Questions Flashcards
pathognomic of alzheimers
amyloid plaques and tau proteins
features: pseudodementia
- short duration of dementia
- equal effect on long and short term memory
- amnesia conercing specific events (often emotional)
- loss of social skills
- equal effect on long and short term memory
- loss of social skills in early illness
- patient often answers “i don’t know” to questions as opposed to guessing
- makes little effort in performing tasks
def: pseudoparkinsonism
primarily associated with cognitive defecits in older patietns with depression
def: vascular dementia
syndromes of cognitive impairment caused by cerebrovascular disease
presentation: vascular dementia
progressive stepwise deterioration in cognition usually occuring over months to years
delirium causes mnemonic
Common causes of delirium can be remembered using the mnemonic DELIRIUMS:
D - Drugs and Alcohol (Anti-cholinergics, opiates, anti-convulsants, recreational)
E - Eyes, ears and emotional
L - Low Output state (MI, ARDS, PE, CHF, COPD)
I - Infection
R - Retention (of urine or stool)
I - Ictal
U - Under-hydration/Under-nutrition
M - Metabolic (Electrolyte imbalance, thyroid, wernickes
(S) - Subdural, Sleep deprivation
test for delirium
4AT
pressure ulcer score tool
waterlow score
cognitive impairment screening tool
cognitive impairment
nutrition screening tool
MUST
fitness of elderly scoring tool
rockwood frailty score
oral to subcut morphine ration
2:1
pain medication causing seizures
tramadol
seizure thrashold lowering drugs
- Antibiotics: Imipenem, penicillins, cephalosporins, metronidazole, isoniazid
- Antipsychotics
- Antidepressents: Bupropion, Tricyclics, Venlafaxine
- Tramadol
- Fentanyl
- Ketamine
- Lidocaine
- Lithium
- Antihistamines
med for aggressive patient who has not resolved with de-escalation technique
PO/IM haloperidol
subdural hyperdense unilateral area on CT
subdural haemorrhage
RF: subdural
- advancing age >65
- bleeding disorders or anticoagulant therapy
- chronic alcohol use
- recent trauma
presentation: subdural haemorrhage
- headache
- nausea/vomiting
- confusion
- diminished eye/verbal/motor response
phases of subdural haemorrhage
In the hyperacute phase (<1 hour) the clot may appear as a relatively isodense lesion, with underlying cerebral oedema. Note that patients with a SDH rarely present in the hyper-acute phase.
In the acute phase (<3 days) the classic appearance is of a crescent-shaped homogeneously hyperdense extra-axial collection over the affected hemisphere.
In the sub-acute phase (3 days to 3 weeks) there is organisation of the clot, and the density of the clot falls. The haematoma will therefore appear more isodense compared to the adjacent cortex, making identification more difficult. Contrast-enhanced CT or MRI can aid identification. There may be associated mass effect causing midline shift and sulcal effacement.
In the chronic phase (>3 weeks) the haematoma becomes hypodense relative to the adjacent cortex.
def: subdural haemorrhae
collection of venous blood accumulating in potential space between dura mater and arachnoid mater
dopmaine agonist monitoring
impulsivity
what medication should not be prescribed in parkinsons?
haloperidol
pattern of lewy body dementia
fluctuating worsening condition
def:Lewy body dementia
porgressive, complex and challenging condition caused by abnormal portein called Lewy bodies inside brain cells
clinical features: Lewy bpdy dementia
- characterised by alpha-synuclein cystoplasmic inclusions (lewy bodies) in substantia nigra, paralimbic and neocortical areas
- associated with Parkinsons disease
- highly sensitive to neuroleptics causing seterioration in parkinsonism
*
3 core features: Lewy body dementia
- flucuating cognition
- parkinsonism
- visual hallucinations
scanning:Lewy body dementia
dopamine uptake scanning
Early movement signs: parkinsons
tremor
bradykinesia
rigidity
postural impairment
pathophysiology: parkinsons
- low levels dopamine in basal ganglia (movement structures)
- due to death of dopamine neurons in substantia nigra
hallmark brain sign of parkinsons
<50% domapine neurons in substantia nigra
tx: parkinsons
L-dopa crosses blood brain barrier to synthesise dopamine
effect of L-dopa treatment in parkinsons
- increases dompaine levels to improve movement-related problems
- does not affect neurodegenration of parkinsons
cardinal features: parkinsons
mnemonic TRAP
Tremor
Rigidity
Akenesia (bradykinesia)
Postural instability
cardinal features: parkinsons
mnemonic TRAP
Tremor
Rigidity
Akenesia (bradykinesia)
Postural instability
craiofacial symptoms: parkinsons
- hypomimia
- dysphagia
- hypophonia
- blurred vission and eyelid apraxia
- shuffling, festination and freezing gait
how to test bradykinesia: parkinsons
finger-thumb testing
quaking hand movements
feet stoming
desribe parkinsons tremor
resting
high amplitude, low frequency
RFs: parkinsons
- increased age
- high intake dairy products
- pesticides
- cancer
- traumatic brain injury
gene identified in Parkinsons
LRRK2
protective factors: parkinsons
tobacco
coffee intake (cafffeine)
high uric acid levels
physical activity
diagnosis: parkinsons
badykinesia PLUS at least one of:
tremor, rigidity or postural instability
non-motor signs and symptoms: parkinsons
- olfactory - hyposomia (can preceed motor symptoms couple of years)
- cognitive impairment (memory)
- psychiatric - hallucinations, depression
- autonomic dysfunction - postural hypotension
- pain - shoulder girdle from bradykinesia
- fatigue - usually during day
- sleep disturbance (REM sleep)
- speech- quiet voice
medical initiation treatment: parkinsons
- levodopa and decarboxylase inhibitor
- dopamine agonist
- MAOI
advjuvant treatment: parkinsons
- COMT inhibitor (entacapone - decreases peripheral levodopa breakdown)
- amantadine
- apomorphine
describe parkinsons tremor
- 4-6Hz
- pill rolling
- worse at rest
- asymmetrical
describe parkinsons regidity
lead pipe
cogwheel
describe parkinsons bradkinesia
micrographia
hypomimia
festinating gait
reduced arm swing
tx: parkinsons not impacting life
MAO-B - selegline or dopamine agonist - ropinirole or rotigotine
when is selegiline contraindicated in non-life impacting parkinsons treatment
SSRI
tx: parkinsons symptoms impacting life
levodopa + dopa-decarboxylase inhibitor (carbidopa)
side effects: levodopa and carbidopa in parkinsons
- N+V
- postural BP
- oedema
- confusion
- visual hallucinations
- red urine
- drowsiness
- dyskinesia
- wearing off
- freezinf
what happens in Levodopa dose is missed in parkinsons
neuroleptic malignant syndrome
what is neuroleptic malignant syndrome?
life-threatening neurologic emergency associated with the use of antipsychotic (neuroleptic) agents and characterized by a distinctive clinical syndrome of mental status change, rigidity, fever, and dysautonomia (fast HR, irregular HR and tachypnoea)
what is neuroleptic malignant syndrome?
life-threatening neurologic emergency associated with the use of antipsychotic (neuroleptic) agents and characterized by a distinctive clinical syndrome of mental status change, rigidity, fever, and dysautonomia (fast HR, irregular HR and tachypnoea)
tx: daytime sleepiness parkinsons
medafinil
tx: REM parkinsons
melatonin or clonazepam
tx: orthostatic hypotension parkinsons
fludrocortisone
tx: restless leg syndrome parkinsons
gabapentin
tx: essential tremor
(essential tremor - symmetrical and postural, improves with alcohol)
propranolol
def: essential tremor
symmetrical, postural and improves with alcohol
def: drug induced parkinsonism
bilateral, subacute, postural tremor
causes: drug induced parkinsonism
- antipsychotics
- antiemetics
- valproate
- fluoxetine
- CCBs and
- amiodarone
tx: dopamine psychosis
, olanzapine, quetiapinedrug withdrawal - slowly
reduce stimuli
antipsychotic agents - clozapine
signs of hedonistic dopamine dysregulation syndroem
- OCD - punding (repetitive/mindless behaviours - dimantiling, DIY, collecting, sorting) or walkabout
- Risk behaviour - grandiose business plans
- appetite alterations (weight loss or food cravings)
- hypomania/ psychosis
- gambling
- hypersexuality
Braak’s hypothesis of Parkinsons
stage 1 - changes in dorsal nucleus and olfactory bulb
stage 2 - lewy body formation in pons and medulla
stage 3 and 4 - motor symptoms
stage 5 and 6 - cognitive and dementia signs
4 types of parkinson plus syndromes
- progressive spuranuclear palsy
- mutiple system atrophy
- corticobasal degenration
- lewy body dementia
features: progressive supranuclear palsy parkinson’s plus syndrome
vertical gaze palsy with parkinsonism
features: mustiple system atrophy PPS
postural hypotension, incontinence and impotence plus parkinsonism
features: cortico-basal degeneration PPS
parkinsonism and spontaneous activity or affected limb or akinetic rigidty of limb
features: lewy bosy dementia PPS
parkinsonism plus fluctuations in cognitive impairment and visual hallucinations often before parkinsonism features occur
what can be given instead of haloperidol in parksinsons
lorazepam
drugs to review in elderly (STOPP/START)
- Diuretics
- Antidepressants
- Antipsychotics
- Hypnotics
- Digoxin
- NSAIDs
- Hypotensive agents
- Drugs for Parkinson’s disease
causes of transient incontinence
DIAPPERS
- delirium
- infection
- atrophic urethritis/vaginitis
- pharmaceutical
- psychological
- excessive urinary output
- reduced mobility
- sstool impaction
symptoms: overactive bladder syndrome
- sudden desire to void
- often have nocturia
- frequent, periodic incontinentepisodes (wet OAB)
- may not be incontinent (dryOAB)
how is detrusor overactivity demonstrated
urodynamics
def: reflex urinary incontinence
- sudden loss of control of bladder
- no prior awareness of need to micturate
- neurological problem (MS, parkinsons, brain tumour, spinal cord injuries)
def: stress incontinence
- when standing, physical activity, coughing or laughing causes urine leakage
- usually due to weakness in pelvic floor/sphincter damage
def: urethral obstruction - overflow incontinenec
- common in eldery men
- post void dribbling
*
causes: urethral obstruction
neuro: spinal cord lesions
non-neuro: prostate enlargement, urethral stricture, adrenergic agonist medications, tumours
def: functional incontinence
lower urinary tract intact
poor mobility, poor dexterity, poor cognition
def: mixed incontinence
any incontinence causes in combination
drugs causing incontinence
- diuretics
- anticholinergics - esp haloperidol - cause retention
- opiates - constipation - overflow incontinence
- alcohol and caffeine
- alpha blocks - relax bladder outlet
- alpha agonists - urinary retention causing overflow
examination: incontinence
- functional status
- cognitive status
- neuro
- rectal exam - prostate size
- pelvic exam - cystocele, rectocele, atrophic vaginits
inv: incontinece
- MSSU
- post void residual volume
- uroflowometry
- cystometry
- vaginal cytology
- urodynamics
- U+E, CA, serum glucose
tx: OAB
- bladder training and prompted voiding
- anti-muscarinics - oxybutanin, derifenacin
- mirabegron - beta 3 agonist
tx: stress incontinence
weight loss
treat cough
pelvic floor excercises
duloxetine and oestrogern
surgery
def: stroke
acute neurological event due to cerebrovascular pathology >24hrs
RFs: stroke
- HTN
- smoking
- AF
- DM
- hyperlipiaemia
- anticoagulation
what does ischaemic strokw look like on CT
hypodense
causes: ischaemic stroke
emboli from
AF
infective endocarditis
valve disorder
air embolus
fat embolus
causes: haemorrhagic stroke
sponaneous
aneurysm rupture
SAH
haemorrhagic stroke on CT
hyperdense
management: stroke
- urgent CThead to exclude bleed
- FBC, U+E, ESR, glucose
- BP
- NBM until formal SALT test
- ECG
- echo
- carotid artery dopplers
*
tx: ischaemic stroke
- admit to stroke unit
- alteplase (0.9mg/kg to 90mg max) lysis within 4.5 hours
- thrombectomy within 24 hours
- aspiri 300mg for 2 weeks
- mechanical leg compressors rahter than prophylactic clexane
what should be done before first dose 300mg aspirin after ischaemix stroke
rescan after 24 hours before aspirin dose in case of haemhorrage
tx: haemhorragic stroke
BP control 140-150mmHg
stop and reverse anticaogulants
longterm tx: stroke
atorvastatin 80mg
clopidogrel 75mg
physio
OT
SALT
indication: carotid endarterectomy
if>50% after TIA
what is contraindicatcated 10-14 days post stroke/TIA
anticoagulation
bamford stroke classification
TACS - ALL 3 of 1. unilateral weakness (and/or sensory defecit) of the face, arm and leg 2. homonymous hemianopia 3. higher cerebral dysfunction (dysphasia, visuospatial disorder)
PACS - 2 of the TACS
LACS - one of 1. pure motor, 2. pure sensory, 3. sensori-motor, 4. ataxic hemiparesis
POCS - one of: 1. cranial nerve palsy and contralateral motor/sensory defecit 2. bilateral motor/sensory defecit 3. conjugate eye movement disorder (gaze palsy) 4. cerebellar dysfunction - ataxia, nystagmus or vertigo and 5. isolated homonymous hemianopia or cortical blindness
TACS
TACS - ALL 3 of 1. unilateral weakness (and/or sensory defecit) of the face, arm and leg 2. homonymous hemianopia 3. higher cerebral dysfunction (dysphasia, visuospatial disorder)
PACS
2 of 3 of 1. unilateral weakness (and/or sensory defecit) of the face, arm and leg 2. homonymous hemianopia 3. higher cerebral dysfunction (dysphasia, visuospatial disorder)
LACS
one of 1. pure motor, 2. pure sensory, 3. sensori-motor, 4. ataxic hemiparesis
POCS
one of: 1. cranial nerve palsy and contralateral motor/sensory defecit 2. bilateral motor/sensory defecit 3. conjugate eye movement disorder (gaze palsy) 4. cerebellar dysfunction - ataxia, nystagmus or vertigo and 5. isolated homonymous hemianopia or cortical blindness
scoring tools for risk stratification after stroke
CHA2DS2VASc
CHF
Hypertension
Age >75 2
DM
Stroke 2
Vascular disease
Age 65-74
Sex
HASBLED
Hypertension
Abnormal liver/renal fnx
Stroke
Bleeding tendency
Labile INR
Age >65
Drugs (aspirin or NSAIDs or alcohol)
contraindications: thrombolysis in stroke
- bleed
- seziures at presentation
- HTN >180/100
- NIHSS >25
- LP in past week
- stroke/head injury in past 3 months
- surgery trauma within past 2 weeks
alteplase dosing in stroke
0.9mg/kg upo to 90mg
delirium casues mnemonic
PINCH ME
pain
infection
nutrition
constipation
hydration
medication
environment
screening for delirium
4AT
Rockwood frailty scoring
1 - very fit (fittest for their age)
2 - well (no active disease but less fit than 1 seasonally active
3 - managing well - medical problems well controlled, not regularly active
4 - vulnerable - not dependent for daily things, symptoms limit activities “slowed up”
5 - mildly frail - more evident slowing and need help with high order IADLs - finances, transport, heavy housework etc - shopping and walking outside alone, meal prep and housework impaired
6 - moderatley frail help with all outside activities and keeping house. help with bathing and minimal assistance dressing. problems with stairs
7 - severely frail - completely dependent for personal care (not high risk dying within 6 months)
8 - very severely frail - completely dependent and approaching wend of life - couldn’t recover from minor illness
9 - terminally ill - approaching end oflife - life expectancy <9months
certification of life extinct
- no heart sounds after 3 mins ausc
- no breath sounds
- no respiratory effort
- no central pulse
- pupils fixed and dilated
- no response to stimuli/pain
what scan is used in perkinsons
DaT
def: dementia
gradual decline in 2+ areas of cognition (memory, personality, behaviour) that affects ADLs
screening tool and score for dementia
MMSE 24/30 or less suggestive
Addenbrooks <85 suggests cognitive impair
def: Alzheimer’s dimentia
global, progressive, amnesia, aphasia, agnosia, apraxia, apathy
worse in evening (sundowning)
RFs: alzheimers dimetnia
- HTN
- DM
- FHx
- Doen’s
- brain injury
- female
- > 65yrs
pathophys: alzheimers dimentia
amyloid and tau proteins (plaquesand neurofibrillary tangles) in cortex and hippocampus
tx: alzheimer’s dimentia
acetylcholinesterase inhibitors(donezepil, galantamins, rivastigmine)
memantinein severe
def: vascular dimentia
step-wise, rapid, preserved personality/insight, focal neurology
criteria for vascular dimentia
NINDS-AIREN
RFs: vascular dimentia
IHD, smoking, DM, obesity, Af
causes of vascular dimentia
accumulation of strokes or TIAs
def: Lewy body dementia
fluctuating cognition, lucid periods, visual hallucinations, prkinsonism, lack of REM sleep
pathophys: LB dementia
alpha synuclein ubiquitin aggregation in sustantia nigra
tx: LB dementia
acetylcholinesterase inhibitors
memantine
def: frontotemporal dementia
personality/speech affected first
disinhibited
onset <65yrs
autosomal dominant
pathophys frontotemporal dementia
atrophy of frontotemproal lobes - knife blade appearance (Picks dx
tx: frotnotemporal dementia
none available
def Charles Bonnet syndrome
Charles Bonnet Syndrome presents with visual hallucinations in a patient with bilateral visual loss, typically secondary to glaucoma or cataracts. Importantly, the patient has insight and no other psychiatric or cognitive symptoms.
what abx to avoid in epilepsy
ciprofloxacin
