Neurology

Question 1

When making a diagnosis of epilepsy what is the most useful component of assessment?

Answer 1

History of symptoms
Pallor
UI
Tongue biting
Postictal confusion, drowsiness, paresis or speech disturbance

Question 2

What is the utility of an EEG in making diagnosis of epilepsy?

Answer 2

Interictal EEG may be limited utility on older adult, low Sn and Sp
Non specific EEG abnormalities seen in 12-38% older adults without seizures
Normal EEG doesn’t rule out epilepsy, seen in about 1/3 patients

Can assess for focal vs. generalized which can guide treatment options
Identify ongoing epileptiformn activity which is risk for recurrence

Question 3

What is the most likely type of seizure in older adults?

Answer 3

Focal onset
With or without evolution to bilateral tonic-clonic seizures

Question 4

What would lead you to treat patient for epilepsy?

Answer 4

1. 2 unprovoked seizures
2. EEG findings of epileptiform abnormalities
3. CT head no acute stroke or bleed

Question 5

4 things to be cautious of when starting anti epileptic

Answer 5

1. Drug drug interactions
2. Risk of further cognitive impairment
3. Predispose to arrhythmias
4. Risk of osteoporosis
5. Renal and hepatic function

Question 6

What are the etiologies of epilepsy in the elderly?

Answer 6

1. Cerebrovascular - post infarct, SAH or ICH
2. Neurodegenerative disease
3. Brain tumor
4. TBI
5. Metabolic/infectious
   50% unknown

Question 7

What are 4 things to consider when prescribing anti epileptics?

Answer 7

1. Efficacy
2. Potential adverse effects
3. Drug drug interactions
4. Economic/practical factors

Question 8

What are the recommendations for which anti epileptic to use?

Answer 8

Lamotrigine and gabapentin seem to be first line choices
Other: carbamazepine, topiramate, valproate

Question 9

What are common side effects of lamotrigine?

Answer 9

Rash
Helps with depression

Question 10

What are common side effects with gabapentin?

Answer 10

Weight gain

Question 11

What are common side effects with carbamazepine?

Answer 11

GABA agonist
Confusion/drowsiness
HypoNa
Cardiac conduction
Weight gain
Rash

Question 12

What 3 anti epileptics cause cognitive impairment?

Answer 12

Phenytoin
Topiramate
Zonisamide

Question 13

What pharmacodynamic changes occur with aging that affects AEDs?

Answer 13

Decreased number and sensitivity of receptors = hard to keep stable levels

Question 14

What blood work would you send for somebody presenting with seizures?

Answer 14

CBC
Lytes/extended lytes
Cr
Lactate/CK
Blood glucose/A1c
Tox screen

Question 15

What anti depressant would you not prescribe in patient with seizures?

Answer 15

Bupropion - lowers seizure threshold

Question 16

How can malnutrition affect pharmacokinetics of AEDs?

Answer 16

Most bind to albumin and become inactive
If you have malnutrition = lower albumin = more free and active drug

Question 17

Why is phenytoin not recommended as an AED?

Answer 17

Drug drug interactions
Narrow therapeutic window
Cognitive impairment
Cardiac conduction abnormalities
Diplopia
Nystagmus

Question 18

What should you know before deciding to take somebody off of phenytoin?

Answer 18

Was seizure provoked?
If provoking factor modifiable?
Hx of other seizures?
What were EEG results?
MRI results?
Patient preference
Experiencing AEs

Question 19

What medications can decrease seizure threshold?

Answer 19

Moderate risk
Methotrexate
Olanzapine/clozapine

Intermediate
TCAs, bupropion
Flagyl

Low risk
Quetiapine, risperidone
SSRIs
MAOis
Quinolones
Beta blockers

Donepezil

Question 20

What DOAC interacts with phenytoin?

Answer 20

Phenytoin decreases rivaroxaban
Since it is a Pgp inducer and CYP3A4 inducer, both of which metabolize rivaroxaban