Neuropsychiatry Flashcards
what are the most commonest causes of traumatic brain injury?
MVA
Falls
Assaults
what are the 2 mechanisms of pathophysiology for traumatic brain injury
Focal pathology- lesions of scalp/skull/dura; contusions, haematomas
Diffuse axonal injury
Tell me about diffuse axonal injury?
acceleration/deceleration causes traumatic shearing of white matter in brain
- often not seen on first presentation/delayed presentation
- may be difficult to see radiologically as well
- need MRI to find it, but even then it can miss it
what are some ways we can assess the severity of traumatic brain injury?
- duration of loss of consciousness/coma
- Measure initial GCS and compare
- duration of post traumatic amnesia
how might we monitor post traumatic amnesia?
Westmead PTA scale
Daily measurement
- can be unhelpful in severe PTA, and also presents logistical issues
what is post traumatic amnesia?
-period from time of TBI to return of continuous memory and orientation
what are some features of post traumatic amnesia?
Includes LOC, amnesia + disorientation, no continuous day to day memory, dream-like state
Poor attention/concentration
altered sleep/wake cycle
Fatigue
Irritable/agitation
how might we manage post traumatic amnesia?
no curative treatment, self limiting usually.
Management is supportive and aims to minimise complications such as malnutrition, prevent contractures etc
how might we manage an agitated PTA patient?
first line- modify the environment. Calm safe environment, structured, little external stimuli, non-threatening environment for patient
second line- Propranolol or mood stabilisers like carbamazepine
tell me about the westmead PTA scale?
a series of 9 questions and 3 pictures, patient needs to answer all questions and identify all pictures correctly. if one is incorrect, there is cognitive impairment.
When patient achieves 12/12 on three consecutive days, then the PTA period is said to have ended
how do we manage patients who have come out of PTA?
Through an individualised, goal oriented, interdisciplinary approach- i.e. cognitive rehabilitation.
Get a neuropsych assessment to assess cognitive state + competency!!
Cognitive rehab includes both cognitive remediation (ADL based) and behavioural management (identify behaviour and triggers)
Educate family/carers/patients about PTA.
No alcohol for 12 months.
Think about ‘graduated rehabilitation’. Gradually getting the patient back to driving, back to work/study, back to premorbid function
Refer to appropriate community services for support, and they may require an OT driving assessment and medical clearance before going back to driving.
Ensure follow up is made
what allied health staff do you want to get involved with traumatic brain injuries?
Neuropsychologists!! Physiotherapists/occupational therapy etc if required
what comprises of a neuropsychological assessment?
Looking at the strength and weaknesses in 6 areas of cognition:
- attention
- memory
- language
- visual spatial
- executive functions
- personality
what are some factors that you have consider before conducting a neuropsychological assessment?
premorbid intellectual status
substance abuse
fatigue
a young patient comes in to see GP with tiredness, headache and difficulty concentrating a few months post concussion. what are your steps with management?
- assess whether the patient has mild PTA- look at past medical records for GCS at time of insult or hospital progress
- if none available- can order ix like CTb or MRIbrain
- Get neuropsychology assessment
- neuro and depression screen examination
- organise family meeting, patient education: explain assessment, talk about management of behaviours, explain seizure risk, recommend cutting out alcohol/recreational drug use
- arrange follow up
what is the most common symptom of mild traumatic brain injury?
headache
what does BPSD stand for? how might we manage it?
behavioural and psychological symptoms of dementia
- non-pharmacological approaches first including supporting carers
- risperidone/olanzapine
what are symptoms of PTA may persist in the post PTA period?
Memory impairment
Reduced attention
Reduced speed of processing
Change in behaviour and or personality
what determines the age of onset for HD?
no of cag repeats. the greater the number, the earlier the onset of disease
what are the main features of huntington disease?
chorea, dementia, psychiatric comorbidities including personality change/irritability/disinhibition
what are some medical complications from TBI?
spasticity heterotropic ossification hydrocephalus SIADH and DI depression
describe post concussion syndrome?
headaches, dizziness, fatigue, difficulty with short term memory persisting for greater than 3 months post concussion
what length of PTA is associated with permanent disability?
generally the longer the PTA period, the more severe the injury and the worse the outcome.
So generally PTA greater than 4 weeks may result in permanent disability
what are some social issues that may occur post traumatic injury?
difficulty returning to work (employment)
difficulty with relationships with others
inability to return to premorbid activity/function
what are some rehab goals for spinal cord injury and how might we achieve them?
- Prevent complications such as contractures + respiratory infections- daily neurological exams; management of spasticity including stretching and baclofen
- ensure annual influenza vaccination, aid expectoration and cough - psychosocial management- social worker, psychiatry input
- equipment and home modification- OT home review; wheelchair etc
- bladder mx- initially IDC/SPC and if possible, begin to encourage reflex emptying and intermittent self catheterisation–> urodynamic study may be required; prevention of UTI or mx of UTI if relevant
- Adequate bowel care
- Pain management- psychological and pharmacological therapies (pregabalin/gabapentin)
what is Pick’s disease?
a rare type of frontotemporal dementia that presents early (middle aged individual), is familial, and is associated with acute functional decline/poor prognosis. Often involves personality/behaviour changes and language difficulties including aphasia
what are some neurological complications of TBI?
visual changes, particularly diplopia (usually VIth nerve palsy), altered accommodation and hemianopia.
• anosmia (up to 40%)
• high level balance/co-ordination -difficulties/vertigo/dizziness
• high level word finding difficulties, language difficulties
• focal neurological deficits such as hemiparesis/dyspraxia/dysphasia are less common and related to focal trauma in many cases (eg assault with a blunt instrument causing local damage only)
