Module 2 EB Flashcards
(213 cards)
1
Q
-In the geriatric population, how do diseases often present?
-Do all abnormalities require evaluation and treatment?
A
-present atypically or with nonspecific sx
-not all abnormalities require evaluation and treatment
2
Q
-in addition to conventional assessment of symptoms AND diseases, the comprehensive assessment addresses 3 topics for the geriatric population. what are they?
A
-prognosis, values/preference, ability to function independently
3
Q
Assessment of prognosis:
-life expectancy >10y, how should PCP consider tests/treatments for geriatric patient?
-life expectancy <10y, how should PCP consider tests/treatments for geriatric patient?
A
-as you would in young person
-made based on ability to improve patient’s prognosis and quality of life
4
Q
What do most frail older adults prioritize maintaining (in comparison to)?
A
independence over prolonged survival
5
Q
-25% of pt >65syo and 50% of >85yo need help with what?
-Thus, it is important to assess what?
A
-ADLs
-functional screening –> assessment of ADLs/IADLs
6
Q
Dementia:
-def
-dementia is NOT ___________.
A
-progressive decline of intellectual function; loss of short-term memory + 1 other cognitive deficit; deficit severe enough to cause impairment of function
-delirium
7
Q
-agnosia
-aphasia
-apraxia
A
-inability to recognize objects
-word-finding difficulty
-inability to perform motor tasks
8
Q
General considerations for dementia
A
-acquired, persistent, progressive impairment in intellectual function
-compromise of memory + one other cognitive domain:
1. aphasia (words)
2. apraxia (motor tasks)
3. agnosia (recognize)
4. impaired executive function
9
Q
Dementia:
-diagnosis
A
-significant decline in function that is severe enough to interfere with work, social life, performance of routine activities
10
Q
How many of dementia patients have Alzheimer’s?
A
2/3 in US
11
Q
What is the most common concomitant of early dementia?
A
Depression
12
Q
-What is the susceptibility gene associated with dementia?
-is it recommended to be tested?
-if so, what kind of counseling should coincide with this test?
A
-Susceptibility gene associated with late-onset Alzheimer’s disease (APOE-e4)
-NO
-genetic counseling
13
Q
-Lab work for dementia patients
-Lab work not part of routine testing
A
CBC, CMP (serum electrolytes, calcium, Cr, glucose), TSH, vitB12
-not part of routine testing: liver panel, HIV, RPR, heavy metal screen
13
Q
Tools for cognitive impairment
-Mini-cog
-Montreal cognitive assessment (MoCA)
A
-combo of 3-item word recall with a clock drawing task, completed within 3 min; if patient fails, requires further cognitive function evaluation with standardized measurement
-30pt test, takes 10 min, examines several areas of cognitive function. Score <26 = cognitive impairment
14
Q
-How is imaging helpful in dementia patients?
-when is MRI warranted?
A
-rules out subdural hematoma, tumor, previous stroke, hydrocephalus
-younger patients + focal neuro deficits, seizures, gait abnormalities
15
Q
How is delirium distinguished from dementia?
A
delirium is acute in onset, fluctuating coarse, deficits in attention
16
Q
what are medications that cause delirium?
A
anticholinergic, hypnotics, neuroleptics, opioids, NSAIDs, antihistamines, corticosteroids
17
Q
what kind of imaging is used for older patient with classic Alzheimer findings?
A
non-contrast CT
18
Q
when do you refer a dementia patient?
A
refer to neuropsychological testing to distinguish dementia from depression
-dx dementia in those with poor education, aid dx when impairment is mild
19
Q
Dementia: cognitive impairment
-drug class
-use
-drugs
-MOA
A
-acetylcholinesterase inhibitors
-mild-mod Alzheimer disease
-donepezil, galantamine, rivastigmine
-produce modest improvement in cognitive fx that is not likely to be detected in routine clinical encounters
*DOES NOT DELAY FUNCTIONAL DECLINE OR HOSPITALIZATION
20
Q
Dementia: cognitive impairment
-drug used for advanced disease
A
memantine
-N-methyl-D-aspartate (NMDA) antagonist
21
Q
Dementia: behavioral problems
-nonpharmacological approach
A
-rule out delirium, pain, urinary obstruction, fecal impaction FIRST
-determine if caregiver/institutional staff can tolerate behavior
-Keep log describing behavior + antecedents’ events
-use simple language, break down activities into simple component tasks
22
Q
Dementia: behavioral problems
-pharmacological approach
*who is this approach reserved for?
*drug class used?
*drug names
A
-patients who are a danger to others/themselves or symptoms are very distressing to patient
-atypical psychotropics
-risperidone, olanzapine, quetiapine, aripiprazole
23
Q
Dementia: behavioral problems
-pharmacological approach
*medication used to improve symptoms of agitation?
A
citalopram
24
Fragility
-essentials of diagnosis
syndrome characterized by loss of physiologic reserve and dysregulation across multiple systems --> greater risk of poor health outcomes
25
Fragility
-how to diagnose
3+ features must be present:
*weakness, slow gait speed, dec physical activity, weight loss, exhaustion, low energy
26
Fragility
-at risk for?
-treatment
-falls, hospitalizations, functional decline, death, worse outcomes after surgery
-supportive, multifactorial, individualized based on pt goals, life expectancy, co-morbidities, may need palliative care
**Exercise (strength/resistance training) is intervention with the strongest evidence for benefit
27
Immobility
-associated with increased rates of?
-prevention
-most common etiology
-morbidity, hospitalization, disability, mortality
-structured physical activity programs (reduce mobility-related disability)
-hospital-associated bed rest
28
Immobility
-hazards of bedrest in older adults
hazards are multiple, serious, quick to develop, and slow to reverse
29
Falls & Gait Disorders:
-how often do falls occur in >65yo?
-percent of falls that cause serious injury?
-complication from falls
-1/3
-10%
-leading cause of death from injury in person >65yrs (hip fracture common precursor to functional impairment, nursing home placement, death)
30
Falls & Gait Disorders:
-what test helps determine a thorough gait evaluation?
-up and go test
*ask pt to stand up from sitting position without use of hands, walk 10ft, turn around, walk back, sit down: should take <10sec; abnormal if takes >13.5 sec (INCREASED RISK OF FALLS)
31
Falls & Gait Disorders:
-what is the most common/significant reversible cause of falls?
polypharmacy
32
Falls & Gait Disorders:
-what must be considered in any elderly patient presenting with new neuro sx/signs?
*what sx may be absent?
-chronic subdural hematoma
*HA and trauma
33
Depression:
-among which geriatric population has the highest rates for suicide?
-older single men
34
Depression: what questions are highly sensitive for determining depression in geriatric population?
1. during the past 2 weeks, have you felt down, depressed, or hopeless?
2. during the past 2 weeks, have you felt little interest or pleasure in doing things?
35
Depression: what drug is first line?
-SSRI
36
Delirium:
-essentials of diagnosis
-rapid onset
-fluctuating course
-primary deficit in attention rather than memory
-may be hypoactive/hyperactive
-dementia frequently coexists
37
Delirium:
-general considerations
-cause
-risk factors
-acute, fluctuating disturbance of consciousness - change in cognition or development or perceptual disturbances
-pathologic consequence of underlying general condition (infection, coronary ischemia, hypoxemia, metabolic disturbance)
-cognitive impairment; severe illness, polypharmacy, use of psychoactive meds, sensory impairment, depression, alcoholism
38
Delirium:
-delirium assessment tool (and what it requires)
-CAM
*acute onset and fluctuating course
*inattention and either: disorganized thinking or altered level of consciousness
39
Delirium:
-medications known to cause delirium
-sedative/hypnotics, anticholinergics, opioids, benzos, H1/H2 antihistamines
40
Delirium:
-lab work
CBC, BUN, cr, glucose, calcium, albumin, liver panel, UA, ECG (select cases CXR, UDS, lumbar puncture)
41
Delirium:
-do any medications prevent or improve outcomes?
NO
42
Delirium:
-tx
supportive, tx underlying causes, eliminate unnecessary meds, avoid indwelling catheters/restraints
43
Delirium:
-prognosis
-when to admit
-most episodes clear in matter of days after correction of precipitant
-pt w/ delirium of unknown cause
44
Urinary incontinence:
-stress
-urge
-overflow
-leakage of urine upon coughing, sneezing, standing
-urgency and inability to delay urination
-variable presentation; leak or dribble urine because bladder is too full
45
Urinary incontinence:
DIAPPERS
-D: delirium
-I: infection
-A: atrophic urethritis/vaginitis
-P: pharmaceuticals
-P: Psychological factors (depression)
-E: excess urinary output
-R: restricted mobility
-S: stool impaction
46
Urinary incontinence:
-what is one of the most common causes of urinary incontinence?
-pharmaceuticals
*D/C any anticholinergic meds first!
47
Involuntary weight loss:
-what happens to appetite as we age?
-what are the main causes?
-what should be considered if not cause identified?
-reduces
-medical, psychiatric, unknown
-Frailty syndrome should be evaluated
48
Involuntary weight loss:
-what can be used to help?
-oral nutritional supplements of 200-1000kcal/day
-megestrol acetate (appetite stimulant)
49
Pressure injury:
-stage 1
-stage 2
-stage 3
-stage 4
-Unstageable
-Deep tissue
-stage 1: non-blanchable erythema or intact skin
-stage 2: partial-thickness skin loss with exposed dermis
-stage 3: full-thickness loss
-stage 4: full-thickness and tissue loss
-unstageable: obscured full-thickness and tissue loss
-persistent non-blanchable deep red, maroon, purple discoloration
50
Pressure injury:
what is the primary risk factor?
immobility
51
Vision impairment:
-how often should geriatric patients receive eye exams?
complete eye exam by optho annually or biannually!!!
-age-related refractive error "presbyopia", macular degeneration, cataracts, glaucoma, diabetic retinopathy, physical/mental health comorbidities, falls, mobility, impairment, reduced quality of life
52
Hearing impairment:
-those with hearing loss >65yo
-those with hearing loss >85yo
-1/3
-1/2
53
Hearing impairment:
-what test helps determine if hearing impairment?
Whisper test
54
Contributing risk factors to pressure ulcers
-immobility
-reduced sensory perception
-moisture (urinary/fecal incontinence)
-poor nutritional status
-friction/shear forces
55
when is a pressure ulcer unstagable?
-base is covered in slough (yellow, tan, gray, green, brown) or eschar (tan, brown, black)
56
who should be consulted for a pressure injury?
Wound care
57
Elder Mistreatment & Self-Neglect:
-def
-what is the most common form of elder mistreatment?
-actions that cause harm or create a serious risk of harm to an older adult by caregiver or other person who stands in a trust relationship to the older adult, failure by caregiver to satisfy the elder's basic needs or to protect the elder from harm
-self-neglect
58
Epilepsy:
-def
-seizure is a transient disturbance of cerebral function due to an abnormal paroxysmal neuronal discharge in the brain
-if the patient has a readily reversible cause (withdrawal from ETOH/drugs, hypoglycemia, hyperglycemia, uremia) - DO NOT HAVE EPILEPSY
-recurrent unprovoked seizures; characteristic EEG changes + seizures; mental status abnormalities or focal neuro sx persisting for hours postictally
59
Epilepsy: focal onset seizures (also known as partial seizures)
-EEG
-focal motor
-nonmotor
-only a restricted part of 1 cerebral hemisphere has been activated; ictal manifestations depend on area of brain involved
-clonic jerking
-paresthesia, tingling, gustatory, olfactory, visual/auditory sensations
60
Epilepsy: complex partial seizure (also known as focal seizure)
-awareness vs impaired awareness
-knowledge of self or environment, and events occurring during seizure
-impaired awareness may be preceded, accompanied, or followed by various motor/non-motor sx
61
what type of seizure is most common in those with epilepsy?
-focal onset seizures (partial seizures)
62
General Onset Seizures: Motor seizures
-tonic-clonic phase
-sudden LOC
-rigid, falls to ground
-respiration arrested
-tonic phase <1min
-clonic phase (jerking 2-3 min)
-flaccid coma/drift into sleep/further convulsion without recovery (status epilepticus)
63
Generalized onset seizures: motor seizures
-postictal phase
-HA
-disorientation
-confusion
-drowsiness
-nausea
-soreness of muscles
64
Generalized onset seizures: Motor seizures
-myoclonic
single/multiple jerks
65
Generalized onset seizures: motor seizures
-atonic
very brief, <2sec loss of muscle tone = falls
66
Generalized onset seizures: motor seizures
-epileptic spasms
sudden flexion or extension of truncal muscles (infancy)
67
Epilepsy: treatment
-what does the choice of medication depend on?
depends on seizure type
-gradually increase dose until seizures are controlled or SE prevent further increases
-if seizures persist despite max dose, add 2nd medication w/ dose increased until tolerated (gradually withdraw 1st medication)
68
Epilepsy: are medications safe in pregnant women?
NO! Teratogenic!!!
????????????
during pregnancy, if break-through seizure occurs, dose change, another interacting med is added to regiment
69
Epilepsy: how to titrate treatment medications
dose of antiepileptic is increased depending on clinical response regardless of serum drug level
-when dose is achieved (either controls or is max tolerated) - steady state trough drug level may be obtained
70
Epilepsy: what is the most common cause of lower concentration?
suboptimal patient adherence
71
Epilepsy: when can you discontinue seizure medications?
when adult has been seizure free for 2 years
-gradually reduce dose (weeks-months)
-if seizure recurs, reinstitute tx
72
ETOH Withdrawal seizures
-def
-tx
-1 or more generalized tonic-clonic seizures that occur within 48 hours of withdrawal
-benzos
73
Tonic-clonic status epilepticus
-medical emergency?
-most common cause?
-YES, requires airway management
-poor adherence to regimen
74
Epilepsy: etiology
-perinatal injuries (pediatric)
-trauma (any age)
-vascular dx (stroke) = most common cause w/ onset age >=60yo
-genetics
-metabolic (pyridoxine deficiency, -mitochondrial disease) - childhood presentation
-immune (SLE, limbic encephalitis)
-Tumor
-degenerative (Alzheimer's)
-infectious (meningitis, herpes encephalitis, etc.)
75
Epilepsy: diagnostic studies
MRI
EEG
76
Epilepsy:
-when is lumbar puncture necessary?
-S/S
-with any sign of infection present or in evaluation of new-onset seizures in acute setting
-HA, mood alterations, lethargy, myoclonic jerking; aura
77
Dysautonomia
-essentials of dx
-etiology
-postural hypotension or abnormal heart rate regulation; abnormalities of sweating, intestinal motility, sexual function, sphincter control; syncope may occur; symptoms occur in isolation or any combo
-pathological processes in central/peripheral nervous system - manifested by variety of sx (abnormal bp, thermoregulatory sweating, GI function, sphincter/sexual function, respiration, ocular function)
78
Dysautonomia
-CNS causes
-Postural hypotension: spinal cord transection; myelopathies (tumor) above the t6 level, brainstem lesions (syringobulbia/posterior fossa tumors); sphincter/sexual disturbances
**primary degenerative disorders: parkinsonism, pyramidal sx, cerebellar deficits
79
Epilepsy:
-causes in PNS
*pure autonomic neuropathy
*GBS
*Metabolic disturbance
-Pure autonomic neuropathy: viral infection; paraneoplastic disorder r/t small cell lung cs
-marked hypo/hypertension, cardiac arrhythmias
-diabetic, uremic, amyloidotic; leprosy, changas disease
80
Epilepsy:
-what determines the extent and severity of autonomic dysfunction?
evaluation of the patient
+ presence of associated neurological s/s
81
Dysautonomia:
-S/S
-syncope
-postural hypotension
-paroxysmal HTN
-persistent tachycardia without other cause
-facial flushing
-hypohidrosis/hyperhidrosis
-vomiting
-constipation
-diarrhea
-dysphagia
-abd distention
-disturbances of micturition/defecation
-erectile dysfunction
-apneic episodes
-declining night vision
82
Dysautonomia: syncope
-is recovery rapid or slow?
recovery is rapid once patient is recumbent; headache, nausea, fatigue are COMMON
83
Dysautonomia: treatment
-avoid?
-supportive tx
-abrupt postural change, prolonged recumbency
-wear waist-high elastic hosiery, salt supplementation, sleeping in semierect position
84
TIA:
-acute or chronic onset?
-does clinical deficit resolve completely? if so, how long?
-risk factors
-acute
-resolves completely within 24 hrs
-vascular disease (present)
85
TIA:
-characterized by?
-30% of patients have a ________ within 90d
-when is the risk of stroke high following TIA?
-focal ischemic cerebral neuro deficits, lasting for <24 hours (usually 1-2 hours)
-stroke
-3 months; >60yo, DM, TIA lasting >10m with residual focal neuro deficits
86
Stroke:
-risk factors
-distinctive neuro signs reflect what?
-HTN, DM, tobacco use, a-fib, atherosclerosis
-region of brain involved
87
what is the 5th leading cause of death?
what is the leading cause of disability?
STROKE
STROKE
88
TIA:
-LOC?
-confusion?
-sx
-rarely
-rarely
-depends on arterial distribution affected
89
TIA:
-imaging
-CT/MRI: indicated within 24 hours of sx onset
-MRI w/ diffusion weighted sequences reveals acute or subacute infarction (wake-up strokes)
90
TIA:
-treatment goal
-tx
-prevent future attacks + stroke
-supportive tx
91
Stroke:
-essentials of dx
sudden onset of neurologic deficit of cerebrovascular origin
92
Stroke:
-types of stroke?
ischemic
heomrrhagic
93
Stroke:
-types of ischemic stroke
-types of hemorrhagic stroke
-lacunar infarct; carotid circulation obstruction
-spontaneous intracerebral hemorrhage; subarachnoid hemorrhage
94
Stroke:
-secondary tx for ischemic stroke
Antiplatelet
95
-what imaging type is used to dx lacunar infarct?
-what imaging type is used to dx carotid circulation obstruction?
-MRI w/ diffusion-weighted sequences (CT is insensitive acutely)
-Noncontrast CT (exclude hemorrhage); diffusion-weighted MRI is gold standard
96
-what imaging type is used in dx of spontaneous intracerebral hemorrhage?
-what type of imaging is used to dx subarachnoid hemorrhage?
-Noncontrast CT (superior to MRI for detecting bleeds of <48 hours duration); do not perform LP!!
-CT: confirm dx; if CT negative and suspicion high, perform LP. Angiography: used to determine source of bleed in candidates for tx
97
Essential Familial Tremor
-family hx?
-how does ETOH effect it?
-any other abnormal findings?
-cause
-yes, common
-improves temporarily
-no abnormal findings
-uncertain; sometimes inherited (autosomal dominant manner)
98
Essential Familial Tremor
-tx
-when to refer
-often unnecessary; propranolol 60-240mg PO daily; primidone if propranolol is ineffective; botox
-1st line tx with propranolol or primidone refractory; additional neuro signs present
99
Essential Familial Tremor
-S/S
*onset
*tremor presentation
*physical exam
*prognosis
-any age; enhanced by emotional stress
-involves one or both hands, head, or hands + head (legs are spared); TREMOR WITH ACTION, NOT PRESENT AT REST!!!
-no other abnormalities noted
-little disability
100
Parkinson Disease:
-essentials of dx
-any combination of tremor, rigidity, bradykinesia, progressive postural instability
-cognitive impairment (sometimes prominent)
-occurs in all ethnic groups
101
Parkinson Disease:
-onset
-progressive or static?
-45-65 years
-progressive
102
Parkinson Disease:
-etiology
-dopamine depletion due to degeneration of dopaminergic nigrostriatal system leads to imbalance of dopamine and acetylcholine (NTs normally present in corpus striatum)
103
Parkinson Disease:
-tx of motor disturbance
-what is associated with decreased risk of developing Parkinson disease?
-risk factors
-blocking effect of acetylcholine with anticholinergic med or administration of levodopa (precursor of dopamine)
-ibuprofen
-age, family hx, male sex, ongoing herbicide/pesticide exposure, significant prior head trauma
104
Parkinson Disease:
-cardinal motor features
-non-motor features
-tremor, rigidity, bradykinesia, postural instability
-depression, anxiety, apathy, cognitive changes, fatigue, sleep disorders, anosmia, autonomic disturbances, sensory complaints or pain, seborrheic dermatitis
**TREMOR AT REST IS ENHANCED BY EMOTIONAL STRESS AND LESS SEVERE WITH VOLUNTARY ACTIVITY
105
Parkinson Disease:
-tremor characteristics
-what is dx based on?
-confined to 1 limb or limbs on 1 side for months - years before becoming generalized
-clinical exam: relatively immobile face with widening palpebral fissures, infrequent blinking, fixity of facial expression
106
Parkinson Disease:
-impact on muscle strength
-impact on DTRs
-no muscle weakness or altered DTRs
107
Parkinson Disease:
-treatment
-amantadine
-levadopa
-sinemet
-anticholinergic meds (aid in alleviating tremor/rigidity - poorly tolerated in older adult)
-antipsychotics (can be d/t dopa therapy or underlying illness; clozapine and quetiapine)
-rivastigmine (cognitive impairment/psychiatric sx)
108
Huntington Disease:
-essentials of dx
*gradual or acute onset?
*what sx progress?
*family hx?
*responsible gene ID's on chromosome _____?
-gradual onset
-progression of chorea and dementia or behavioral change
-family hx
-4
109
Huntington Disease:
-characterized by?
-imaging
-chorea and dementia
-CT scan/MRI; PET
110
Huntington Disease: S/S
-onset
-timeline of disease (how many years)
-genetic counseling?
-30-50 years
-15-20 years
-offer to offspring
111
Huntington Disease:
-treatment
*can progression be halted?
*is there a cure?
*meds to tx
-no
-no cure
-Tetrabenazine; deutetrabenazine, amantadine, deep brain stimulation, phenothiazines haloperidol, quetiapine, clozapine
112
RLS:
-essentials of dx
*common?
*what can cause RLS?
-common
-idiopathic OR r/t Parkinson's disease, pregnancy, IDA, peripheral neuropathy
113
RLS:
-def
-onset
-complications
-restlessness and curious sensory disturbances lead to an irresistible urge to move the limbs (esp during periods of relaxation); movement of limbs provides relief
-occurs exclusively in the evening and at night; worse at night (flexion at ankle, knee and hip)
-disturbed nocturnal sleep + excessive daytime somnolence
114
RLS:
-what labs should always be measured?
-tx
-ferritin level
-low iron = PO oral iron sulfate
-physical sx: pramipexole, ropinirole or rotigotine
-improve sx: gabapentin, pregabalin
-unresponsive to normal meds: levodopa
115
Dementia:
-acute or progressive?
-is this related to delirium?
-is this related to psychiatric disease?
-main risk factor
-more common in women or men?
-onset?
-progressive
-no
-no
-AGE (2nd), family hx (3rd)
-women
->60yr
116
Dementia:
-progressive decline in intellectual function impacts what?
-how to promote cognitive reserve?
-social and occupational functioning
-increased physical activity, education, ongoing intellectual stimulation, social engagement
117
pathology: plaques containing beta-amyloid peptide, and neurofibrillary tangles containing tau protein, occur throughout the neocortex
-Alzheimer? Vascular dementia? Dementia with Lewy Bodies? Frontotemporal dementia (FTD)?
Alzheimer's disease
118
Pathology: multifocal ischemic change
-Alzheimer? Vascular dementia? Dementia with Lewy Bodies? Frontotemporal dementia (FTD)?
Vascular dementia
119
Pathology: histologically indistinguishable from Parkinson disease: alpha-synuclein-containing Lewy bodies occur in the brainstem, midbrain, olfactory bulb, and neocortex.
*what disease pathology may coexist?
-Alzheimer? Vascular dementia? Dementia with Lewy Bodies? Frontotemporal dementia (FTD)?
Dementia with Lewy bodies
-Alzheimer's disease
120
Pathology: neuropathology is variable and defined by the protein found in intraneuronal aggregates. Tau protein, TAR DNA-binding protein 43 (TDP-43), or fused-in-sarcoma (FUS) protein account for most cases
-Alzheimer? Vascular dementia? Dementia with Lewy Bodies? Frontotemporal dementia (FTD)?
Frontotemporal dementia (FTD)
121
Dementia:
-types of neuropsych assessments?
-Folstein mini mental state exam (MMSE)
-Montreal cognitive assessment (MoCA)
-Mini-Cog: insensitive to mild cognitive impairment or do not correlate with functional capacity
122
Dementia:
-imaging
-MRI/CT without contrast
*goal to exclude cerebrovascular disease, tumor, other identifiable structural abnormality
-PET: sensitive to amyloid pathology - positive evidence for Alzheimer disease in pt w/ cognitive decline
123
Dementia:
-tx
*non-pharmacologic
-no cure
*aerobic exercise 45m/day
*frequent mental stimulation
*maintain an active role in family/community
*vitamin E (does not affect cognition or prevent development of Alzheimer's disease in pt with mild cognitive impairment)
124
Dementia:
-tx
*how to treat cognitive sx
-cholinesterase inhibitors - first line therapy for Alzheimer's disease + dementia with Lewy bodies
*does not prevent progression
*Donepezil, rivastigmine, galantamine
*memantine: tx of mod-severe Alzheimer's disease
125
Dementia:
-labs
-mood/behavioral disturbances
-vitB12/free T4/TSH; RPR/HIV; CBC, electrolytes, glucose, lipid)
-SSRIs, citalopram (agitation) - can cause prolonged QTc
-trazadone: treats insomnia
126
Dementia:
-what medications to avoid in tx
-paroxetine/TCAs - anticholinergic
-avoid OTC antihistamines/benzos - worsen cognition, cause delirium
127
MS:
-essentials of dx
*can a single pathologic lesion explain clinical findings?
*how to diagnose?
-no, single pathologic lesion cannot explain clinical findings
-MRI - multiple foci
128
MS:
-greatest incidence among what population?
-patho
-young patient of western Europeans who live in temperate zones
-focal, perivenular areas of demyelination with reactive gliosis scattered in white matter of brain/spinal cord/optic nerves + axonal damage
129
MS:
-imaging
-labs
-dx
-MRI brain/cervical cord
-used to exclude infections, connective tissue diseases (SLE, Sjogrens), sarcoidosis, metabolic disorders (vitB12 def), lymphoma
-McDonald criteria: only dx if 2 + different regions of central white matter have been affected at different times.
130
-MS:
-do pts have residual deficits?
-what is the most common form of the disease?
-yes
-relapsing-remitting
131
MS:
-tx
-corticosteroids
-many drugs; choose initial agent based on tolerance, risks, pt preference, disease severity
132
MS:
-glatiramer acetate/interferon
-ocrelizumab
-initial med
-only med effective in SLOWING DISABILITY PROGRESSION IN PRIMARY PROGRESSIVE MS
133
Acute idiopathic polyneuropathy (GBS)
-essentials of dx
*acute or subacute?
*is weakness or sensory impairment more severe?
*triggers
-subacute or acute
-weakness
-infective illness, inoculations, surgical procedures (campylobacter jejuni enteritis; immunologic basis)
134
Acute idiopathic polyneuropathy (GBS):
-labs
-main complaint
-where do S/S begin in the body?
-CSF fluid (LP): high protein concentration + normal cell count; WBC > 50cells = consider alternative dx
-weakness that varies widely in severity; proximal emphasis + symmetric distribution
-begins in legs, spreads and frequently involves arms/both sides of face
135
Acute idiopathic polyneuropathy (GBS):
-tx
-plasmapharesis
-IVIG x5days
136
Bells Palsy:
-essentials of dx
*sudden or progressive onset?
*what other symptoms may occur?
-sudden
-hyperacusis or impaired taste may occur
137
Bells Palsy:
-cause?
-triggers
-more common in what population?
-idiopathic; inflammatory rx involving facial nerve
-herpes simplex; varicella zoster virus infection
-pregnant women and DM pts
138
Bells Palsy:
-imaging?
-S/S
-none
-facial paresis, facial pain, ipsilateral restriction of eye closure, disturbance of taste, hard to eat/drink
139
Bells Palsy:
-TX
60% recover completely w/o treatment
-Corticosteroids (prednisone 60mg PO daily x5days) = increases change of complete recovery at 9-12 MO
-Acyclovir/valacyclovir: only indicated when there is evidence of herpetic vesicles in external ear canal
140
Myasthenia Gravis:
-essentials of dx
*do patients feel weak or strong?
*what kind of muscles are impacted?
*what sx are produced?
*does activity help with sx or worsen them?
-weak
-voluntary muscles
-diplopia, ptosis, difficulty swallowing
-activity increases weakness of affected muscles
141
Myasthenia Gravis:
-what medications transiently improve weakness?
-what ages impacted?
-what population is most impacted?
-onset is progressive or acute?
-short-acting anticholinesterases
-all ages
-young women w/ HLA-DR3
-progressive (insidious)
142
Myasthenia Gravis:
-when do exacerbations occur?
-patho
-menstrual period, during/shortly after pregnancy
-variable degree of block of neuromuscular transmission caused by autoantibodies binding to acetylcholine receptors (reducing # of functioning acetylcholine receptors)
143
Myasthenia Gravis:
-labs (what lab is used to dx)
-S/S
-acetylcholine receptor antibodies assay --> elevated, use to dx MG
-ptosis, diplopia, difficulty chewing/swallowing, resp difficulties, limb weakness
144
Myasthenia Gravis:
-characteristics of weakness experienced by these patients
-findings from clinical exam for dx
-remain localized to few muscle groups or become generalized
-ocular palsies and ptosis (asymmetric), normal pupillary response, sustained activity of affected muscles increases the weakness, improves after brief rest; sensation is normal, no reflex changes
145
Myasthenia Gravis:
-tx
-what kind of surgery can help?
-anticholinesterase meds (neostigmine, pyridostigmine)
-corticosteroid prednisone 20mg PO daily, inc by 10mg increments
-IVIG/plasmapheresis (hosp pts.)
-thymectomy (perform when thymoma is present; consider in ALL patients)
146
Palliative care
-goal of care?
-what does palliative care manage?
-def
-addresses and treats sx, supports patients' families, helps ensure that care aligns wit patients' preferences, values, goals
-physical sx (pain, dyspnea, N/V, constipation, delirium, agitation), emotional distress, existential distress (spiritual crisis)
-interdisciplinary team of experts
147
Palliation of Common Nonpain Sx:
-dyspnea
*def
*characterized by?
*Tx
-subjective experience of difficulty breathing
-tightness in chest, SOB, breathlessness, feeling of suffocation
-directed at cause (opioids - single best class of meds for dyspnea)
IR morphine (PO or IV)
SR Morphine: ongoing dyspnea
Supplemental O2
Benzos
148
Palliation of Common Nonpain Sx:
-N/V
*what is the best modality to manage with medication?
*helpful treatments
*optimize sx control by regular dosing and multiple meds
*Nasogastric suction
-metoclopramide (partial gastric outlet obstruction)
-transdermal scopolamine (reduce peristalsis, cramping pain)
-Ranitidine (reduce gastric secretions)
*vomiting due to disturbance of vestibular apparatus: anticholinergic/antihistaminic agents (Benadryl, scopolamine)
-benzos: effective in preventing anticipatory nausea associated w/ chemo
149
Palliation of Common Nonpain Sx:
-delirium and agitation
*sx
*tx
*neuroepileptic agents
-waxing/waning LOC + change in cognition that develops over short time; terminal restlessness
-reversible causes: urinary retention, constipation, anticholinergic meds, pain
-haloperidol, risperidone
150
Palliation of Common Nonpain Sx:
-constipation
*triggers
*ask about...?
*prevention
*prophylactic bowel regimen
-frequent use of opioids, poor dietary intake, physical inactivity, lack of privacy
-difficulty with hard or infrequent stools
-increase activity, intake of fluids, provide privacy, undisturbed toilet time, bedside commode (rather than bedpan)
-stimulant laxative (senna or bisacodyl) should be started when opioid treatment is begun
*Naloxegol/libiprostone: FDA approved to treat opioid-induced constipation in patients w/ chronic non-cancer pain
151
Palliation of Common Nonpain Sx:
-fatigue
*what is the most common complaint of cancer patient?
*contributing factors to fatigue
*coexisting factors
*psychostimulants
-fatigue
-anemia, hypothyroidism, hypogonadism, cognitive/functional impairment, malnutrition
-pain and depression
-methylphenidate (AM, afternoon), modafinil (cancer-related fatigue)
152
Pain Management:
-acute pain
*when does it resolve?
*management
*what tool is used to guide #-needed-to-treat-for-specific doses of various meds?
-within the expected period of healing (self-limited)
-depends on type (somatic, visceral, neuropathic); acute pain that is NOT ADEQUATLEY treated develops into chronic pain
-Oxford League Table of Analgesics
153
Pain Management:
-acute pain
*what meds are used most helpful for acute pain?
*what are the SE of these meds?
*other medication options to manage acute pain?
-NSAIDs or COX inhibitors; PO, IM, IV, intranasal, rectal
-gastritis, kidney dysfunction, bleeding, HTN, MI/stroke
*ketorolac
-acetaminophen - most widely used and best tolerated; opioids (morphine/fentanyl)
154
Pain Management:
-chronic pain
*def
*what kind of management does this type of pain require?
*Does best practice support use of prolonged opioid therapy for chronic low back pain?
-persists beyond expected period of healing; itself is a disease state (>3-6MO)
-Interdisciplinary management
-NO
155
Pain Management:
-Cancer pain
*is cancer pain more acute or chronic?
*what is a complication (related to pain) from chemotherapy?
*what is a complication (related to pain) from radiation?
*what is a complication (related to pain) from surgery?
*WHO Analgesic Ladder (1986)
-Acute AND chronic pain
-peripheral neuropathies
-Neuritis or skin allodynia
-persistent postsurgical pain syndromes (post-mastectomy or post-thoracotomy pain syndromes)
-start tx with nonopioid analgesics, then weak opioid agonist, followed by strong opioid agonist
156
Pain Management:
-Pain at end of life
*pain management may take priority over promoting ________ _________.
*tx for ongoing cancer pain
*according to CDC, FDA, and US supreme court, what is the responsibility of the clinician in regard to seriously or terminally ill patients?
*restorative function
*long-acting opioid analgesic can be given around the clock + short-acting opioid medication PRN "breakthrough" pain
*appropriate treatment of pain
157
Pharmacologic pain management strategies:
-Non-opioid
-acetaminophen (no risk of GI bleed)
*500-1000mg q6hr
-aspirin
*325-650mg/4hr
*do not use in children/teens due to risk of bleeding, allergy, association with reye syndrome
-NSAIDs (can use PPI for GI bleeding prevention)
-Celecoxib (use in caution with: fluid retention, kidney injury, HF exacerbations)
158
Pharmacologic pain management strategies:
-Opioids
*Full opioid agonists
*Short-acting formulations
*IR fentanyl patch
*Buprenorphine
-hydrocodone and codeine (typically combined with Tylenol or NSAID)
-oral morphine sulfate, hydromorphone or oxycodone
-cancer pain tx that breaks through long-acting meds or administered before activity known to cause more pain
-short-acting analgesic reserved for pain management specialists
159
Pharmacologic pain management strategies:
-opioids
*methadone
*Buprenorphine
*common SE of opioids
-long-acting opioid, inexpensive; higher methadone doses = risk of prolonged QT (need baseline ECG)
-moderate to severe chronic pain
-tolerance, dependance, addiction
160
Pharmacologic pain management strategies:
-neuropathic pian "burning, shooting, pins/needles, electricity"
*gabapentin/pregabalin
*SSRIs
*Tricyclics
*1st line treatment; can cause dizziness, ataxia, GI upset
*duloxetine (Cymbalta), venlafaxine; take on full stomach
*nortriptyline, desipramine
161
Common emergencies:
-cough
*when to get chest Xray
*patho
*what does an effective cough depend on?
-unexplained cough >3-6 weeks
-stimulation of mechanical/chemical afferent nerve receptors in bronchial trees
-depends on intact afferent-efferent reflex arc, adequate expiratory/chest wall muscle strength, normal mucocilliary production and clearance
162
what is the most common sx patients seek care for?
Cough
163
what sx would indicate pneumonia?
acute cough + tachycardia, tachypnea, fever
164
what does wheezing and rhonchi indicate?
bronchitis
165
Differentials for persistent cough
chronic sinusitis, postnasal drip, asthma
166
what would be indicated with sx of cough + dyspnea + JVD?
HF
167
What dx would be indicated with airspace consolidation (rales, dec breath sounds, fremitus, egophony)
CAP
168
Cough:
-Acute
-persistent
-subacute
-chronic
<3 weeks
3-8 weeks
postinfectious cough 3-8 weeks
>8 weeks
169
Cough: acute
-what confirms diagnosis?
-adults with acute cough, abnormal VS, abnormal CXR suggests what?
*what could C-reactive protein be?
-tx
-fever, nasal congestion, sore through
-pneumonia
*>30 (improves dx accuracy)
-target underlying etiology of illness, cough reflex, exacerbating factors of cough
170
Cough: acute
-influenza tx
-Chlamydophila/mycoplasma tx
-bronchitis + wheezing tx
-acute cough + accompanying postnasal drip tx
-PO oseltamivir/zanamivir (initiate w/i 30-48 hours of illness onset)
-erythromycin/doxy
-inhaled beta 2 agonist
-antihistamines, decongestants, nasal corticosteroids
171
Cough:
-when to refer
failure to control cough; recurrent sx referred to otolaryngologist, pulmonologist, gastroenterologist
172
Cough: persistent/chronic cough
-when should a cough resolve?
-what should be considered when cough lasts more than 3 weeks (in adults/teens)?
-what are most cases of persistent/chronic cough due to?
-what imaging should be used if ACE-I related and postinfectious cough are excluded?
-how to treat pertussis
-by 3 weeks
-pertussis
-postnasal drip, asthma, GERD
-macrolide antibiotic (early ID, revaccinate with Tdap, tx pts who work or live with high risk persons (pregnant, infant <1 year, immunosuppressed)
173
Postnasal drip
-step 1 (empiric therapy)
-step 2 (definitive testing)
-therapy for allergy or chronic sinusitis
-sinus CT scan; ENT referral
174
Asthma
-Step 1 (empiric therapy)
-step 2 (definitive testing)
-beta-2-agonist
-spirometry: consider methacholine challenge if normal
175
GERD
-step 1 (empiric therapy)
-step 2 (definitive testing)
-lifestyle and diet modification with or without proton pump inhibitors
-esophageal pH monitoring
176
Dyspnea
-def
-diagnostic studies of pneumonia
-diagnostic studies of HF
-diagnostic studies of PE
-subjective experience or perception of uncomfortable breathing
-CXR + elevated procalcitonin/CRP
-low procalcitonin, CXR (new onset CHF), proBNP
-tachycardia + hypoxemia + normal CXR/ECG = obtain spiral CT scan
177
Dyspnea
-tx
immediately provide supplemental O2
178
-Heat stroke hallmark sx
-what type of thermometer can you use?
-is core body temp elevated in heat cramps or heat exhaustion?
-are oral salt tabs recommended tx for heat cramps?
-do antipyretics have effect on environmentally induced hyperthermia?
-cerebral dysfunction with core body temp over 40C
-internal rectal, foley, esophageal
-heat exhaustion
-NO, need electrolytes
-NO
179
Accidental Systemic Hypothermia:
-what is core body temp below?
-at what temp does core body need to be at to terminate resuscitation efforts?
-what should hypothermic patient be evaluated for?
-below 35C
-above 32C
-hypoglycemia, trauma, infection, overdose, peripheral cold injury
180
Accidental Systemic Hypothermia:
-Stage I
-Stage II
-Stage III
-Stage IV
-core body temp between 32-35C; shivering, normal LOC, hemodynamically stable
-core body temp between 28-32C; shivering stops, bradycardia, confusion, J wave or Osborn wave on ECG
*will cardiac arrest if core body temp <28C
-Core body temp between 24-28C; loss of consciousness but present VS
-Core body temp <24C; loss of VS; coma, loss of reflexes, asystole, or v-fib
*can reverse even at this stage
181
do NP's treat hypothermia?
NO, refer to ED.
182
Frostbite
-when to refer?
-what to avoid
-method of rewarming
-ALWAYS
-secondary exposure to cold; hypovolemia and to improve perfusion (provide PO and IV hydration)
-warm bath immersion (immersed for several min in moving water bath heated to 40-42C until the distal tip of the part being thawed flushes
183
Thermal Burns:
-palm of hand constitutes what percent of body surface area in adults (TBSA)?
-1st degree burn Superficial burns
-2nd degree burn Superficial partial-thickness.
-Deep partial-thickness
-3rd degree burn (full-thickness)
-1%
-superficial burn: red, gray, excellent cap refill; not blistered initially
-superficial partial-thickness burn: blistered, appears pink and wet
-appears white and wet, bleed if poked; maintains cutaneous sensation
-loss of adnexal structures; appear white/yellow in color; may have black charred appearance that's still, dry skin dose NOT bleed when poked (lost cutaneous sensation)
184
Rule of 9's
Entire arm 9%
Posterior surface of each leg 9%
Entire head and neck 9%
Posterior surface of upper trunk (9%)
185
Neurological Disorders: Acute headache
-imaging used for acute headache
-follow-up initial imaging with what? what is the purpose?
-CT without contrast: excludes intracranial hemorrhage, intracranial mass
-LP; excludes infectious causes of HA
186
Neurological Disorders: Acute headache
-sx of meningeal inflammation?
-if patient is older than 60YO with severe headache, what should you examine?
-in the physical exam, what are crucial assessment pieces?
-which type of exam should be completed?
-fever + acute HA: meningeal inflammation (Kernig/Brudzinski signs; absence of jolt accentuation of HA cannot accurately rule out meningitis - need LP)
-scalp or temporal artery tenderness
-careful assessment of visual acuity, ocular gaze, visual fields, pupillary defects, optic disks < and retinal vein pulsations
-complete neuro exam; if any abnormality, need emergency neuroimaging.
187
Pieces of a neuro exam
-mental status
-motor/sensory systems
-reflexes
-gait
-cerebellar function
-pronator drift
188
OTTAWA SAH Clinical Decision Rule
-100% sensitivity in predicting SAH
-use on pt seeking care in ED c/o acute nontraumatic HA
-need to have one or more of the following (6):
-40 years or older
-neck pain/stiffness
-Witnessed LOC
-Onset during exertion
-Thunderclap headache (instantly peaking pain)
-Limited neck flexion (on exam)
189
Make sure to consider these differential diagnoses with acute headache:
-imminent or completed vascular events
-infections
-intracranial masses
-preeclampsia
-carbon monoxide poisoning
190
Treatment for migraine headaches
*and what should you avoid as first line therapy?
-NSAIDs
-metoclopramide
-dihydroergotamine
-triptans (PO, nasal, subQ)
*morphine/hydromorphone as first line therapy
191
What medication can be used for chronic migraine treatment when unresponsive to other therapy?
Ketamine infusions
192
Migraines
-how long do they usually last?
-what is a main characteristic of migraine headaches?
-is pain generalized or unilateral?
-what aggravates migraines?
-sx
-does an aura precede migraine HA?
-4-72hr
-pulsatile
-unilateral
-routine physical activity
-nausea, vomiting, photophobia, phonophobia.
-Commonly visual, may precede migraine but not always
193
Medication treatment of Migraine headaches
-symptomatic therapy (acute attack)
*ergotamines
*triptans
*other agents
*Neuromodulation
-Cafergot (ergotamine tartrate + caffeine); do not take when pregnant, CV disease or RF, pts taking potent CYP3A4 inhibitors
-Sumatriptan - helps abort attacks; eletriptan (immediate therapy); frovatriptan (long-half-life)
*greater benefit when combined with Naproxen
-chlorpromazine, butalbital-containing combo meds, opioid analgesics (can cause rebound HA)
194
Medication treatment of Migraine headaches
-preventative therapy (2)
-Acupuncture
-Botulinum toxin Type A
195
Medication treatment of Migraine headaches
-prophylactic treatment of migraine
-antiepileptic
-cardiovascular (guanfacine, propranolol, verapamil))
-antidepressant (Amitriptyline, venlafaxine)
-other: acupuncture, botulinum toxin A, riboflavin (changes urine color)
196
Tension-Type Headache
-sx
-location
-exacerbated
-tx
-precranial tenderness, poor concentration, other non-specific sx + constant daily HA that are described as "vist-like or tight" in quality; not pulsatile or associated with focal neuro sx
-most intense at neck or back of head; can be generalized
-stress, fatigue, noise or glare
-NO triptans; address comorbid anxiety or depression; similar to migraine tx
197
what is the most common type of primary headache disorder?
Tension-type HA
198
What type of HA can you not use Triptans to treat?
Tension-type headache
199
Cluster HA
-most prevalent in what population?
-family hx of headaches or migraines?
-sx
-middle-aged men
-no family hx
-episodic, severe unilateral periorbital pain; occurs daily for several weeks
*accompanied by 1 or more of the following: ipsilateral nasal congestion, rhinorrhea, lacrimation, redness of the eye, and Horner syndrome (ptosis, pupillary meiosis, facial anhidrosis or hypohidrosis)
200
Cluster HA
-at what time of day do these HA typically occur?
-do these HA cause patient to wake up?
-tx
-night
-awakens patients from sleep
-1st line: sumatriptan; prophylactic meds: lithium, verapamil, topiramate
201
Tx for post-traumatic HA
simple analgesics
202
Analgesic rebound HA
-cause?
-R/F
-what meds can cause this? and for how long after taking these meds consistently can this type of HA occur?
-medication overuse
-chronic daily HA
-ergotamines, triptans, meds containing butalbital, opioids --> when taken for more than 10 days; Tylenol, acetylsalicylic acid, NSAIDs --> when taken more than 15 days per month
203
treatment for primary cough headache
indomethacin PO daily
204
How to diagnose intracranial mass (imaging)?
CT/MRI
205
Facial Pain
-Trigeminal neuralgia
*sx
*exacerbated by?
*most common in what demographic? at what age?
*is neuro exam abnormal?
-stabbing facial pain, commonly arises near one side of mouth and shoots toward ear, eye, or nostril on that side
-exacerbated by touch, movement, drafts, eating
-middle and later life; affects women > men.
-no abnormality except if sx of underlying lesion (ie MS)
206
Does trigeminal neuralgia occur on both side or one side of face?
Unilateral
207
208
Trigeminal neuralgia
-treatment
*first line
*if ineffective, then what?
*tx of trigeminal neuralgia + MS
-oxcarbazepine or carbamazepine
-phenytoin
-gabapentin
209
-R/F associated with postherpetic neuralgia
-tx
*do systemic corticosteroids help?
-elderly, immunocompromised, hx of shingles
-acyclovir (5x/day) or valacyclovir (3x/day) when given w/i 72 hours of rash onset - reduces postherpetic neuralgia by 50%
*NO!
210
Spontaneous SAH
-s/s
-LOC
-diagnostic imaging
-any focal neuro deficits?
-sudden "thunderclap" HA of a severity never experienced previously by the patient --> N/V
-confused and irritable
-CT scan (angiography preferred); should be performed immediately
-absent
211
Spontaneous SAH
-tx
nimodipine
212
Pseudotumor Cerebri - "Idiopathic Intracranial Hypertension""
-sx
-what kind of palsy is common?
-cause?
-is CSF normal or abnormal?
-tx
-HA - worse on straining, visual obscurations or diplopia (due to papilledema and abducens nerve dysfunction)
-idiopathic (most often)
-normal
-acetazolamide 3x/day
