmetic defects
- permanent neurologic sequelae that are cosmetically and clinically obvious (rare)
Bell’s Palsy: Expected Course (Recovery Times)
- Majority have complete resolution within 6 weeks to 3 months
- Symptoms usually begin to improve within 2 weeks
- Extent of nerve damage determines extent of recovery
** Prognosis is related to severity
Concussion: What is it?
A change in mental status or cognitive function as a result of trauma; a mild traumatic brain injury
Concussion: General Considerations
- may or may not involve loss of consciousness
- usually resolves in 7-10 days with rest and observation
- head injuries account for almost half of all trauma-related deaths
Concussion: Etiology
- Direct trauma
- Blast
- Coup-contrecoup injury
** Changes in white matter occur in concussion, likely due to sudden release of excitatory neurotransmitters, quick release of potassium into the extracellular space with resulting calcium entrance into the cells, and decreased cerebral blood flow
Concussion: Incidence
- Underreported because many do not seek treatment
- Estimated 1.6-3.8 million sports and recreation related concussions per year
Concussion: Risk Factors
- Sports participation
- Fall risk patients
- Women have a higher incidence than men
- Postconcussive syndrome is more common in women and those with severe initial injury, previous head injuries, and comorbid psychiatric illness
Concussion: Assessment Findings
- Observed or self-reported loss of consciousness lasting < 30 minutes
- Posttraumatic amnesia < 24 hours
- GCS greater than or equal to 13
- Physical exam often normal
- Battle sign (bruising over mastoid process)
- Raccoon sign (bruising around the eyes)
- Clear fluid leakage from nose or ears
- Visual abnormalities
- Difficulty in coordination or balance
- Irritability or labile mood
- Brain fog
Concussion: Diagnostic Studies
- Acute Concussion Evaluation (ACE) tool for ED
- CT scan
- Possible MRI
Concussion: Prevention
- use helmets with sports and play activities
- use of seatbelts and proper child restraints
- implement safety measures to prevent falls in the home
Concussion: Nonpharmacologic Management
- physical and cognitive rest
- early return to nonstrenuous, noncontact activity as tolerated
- accommodations at school or work
- PT, vocational rehab, education
- evacuation of hematoma
Concussion: Pharmacologic Management
- Focused on symptom management
- Omega 3 fatty acids
- Drug therapy should target specific symptoms, such as anxiety, depression, HA, and insomnia
- Nonbenzodiazepines (zolpidem, zalepion, eszopidone)
- NSAIDs
- Antiseizure meds (gabapentin, topiramate)
- SSRIs (sertraline, escitalopram)
- Nonbenzodiazepine anxiolytics (hydroxyzine, buspirone)
- Antivirals (amantadine)
Concussion: Prognosis
- average recovery 7-10 days, but can last much longer
- metabolic changes in brain tissue can last longer than symptoms, increasing risk for repeat injury if another trauma occurs
Concussion: Possible Complications
- Postconcussive syndrome
- Second impact syndrome (second injury after initial concussion, causing severe cerebral edema; can be fatal)
- Repeated concussions cause increased risk for multiple diseases (chronic traumatic encephalopathy, Parkinsons, Depression, ALS, Epilepsy)
Concussion: Referral
- Refer immediately to ED for any signs of intracranial hemorrhage, skull fracture
- Refer to neurology or psychiatry for persistent symptoms not suitable for primary care
Cluster Headaches: What is it?
A primary neurovascular headache disorder that causes a grouping of headaches, usually over a period of several weeks
Cluster Headaches: General Considerations
- may be classified as episodic or chronic
- men affected more than women
- possible causative factor is release of histamines or serotonin
Cluster Headaches: Risk Factors
- Heritable tendency in first-degree relatives
- Age of onset 20-40 years
- Previous head trauma or surgery
- Small amounts of vasodilators (alcohol)
Cluster Headaches: Possible Triggers
- Histamine
- Stress
- Allergens
- Seasonal changes
- Nitroglycerin
- Tobacco use
- Alcohol intake
Cluster Headaches: Assessment Findings
- Severe unilateral periorbital pain with sudden onset, usually at night, lasting 15 minutes to 3 hours
- Ipsilateral nasal congestion, rhinorrhea, lacrimation, redness of the eye, and Horner syndrome
- Restless and agitation during attacks
- Eyelid and facial swelling
- Aural fullness
Cluster Headaches: Diagnostic Studies
- Based on clinical history
- At least 5 attacks that fulfill the cluster headache diagnostic criteria
- Lab testing and imaging to rule out other possible causes
Cluster Headaches: Prevention
- Avoid triggering substance (alcohol, nicotine)
- Temper, strong emotions
- Maintain usual sleep/wake hours
- Pharmacologic interventions for prophylaxis (melatonin)
- Avoidance of vasodilators (nitroglycerin, alcohol)
Cluster Headaches: Pharmacological Management
- 100% oxygen for 15 minutes
- Triptans (sumatriptan/imitrex)
** oral agents not effective
** aborts individual attacks but does not reduce duration of clusters
Cluster Headaches: Consultation/Referral
- refer to neurologist for severe headaches or headaches unresponsive to drug therapy
- atypical features such as
1. absence of a periodic pattern
2. residual headache between exacerbations
3. bilateral headache
4. incomplete or minimal response to standard therapy
5. presence of lateralizing findings on examination
Cluster Headaches: Follow Up
- RTC or ED if headache unresolved after treatment
- periodically monitory ECG, thyroid function, renal function, and electrolytes
- Taper of preventative medications
1. Episodic: completely headache free for 2 weeks and/or moved beyond typical cluster period duration
2. Chronic: after 6-12 months of therapy, can consider taper, as long as headaches do not recur
Cluster Headaches: Potential Complications
- No real long term complications, but may be excruciating and incapacitating
- Depression and aggression with suicidal ideation
- Possibility of self-injury during an attack
- Risk of addiction to narcotic analgesics
Migraine Headaches: What is it?
A common primary headache disorder characterized by recurring headaches that are complex and can be disabling
Migraine Headaches: General Considerations
- Two main types: with aura and without aura
- More common in white females
- Strong genetic component
Migraine Headaches: Assessment Findings
- common while awake or upon awakening
- unilateral; may be pulsating or throbbing
- if < 18 years old, more commonly bilateral
- frontotemporal
- builds over 1-2 hours
- prodrome may begin hours or days before and cause changes in mental status, photophobia, stiff neck
- postdrome may last 48 hours (fatigue, difficulty concentrating, neck stiff)
- nausea and vomiting
- blurred and/or double vision
- photophobia/phonophobia
Migraine Headaches: Diagnostic Studies
- CT, MRI, and/or MRA
- Consider sinus series
- CBC, CMP, TSH
- Cervical xrays
- EEG
- LP
- Sed rate
- UDS
- UA
Migraine Headaches: Prevention
** Avoid triggers
- nitrite containing foods (hot dogs, etc)
- MSG containing foods (Chinese food, etc)
- tyramine containing foods (chocolate, red wine, caffeinated beverages)
- hormonal changes (menstruation, pregnancy, ovulation)
- stress
- medications (vasodilators, OCP)
- excessive/insufficient sleep
- exposure to bright/fluorescent light
- strong odors
- head trauma
- weather changes
- motion sickness
- cold stimulus (ice cream, etc.)
- lack of exercise
- fasting or skipping meals
Migraine Headaches: Nonpharmacologic Management
- Avoid triggers
- Application of ice or cool compresses to head, face, scalp, and neck
- Darkened room
- Quiet atmosphere
- Cognitive behavioral therapy
- Relaxation techniques
- Biofeedback
Migraine Headaches: Pharmacologic Management
- Abortive:
1. ASA, tylenol, ibuprofen, naproxen
2. Ergotamines (all end in “-ergotamine”)
3. Triptans (all end in “-triptan”) - Prophylactic
1. Beta blockers (propranolol, timolol)
2. Anticonvulsants (topiramate, divalproex)
3. Calcitonin gene-related peptide antagonists (end in “-umab”)
Migraine Headaches: Consultation/Referral
Refer to neurologist for severe headaches or lack of response to drug therapy
Migraine Headaches: Expected Course
- Most resolve within 72 hours
- Severity and frequency diminish with age
Migraine Headaches: Possible Complications
- medication overuse
- risk of addiction to narcotic analgesics
- status migrainosus
- persistent aura without infarction
- migrainous infarction
- migraine triggered siezures
- severe nausea/vomiting may lead to shock
- increased risk of ischemic strokes
Tension Headaches: What is it?
Bilateral, nonthrobbing headaches of mild to moderate intensity, without other associated features