Neurological disorders other than dementia Flashcards
ALS
- life expectancy 2-4 years from symptom onset
- Spinal variant:
- early tetraparesis
- late onset cranial nerve dysfunction
- Bulbar variant:
- 20%
- speech and swallowing
- progressive muscle weakness
- neurobehaviour sx (apathy, disinhibition)
- decreaesd mobility, loss of speech and swallowing, dyspnea, dysphagia, mucous, muscle cramps, insomnia
ALS : Respiratory insufficiency
- Influenza and pneumococcal vax
- 02 not recommended - hypercarbia
- nocturnal NIPPV for headache and daytime somnolence
- 24 hour NIPPV as disease progresses
- survival effect of NIPV
- withdrawal of NIPPV - palliative sedation
- tracheostomy extends life, but large burden of care
- dyspnea tx opioids
- anxiety : benzos
ALS : Mucous congestion of airways
- impaired coughing
- mucolytics : NAC
- beta receptor agonist, nebulized saline, furosemide
- cough assist device
ALS: malnutrition
- Dysphagia
- hypermetabolism
- discuss feeding tube placement early
- SLP
ALS : Sialorrhea
- drooling common result of swallowing deficits
- SLP
- amitiptyline
- hyoscine hydrobromide (scopalamine) patch
- atropine drops orally
- glycopyrrolate
- botox injection in salivary glands
ALS: Spasticity and muscle cramps
- common in primary motor neuron disease
- physio
- baclofen
- tizanadine
- many SE of meds: athenia and weakness
- Nabiximols - synthetic cannabinoid
- botox for focal spasticity
- Muscle cramps:
- Levetiracetam (keppra)
- quinidine
- phenytoin
- carbamazepine
ALS: Insomnia and fatigue
- muscle cramps, pain, respiratory distress, depression
- sleep: amitriptyline, mirtazapine, zolpidem
- fatigue : modafinil, ritalin
ALS: Pseudobulbar effects
- corticobulbar degeneration
- inappropriate laughter or crying incongruent to patient’s mood
- Dextromethorphan and quinidine
- SSRI (citalopram, amitriptyline)
ALS: Depression, suicidality and death
- common
- increased desire for hastened death
- psychosocial support
- most patients die a sudden, non violent death, often while sleeping
Parkinson’s disease : Motor symptoms
- bradykinesia, muscle rigidity, dystonia, gait instability, tremor
- carbidopa/levodopa
- amantadine
- botulism
- analgesics for pain
Parkinson’s: Autonomic dysfunction
- Orthostatic hypotension
- Multi system atrophy most common
- reduction of L dopa
- compression stockings
- increased sodium
- fludrocortisone
- midodrine
- urinary urgency and incontinence
- oxybutynin, tolteridine
- botox
- increased sweating, delayed gastric emptying, constipation, sialorrhea
Parkinson’s : Psychiatric symptoms
- psychosis, hallucinations, delusions
- dose reduction of l-dopa helps
- stop anticholingerics, amandatine
- very low dose atypical neuroleptics (seroquel)
- personality and mood changes common
- subcortical dementia
- cholinesterase inhibitors modestly effective
Depression, panic attacks
- SSRIs
Parkinson’s: Sleep disorders
- restless legs syndrome
- low dose dopamine agonists at bedtime
- valproic acid, gabapentin, benzodiazepines
- Rapid eye movement sleep disorder
- may harm themselves or partner
- clonazpeam
- melatonin
- dopaminergic and ach drugs worsen this
Atypical parkinsonian disorders:
PSP, corticobasal degeration, multiple system atrophy, dementia with lewy bodies
- Parkinson-like symptoms that do not respond to antiparkinsonian drugs
- much shorter prognoses
Atypical Parksinoniah disorders: Management
- Motor function
- carbidopa/levodopa
- amantadine, imipramine
- become ineffective over time
- Neck and back pain from rigidty and spasm
- botox
- physio
- analgesics
- myoclonus - benzos
- Dysautonomia
- orthostatic hypotension
- reduce dopamine agonist
- compression stockings, increased Na and water
- midodrine, fludrocortisone
- urinary incontinence
- oxybutynin, tolteridone, botox
- Dysarthria/dysphagia
* feeding tube placement individual - Psychiatric symptoms
- personality and mood changes
- DLB : executive function, but not memory
- subcortical dementia
- Sleep disorders
* REM disorder -clonazepam, melatonin
Terminal phase of parkinsons/ atypical parkinson’s
- Pneumonia
- bradykinesia increases dramatically
- seizures
- eyes wide open but unable to control
- extensive stiffness
Multiple sclerosios
- inflammatory auto immune disorder
- incurable
- variable prognosis
- sx: difficulty using arms or legs, fatigue, spasticity
Symptom control in Neurodegenerative disease :
dyspnea related anxiety
- fast acting benzos
- lorazepam 0.5-1mg q4h prn
Symptom control in neurodegenerative diseases: Fatigue
- SSRI citalopram 20 mg po od
- modafinil 100 mg po od
- methylphenidate 5 mg po bid
Symptom control in Neurodegenerative disease :
Muscle cramps
- quinidine sulphate
- baclofen
Symptom control in neurodegnerative disease :
Pain
- tilidine, metamizole, tramadol, morphine etc
- TCA, SNRI
Symptom management in neurodegenerative disorder:
Pseudobulbar affect
- dextromethorphan 20 mg po od plus quinidine 10 mg po od
- SSRI
Symptom management in neurodegen :
Pseudohypersalivation
- sage tea
- amitriptyline
- scopolamine patch
- botox to salivary glands
- salivary galnd radiotherapy
Symptom control neurodegen :
Psychosis, agitation, irritability, dysphoria
- non pharm : calm, quiet environment
- Quetiapine 25-50 mg po od
Symptom control neurodegen :
REM sleep behaviour disorder
- Clonazepam 0.25-1 mg po qhs)
- Melatonin 3-12 mg
Symptom control neurodegen :
Respiratory failure
- NIPPV
- tracheostomy
- opioids
Symptom control neurodegen :
rigidity, bradykinesia, akinesia
- Amantadine 600 mg po/iv
- dopamine agonist, NMDA antagonist, nicotinic agonist
- morphine
- midazolam
- rotigotine patch
Symptom control neurodegen :
Sleeplessness
- zopiclone, zolpidem
- amitriptyline 25 mg po
- Mirtazapine
- Quetiapine 25 mg po
Symptom control neurodegen disorder :
Spasticity
- Physio
- Baclofen
- Tizanidine
- Botox
Symptom control neurodegen :
Thick secretions
- hydration
- mucolytics (NAC, ambroxol)
- Beta antagonists
- nebulized saline, cough assist device, humidification
