Week 6 - MH/Neuro/Insomnia Flashcards
Which medication has the strongest recommendation for use for insomnia: trazodone, melatonin, or diphendyramine? (for adults with insomnia)
Tricks! None of them – all of these have weak recommendations against their use.
None of the medications used to treat insomnia have strong evidence either FOR or AGAINST their use – all recommendations are weak either way. Weird huh.
In order for a medication for insomnia to be deemed useful for your patient, how many nights is an acceptable trial of efficacy?
Two nights.
What are some classes of prescription medications that can cause sleep disturbance?
SSRIs, SNRIs, bupropion, alpha blockers, beta blockers, diuretics, stimulants, acetycholinesterase inhibitors, dopamine receptor agonsits, systemic corticosteroids, varenicline.
What are some non-prescription medications and substances that can cause sleep disturbance?
ETOH, caffeine, cannabis (withdrawal), cocaine, decongestants, ephedrine, nicotine and nicotine replacement therapy, laxatives (eeeeee)
What is the maximum dose of zopiclone for adults, and for adults over the age of 65?
7.5 mg max for adults
5 mg for adults over 65 (also for those with renal/hepatic dysfunction or on a strong CYP3A4 inhibitor
What is the starting dose of zopiclone for adults?
3.75 mg
Why did Health Canada decrease max doses of z-drugs?
Because next-day impairment and decreased vehicle control was a thing. You should not drive for TWELVE HOURS after taking zopiclone or eszopiclone. Zolpidem is 8 hours (not sure if this one is available in Canada).
A study found impaired driving equivalent to 3-4 beer, 11 hours after taking 7.5 mg of zopiclone.
Studies have shown that the z-drugs include total sleep time per night by 2.5 hours.
True or false?
False!
30 minutes!
People tend to fall asleep approx 18 minutes faster than without the medication, and awake time after onset of sleep is approx 13 minutes.
Health Canada says the use of z-drugs for sleep disturbance should be limited to how long (duration)?
7-10 days.
Medications for insomnia can have crazy long half-lives, so the sedation effects can be felt the next day for many of them.
Matchy-match:
Zopiclone 12-20 hours
Diphenhydramine 30 hours
Lorazepam 4-11 hours
Amitriptyline 5-9 hours
Trazodone 30-40 hours
Clonazepam 3-9 hours
Zopiclone 4-11 hours
Diphenhydramine 3-9 hours
Lorazepam 12-20 hours
Amitriptyline 30 hours
Trazodone 5-9 hours
Clonazepam 30-40 hours
Diazepam is 24-100 hours, and doxepin is 31 hours! - you can see the cautions needed in the elderly peeps with anticholinergic effects and falls risks.
Doxepin is a TCA that has been rebranded as an insomnia medication that helps reduce waking time through the night by about 20 minutes. It does not help with time it takes to fall asleep.
It has been shown to help with sleep maintenance in older adults only.
What is the initial dose for older adults 65+?
How do meals affect this medication?
Initial recommended dose is 3 mg. Max dose 6 mg.
Onset of effect is delayed if taken within 3 hours of a meal.
To treat insomnia, trazadone is a safer choice than benzos, for older adults with falls risks. True or false?
False! Falls risk = falls risk.
Which classes of medications that are sometimes used to treat primary insomnia increases risk of mortality in older adults?
Atypical antipsychotics. The harms simply outweigh the benefits.
amitriptyline, mirtazapine, quetiapine, olanzapine, risperidone
When are atypical antipsychotics recommended?
To treat comorbid conditions, with caution after weighing risks and benefits.
Lemborexant is an orexin receptor agonist, marketed as Dayvigo. It has similar adverse events as others with some that are specific to this med. Can you name some?
Sleep paralysis
Cataplexy-like s/s (sudden leg weakness)
hallucinations
It has also shown risk of being misused as recreational.
In the PP, they discuss how ol’ Sue really liked this medication in her clinical practice. Jen the presenter said she hasn’t really used it because it is new to Canada (2023).
Important patient teaching if you prescribe lemborexant (Dayvigo)?
ETOH will DOUBLE the concentration of Dayvigo in your system. Abstain!
Guidelines across the world have strong recommendations for which treatment for insomnia?
CBTi - cognitive behavioural therapy for insomnia
Jen recommends free MH resources through Kelty’s Key website - they have CBT insomnia modules.
In terms of addressing medication overuse, Jen Carefoot gives us 4 components to include in your plan when tapering down insomnia medications. What are they?
- Plan a gradual dose reduction strategy with education.
- Identify alternative to managing the underlying health issue (that is causing the overuse). ie pain, mood
- Develop strategies to minimize withdrawal.
- Establish a schedule of follow-ups.
You should use a de-prescribing resource to help you taper down insomnia meds, true or false?
Of course! There is no “one best way” to do it. Call your pharmacist, use online tools, sites etc.
When counseling a patient about when to take zopiclone or eszopiclone, what should you tell them?
Take immediately before bed and only if you plan to get a full night’s sleep (8 hours).
What is normal pressure hydrocephalus (NPH)?
NPH = refers to a condition of pathologically enlarged ventricular size with normal opening pressures on lumbar puncture
a form of communicating hydrocephalus
distinguished from obstructive or noncommunicating hydrocephalus, in which there is a structural blockage of the cerebrospinal fluid (CSF) circulation within the ventricular system
What is the classic triad of symptoms in NPH? Are all o f these required for diagnosis?
dementia, gait disturbance, and urinary incontinence
**Patients need not have all three cardinal features, but gait must be the predominant problem
Is NPH a common cause of dementia?
No - rare condition compared with other causes of dementia in older adults
Who is more likely to get NPH?
Idiopathic NPH increases in prevalence with age and is most common in adults over the age of 60 years
Secondary NPH (those cases associated with an identified etiology) can occur in all age groups
M:F
Etiology of NPH
Idiopathic (50%)
Secondary: SAH, meningitis, trauma, radiation-induced (these inhibit CSF resorption)
What does the gait dysfunction of NPH look like? How is it different from parkinsons?
**Most prominent feature (and required for diagnosis)
move slowly and take small steps, often with a wide base
have difficulty turning (eg, they take several steps to turn 180 or 360 degrees) and are most vulnerable to falls when turning
Postural instability demonstrated by the pull test is often present
parkinsonian gait may bear a resemblance to that of NPH but is distinguished by a narrow base and responsiveness to visual and acoustic cues
What does cognitive impairment in NPH present like?
- slow vs gradual onset
- what kind of features
evolves over months to years and usually develops after the onset of gait dysfunction
Patients typically have both subcortical and frontal features, including:
Psychomotor slowing
Decreased attention and concentration
Impaired executive function
Apathy
Will you see the following in NPH: headaches, N/V, vision loss, papilledema
NO - these are pertinent negatives…these are signs and symptoms related to diffusely increased intracranial pressure (ICP) are will NOT be seen in NPH
Diagnosis of NPH
MRI: Enlarged ventricles without increased prominence of cerebral sulci (can also seen on CT but MRI preferable)
Cognitive evaluation
exclusion of alternative causes of gait dysfunction, both neurologic and non-neurologic
In patients with clinical and MRI features suggestive of NPH, we use a lumbar tap test to help identify patients likely to respond to shunt placement
Treatment of NPH. Does it work for everybody?
Main treatment is ventriculoperitoneal shunt – not everyone responds to this
NPH is potentially reversible by the placement of a VP shunt so it’s key is to identify early!
What are the pathognomonic S&S of parkinsons?
SLOW, STIFF, AND SHAKEY
Bradykinesia/Akinesia, Tremor (resting), Rigidity (lead pipe with or without cogwheeling)
Risk factors for parkinsons
Age
family history
male sex (approximately 1.4:1)
head injury
cerebrovascular disease
rural environments
exposure to certain neurotoxins (pesticides, air pollution, well water)
comorbidities including excess body weight and metabolic syndrome
T2DM
history of melanoma or prostate cancer
Factors that protect against parkinsons?
Smoking, caffeine, exercise, ibuprofen, statins
Very basic summary of the patho of parkinsons?
What kind of movement is decreased/increased?
What causes the cognitive deficits?
The central defect in PD is dopamine depletion from the basal ganglia.
- dopamine depletion and a relative excess of acetylcholine
- decreasing voluntary movement, increasing movement inhibition
Pathogenesis is primarily unknown.
Protein deposits caused from degeneration of dopaminergic neurons accumulate forming Lewy bodies causing neurotoxicity which can lead to dementia and cognitive impairment
In what age is parkinsons most often diagnosed?
Adult-onset. Incidence of disease rises rapidly over 60 years of age, with a mean age of 70.5 years
Monogenetic forms of PD, which account for <10% of cases, have a younger onset.
T/F the progression of parkinsons is preditable
F - Progression of symptoms is highly variable making it not possible to predict future course for a patient at the time of diagnosis
*More rapid if autonomic and cognitive changes are prominent
*More benign course if tremor is presenting symptoms
What kind of prodromal symptoms are known to proceed parkinsons?
Prodromal nonmotor symptoms including sleep disorders, constipation, anxiety/depression, and hyposmia/olfactory dysfunction
can precede motor manifestations by years or decades.
In parkinsons, progression from disease impairment to disability generally occurs between ___ - ____years after diagnosis
3-7
T/F Parkinsons symptoms usually have a bilateral onset
Falsoooooooo. Normally unilateral onset.
Describe the typical tremor of parkinsons
resting tremor. May be intermittent but progress over time
“pill-rolling” tremor of hands common can be uni or bilateral (usually assymetric)
suppressed with initiating movement
Describe the rigidity seen in parkinsons
lead-pipe resistance = passive movement of the joints reveals continuous resistance throughout the entire range of motion
Cogwheel resistance is often present and may reflect tremor incidentally felt while assessing tone.
Cogwheel without lead-pipe does not fulfill minimum requirements for rigidity.
Descirbe the bradykinesia & akinesia/hypokenesia in parkinsons. What characteristic things will you see in the patient’s walk, face, and fine movements?
bradykinesia = slowness of movement AND akinesia/hypokinesia decrease in amplitude or speed (progressive hesitations/halts) as movements continue
- must have limb bradykinesia
- loss of facial expression
- loss of arm swing
- difficulty with fine movements (micrographia)
Other early S&S of parkinsons to do with walking and ADLs?
Hyposmia
Trouble turning in bed
Trouble opening jars
Shuffling gait
Trouble rising from chair
Glabellar tap
Difficulty walking heel-toe
What are the later signs of parkinsons?
**At this point, usually has progressed to bilateral
Postural instability
Cognitive impairment, dementia, psychotic symptoms, depression
Sleep disturbance – daytime hypersomnolence and nocturnal akinesia
Autonomic dysfunction (constipation, orthostatic hypotension, excessive sweating) (O’Toole, 2023)
T/F a brain MRI is key to diagnosing parkinsons.
….How is parkinsons diagnosed?
Falso falso falso!
Neuroimaging is usually nondiagnostic in evaluation of PD. Can be used to rule out alternative disorders or clarify diagnosis when clinical symptoms are atypical.
Diagnosis is based on motor manifestations.
MDS Clinical Diagnostic Criteria – global standard for PD diagnosis:
- Must have parkinsonism – bradykinesia with tremor or rigidity
- Must refer to neurology – motor features and most diagnostic features are determined by appropriate history taking and skilled neuro exam (MDS, 2023).
Neurologists use 3 categories to determine if PD is the cause of parkinsonism:
- Absence of absolute exclusion criteria
- At least 2 supportive criteria
- No red flags
Nonpharm management of parkinsons
Encourage regular exercise to maintain or improve flexibility - very important!!
Encourage diet high in fibre and calcium with adequate fluid intake to help limit complications of constipation and osteoporosis
PT/OT/SLP referrals
What are the first and second liine pharm treatments of parkinsons?
1) Levodopa
2) Dopamine agonists
**Rxflies says DAs can be first line for individuals <70 yo
T/F Drug-induced parkinsonism is reversible
True! But may take 2-6 months after withdrawal of the medication to make the symptoms go away
What drugs have moderate to high risk of drug-induced parkinsonism?
- Typical neuroleptics (e.g. haloperidol, ?pimozide, chlorpromazine,
fluphenazine, perphenazine, prochlorperazine, trifluoperazine,
flupentixol, zuclopenthixol) - Some atypical neuroleptics (e.g. aripiprazole, olanzapine,
paliperidone, risperidone, ziprasidone) - Lithium
- Venlafaxine
- CCBs (amlodipine, diltiazem, verapamil)
- Metoclopramide, prochlorperazine, promethazine
- Phenytoin, levetiracetam, valproate
T/F PD therapies are effective for slowing or stopping brain degeneration / disease progression.
False! Just manage symptoms
What dietary counselling needs to be provided when started levodopa with regard to food that decreases absorption?
What can be done to increase absorption speed of levodopa?
For quicker onset, chew levodopa/carbidopa IR tablets or drink with carbonated beverages to
↑ absorption
protein foods may slow or ↓ absorption
PD: Late or missed doses of medications can result in….
confusion and worsen motor symptom control.
What disorder can result from dopaminergic treatments like levodopa?
Impulse control disorders (gambling, hypersexuality…)
T/F Controlled release (CR) levodopa/carbidopa is preferred to immediate release (IR)
False
Levodopa/carbidopa controlled release (CR) is not superior to immediate-release (IR) formulation. The
overall amount of levodopa absorbed from levodopa CR is ~25-30% less than the IR levodopa.
What is the risk of abrupt withdrawal of antiparkinson meds?
may cause neuroleptic malignant
syndrome or worsening motor symptoms (acute akinesia) that may not recover.
What is levodopa? What does carbidopa do?
Levodopa = a dopamine precursor
Carbidopa decreases peripheral conversion of l-dopa to dopamine - in other words, it prevents the levodopa from being broken down before it reaches the brain
Common side effects of levodopa/carbidopa?
Nausea
Nightmares
Hallucinations
Increased libido
Fluctuations (wearing off)
Dyskinesia (~50%)
T/F: Dopamine agonists can be given in conjunction with levodopa to allow lower dose of levodopa to reduce levodopa associated symptoms.
True!
What other medications can we use for tx of parkinsons?
MAOB inhibitors (rasagiline, selegiline) used for mild motor symptoms (levodopa is better)
Anticholinergics – benztropine, ethopropazine
Beta adrenergics – for postural tremor (O’Toole, 2023).
How frequently is levodopa given for PD treatment?
TID to QID
How should the efficacy of PD treatment be judged?
Use patient and care partner’s overall impression of response since started on levodopa or with adjusted dose and not physical exam findings. Physical exam findings can vary from visit to visit d/t the late time the patient had their medication.
Over time, monitor for motor complications of levodopa therapy including….
motor fluctuations (wearing off), failed doses, involuntary movements (dyskinesia), abnormal cramps and dystonia
Belly’s palsy is a neuropathy of what cranial nerve?
VII - facial
Who gets Bell’s palsy?
Median age of onset 40 years old. Usually seen between 15- 60 years but may occur at any age. Rare in children.
M=F
Risk factors for bell’s palsy
- Previous herpes simplex or herpes zoster infection
- Recent infection
- Diabetes
- Pregnancy (especially 3rd trimester)
- Family history of Bell’s Palsy
- HTN
- Hypothyroidism
Patho of Bell’s palsy
Exact etiology unknown; may be viral, autoimmune, or idiopathic
Often due to inflammation resulting in compression of the facial nerve
T/F In Bell’s, the injury of CNVII will result in symptoms on the contralateral muscles of the face
False - ipsilateral
How fast does Bells come on? How long does it last?
Acute onset, progressing over hours to days
Recovery in 3-4 weeks; may take up to 6 months (faster recovery occurs in mild/ moderate cases)
Complete recovery in 80% of cases; without treatment, 70% of patients with complete and 94% with incomplete paralysis recover facial function in 6 months
S&S of Bell’s
Acute onset of unilateral facial weakness or paralysis (primarily motor deficits)
Impaired forehead wrinkling
Inability to close eye of affected side, drooping of eyelid
Mouth drooping to affected side/ inability to smile
Flattened nasolabial fold
Can be associated with involuntary movements (synkinesis)
Facial paresthesia
Drooling
Decreased tearing or abnormal lacrimation with eating
Hypersensitivity to sound (hyperacusis)
Ear pain
Pain associated with facial palsy
Change in sensation of taste (anterior tongue)
Bilateral is extremely uncommon
When assessing a patient for possible Bell’s palsy, what are some red flags that indicate a different/more serious condition?
Forehead sparing (indicates contralateral UMN lesion)
Focal neurological deficits (Bell’s palsy, by nature, only affects one cranial nerve. Presence of focal neuro deficits suggestive of UMN lesion/ stroke)
Bilateral acute facial weakness (i.e., MS)
Fever/ headache/ stiff neck
Vesicles in ear canal (Ramsay hunt)
Additional cranial neuropathies
Sudden onset of symptoms at max severity (Bell’s occurs over 1-3 days and is progressive)
Worsening beyond 3 weeks
Dx of Bell’s palsy
Clinical diagnosis
CT or MRI only if atypical presentation or physical findings suggestive of central lesion (affecting other cranial nerves, associated with limb weakness or ataxia), progressing paralysis, or lack of resolution
Non-pharm tx of bell’s palsy
Facial physical therapy for muscle weakness (following acute stage)
Eye protection: sunglasses, eye patch, taping eye shut at night (otherwise corneal ulceration and visual impairment can occur)
Heat/ cold for pain
Pharm tx of bell’s palsy
Medical management is first line
Focused on reducing inflammation/ nerve compression
Corticosteroids (ASAP and within 48 hours)
Antivirals can be combined with steroids (severe cases only; antivirals alone show no clinical benefit)
Acetaminophen for pain
Eye drops (i.e., methylcellulose) for lubrication
What the heck is giant cell arteritis? AKA?
= autoimmune condition that causes inflammation in both large and medium sized blood vessels, a process called vasculitis
Most often, it affects the arteries in your head, especially those in your temples. For this reason, giant cell arteritis is sometimes called temporal arteritis
Patho of GCA
Triggering event is not complete understood but is an immune-mediated disease
Medial layer of inflamed arteries are invaded by inflammatory cells.
Vascular remodeling & occlusion: intimal hyperplasia & arterial occlusion resulting in vascular stenoses & occlusion
Risk factors for GCA. What age? What condition is it commonly associated with?
Older adult (almost never happens before age 50)
Most commonly age 70-80
F:M 3:1
Northern European ancestry
Famiily history (genetics)
Commonly associated by polymyalgia rheumatica
Most common S&S of GCA?
New onset headache that is different from previous headaches - doesn’t have classic location
Tender scalp/temples
Jaw pain or tongue pain with chewing that is relieved with rest (aka jaw claudication)
Unexplained fever, weight loss, night sweats and fatigue
Sudden vision loss or double vision
GCA may present with S&S of polymyalgia rheumatica (because it’s often associated). What are these?
Pain and stiffness in the shoulders, neck, upper arms, and hip area.
Flu-like symptoms, including low-grade fever, weakness, loss of appetite, and weight loss.
What physical exam findings might you find in a patient with GCA?
Abnormal pulses (occurs in large vessel disease); diminished pulses and discrepancy in BP in arms
Temporal artery abnormalities: thickened, nodular, tender, erythematous
Decreased or absent temporal artery pulse.
Bruits: carotid, axillary, brachial, femoral, abdominal aorta
Heart murmur (aortic regurg)
Ocular findings on fundoscopic exam
- Cotton wool spots on retina
- Swollen pale disc & blurred margins
- Diplopia associated w/reduced EOM
MSK findings:
- dec in active range of motion of shoulders, neck, hips d/t polymyalgia rheumatica
- Distal synovitis, esp wrists and MCP joints
Diagnosis of GCA?
CBC: Thrombocytosis, Normochromic anemia
ESR & CRP( both high)
Elevated hepatic enzymes (esp alk phos) in 25-30% pt’s
Temporal artery biopsy
Treatment of GCA
high dose corticosteroid to prevent further ischemic complications and improve systemic symptoms
May add tocilizumab or methrotrexate to glucocorticoid therapy (not as fast acting, may require year of treatment)
management of pt’s w/large vessel GCA includes antiplatelet therapy and possible surgical interventions
T/F the vision loss caused by GCA is not dangerous & is easily reversed
False! Can be permanent and requires emergency treatment
T/F GCA increases a person’s risk of stroke or MI
True
What is OSA? (I know this isn’t neuro but wanted to put it alongside central sleep apnea)
-OSA is the periodic reduction (hypopnea) or cessation (apnea) of breathing due to a narrowing or occlusion of the upper airway during sleep
-Characterized by recurrent and reversible obstruction of the pharyngeal airway during sleep
In OSA, thickening of tongue and pharyngeal tissues reduces air passage to the trachea
OSA is associated with poor quality of life and has been linked to severe chronic health conditions such as….
obesity, diabetes, metabolic syndrome, and neuro-psychiatric problems
Moderate–severe OSA is associated with an increased risk of CVD, HTN, CAD, stroke, HF, and atrial fibrillation
Is OSA more likely in men or women?
Men
Who else is more prone to OSA?
Risk factors include (BC Guidelines, 2023):
-Down syndrome
-Mandibular hypoplasia (retrognathia, micrognathia)
-low-lying soft palate (i.e., high Mallampati Score)
-large tongue
-tonsillar hypertrophy
-upper body obesity
-short/wide neck
-older age
-male sex
-smoking
-family hx of snoring or OSA
-East Asian origin
-Parkinson’s disease
-TBI
-nasal and nasopharyngeal obstruction
-neuromuscular disease
-Marfan syndrome
-PCOS
A neck circumference of what for men and women is a risk factor for OSA?
neck circumference >17in for men and >16in for women
(STOPBANG just asks if shirt collar is 16in/40cm or larger)