Neuro: Change in MS Flashcards by Kristen Snyder

Acute confused state that is likely reversible and fluctuates over hours or days.

Delirium

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Encephalopathy, MS change, ICU psychosis are all synonyms for what?

Delirium

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What is required for delirium to be diagnosed at bedside?

Has to be acute onset with fluctuating course AND

inattention accompanied by disorganized thinking OR altered level of consciousness

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Hallmark of delirium

Deficit in attention

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Alcohol withdrawal can produce hallucinations, agitation, ANS changes that are classified as what?

Hyperactive delirium

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Opiate intoxication can produce withdrawn patients that are classified as what?

Hypoactive delirium

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True or False: We have a screening tool to assess who is at risk for delirium.

False

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What surgery increases risk of delirium?

Cardiac bypass

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True or false: delirium is caused by a focal brain lesion.

False. It is more likely caused by widespread cerebral dysfunction (cortical and subcortical regions)

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What might you find on an EEG in someone with delirium?

systemic slowing

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What meds can bring out delirium in susceptible people?

Anticholinergics

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What are 3 important things to remember when assessing someone for delirium clinically?

Baseline mental status
Timeline of illness
Current meds or recent changes

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How many cases of delirium are a result of meds?

1/3

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What labs would you order on someone with delirium?

Glucose
CBC and CMP
Check urine
MRI

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True or false: Chemical restraints should be used at the lowest effective dose.

True

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Which works better as a chemical restraint, antipsychotics or benzodiapzepines?

Antipsychotics

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Acquired, chronic deterioration in cognitive abilities that impairs ADLs.

Dementia

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What is the most common symptom in dementia?

Memory loss

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Which type of dementia is memory impairment NOT the most common presenting feature? what is?

Frontotemporal dementia.

Disinhibition

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What is the most common form of dementia?

Alzheimers

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Memory served by which areas is affected in early AD?

hippocampus

Mesial temporal lobes

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What are the two primary cardinal lesions associated with AD?

Neurofibrillary tangles (intracellular tau and ubiquitin proteins)
and extracellular senile plaques (beta amyloid)

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What is needed to diagnose Alzheimers?

Need to look at clinical criteria, lab tests, and imaging to exclude other diagnoses. Most are diagnosed clinically, but a definitive diagnosis requires histopathologic exam (autopsy)

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What abnormal findings may you expect to see on PE of an advanced Alzheimer’s patient?

Myoclonus
Seizures
Incontinence
Frontal release signs

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What is it called when the pt persistently blinks during the glabellar reflex test?

Myerson's sign

What lab tests should be drawn on an AD patient?

``` TSH Vitamin B12 Folate RPR Biomarkers (tau protein, beta amyloid protein, ApoE4) ```

What imaging studies should be done on an AD patient?

MRI. Can help exclude other dx of vascular dz, NPH, neoplasm, and subdural hematoma. May show generalized atrophy, focal atrophy, or be normal.

What is the imaging study in which IV injection of fluorine is given to measure cerebral metabolic rates of glucose? Tests for hypometabolism

FDG PET

What is the imaging study in which Florbetapir F18 is injected to measure amyloid lesion burden in the brain?

Amyloid PET

When is an Amyloid PET scan indicated?

Progressive AD at an early age or for those who are following atypical course of AD

used to treat mild to moderate dementia

``` Cholinesterase inhibitors Vitamin E (2000 IU/day) ```

Used to treat moderate to severe AD

Memantine (Namenda)

Used to treat vascular dementia

Memantine (Namenda)

Used to treat moderate to severe agitation with severe hallucinations

Atypical neuroleptics

Cholinesterase inhibitor that is not used in the US because of hepatotoxicity

Tacrine (Cognex)

Cholinesterase inhibitor that causes bradycardia and syncope

Donepezil (Aricept)

Cholinesterase inhibitor that can be worn as a patch and causes headache and anoreia but not diarrhea.

Rivastagimine (Exelon)

Comes in a tab or oral solution. Cholinesterase inhibitor that comes in extended release or immediate release and causes weight loss.

Galatamine (Razadyne)

Med that blocks receptor sites for glutamate

Memantine (Namenda)

Your pt is on Namenda and says it is not working. You want to up to the dose to see if that will help. When do you change the dose? What if the new dose doesn't work either?

Wait at least 1 week between dosage changes. | Even if no improvement, keep the pt on Namenda.

What are the side effects of Namenda?

Dizziness (Most common) hallucinations increase agitation, delusional behavior

Can you combine memantine with cholinesterase inhibitors?

Yes

What is first line treatment for AD patients with agitation and aggression?

Try behavioral interventions like avoiding triggers, distract pt, keep structured routines

What important information must be given with atypical neuroleptics?

May increase mortality

What SSRI is the most useful in management of agitation and paranoia?

Citalopram

Olanzapine (Zyprexa), Quetiapine (Seroquel), and Risperidone (Risperdal) are all examples of what?

Atypical neuroleptics

Early alteration in personality, behavior, and executive function. Autosomal dominant inheritance in 10-25%.

Frontotemporal dementia

Most common presenting symptom in frontotemporal dementia

DIsinhibition

Early appearance of visual hallucinations. May also have parkinsonism, ANS dysfunction, neuroleptic sensitivity

Dementia with Lewy Bodies

Suspect this in someone with very rapid onset of dementia

Creutzfeldt Jakob Disease

The presence of what protein in CSF is tested for in this transmissible spongiform encephalopathy?

14-3-3 | Prion protein disease

What is the second most common cause of dementia?

Vascular dementia

What is the most common form of vascular dementia from?

Small vessel cerebrovascular disease

Risk factors of vascular dementia

HTN, DM, tobacco use, obesity

What are examples of "treatable" dementias that are reversible to a point?

1. Side effects from meds 2. B12 deficiency 3. Heavy metal poisoning 4. Infection 5. Hepatic/renal failure 6. Hypothyroidism 7. Chronic subdural hematoma 8. NPH

What are the three causes of hydrocephalus?

``` Obstruction of CSF circulation Inadequate absorption (communicating hydrocephalus) Overproduction of CSF (rare) ```

Classic triad of normal pressure hydrocephalus

Dementia, gait disturbance, urinary incontinence (wet, wacky, wobbly)

Most common presenting symptom in NPH

Magnetic gait

Gold standard to diagnose NPH

Improved exam/symptoms after large volume of CSF is drained via LP

Treatment of NPH

Shunting of CSF. Diuretics have NOT been shown to work

Which type of hydrocephalus is third ventriculostomy NOT effective for?

Communicating hydrocephalus

Medical therapy for hydrocephalus

Diuretics Fibrinolytics (newborns with posthemorrhagic hydrocephalus) Serial LP Medical therapy INCREASES complications and are NOT as safe as surgical therapy

Where is CSF produced?

Choroid plexus in lateral ventricles

What would you expect to see on physical exam in someone with suspected hydrocephalus?

Cushing's Reflex (Triad): Bradycardia, Ataxic breathing, HTN

What would you expect to see when examining the eyes of someone with suspected hydrocephalus?

``` EOM paralysis (diplopia) or impaired upward gaze. Papilledema ```

Severe HA with signs of increased ICP

Diagnosis of hydrocephalus in adult

Large head circumference at birth, malformed spine

Diagnosis of hydrocephalus in infants

Which is safer treatment of hydrocephalus? Medical or surgical treatment?

Surgical

Where is the catheter placed in a shunt to treat hydrocephalus?

Right lateral ventricle | Connected to right atrium or peritoneal cavity

In a third ventriculostomy, what is the third ventricle connected to?

Subarachnoid space

Who normally gets Wernicke encephalopathy and what is the cause?

Chronic alcoholics | Thiamine (B1) deficiency

What is the classic triad of Wernicke Encephalopathy?

Global confusion Opthalmoplegia Gait ataxia (80% also have polyneuropathy)

Treatment of Wernicke Encephalopathy

IV thiamine

A patient with Wernicke Encephalopathy comes to the hospital and also has low blood sugar. He is a diabetic. The nurse gives him glucose. What did she do wrong?

She also should have given him thiamine with the glucose--the glucose will use up all the thiamine reserves left over, making his WE worse.

Residual amnesic state that follows resolved Wernicke encephalopathy

Korsakoff syndrome

Symptoms of Korsakoff syndrome

``` Classic triad (opthalmoplegia, gait ataxia, global confusion) PLUS confabulation and amnesia ```