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NURS 871: NP Role in Illness > Weeok 07.Neurology > Flashcards

Weeok 07.Neurology Flashcards

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1
Q

Why do patients with intention tremors and cerebellar signs need to be referred to neurology?

A

Because demyelinating or hereditary degenerative diseases may be responsible

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2
Q

Patients with what kind of tremors should be referred to neurology and why?

A

Intention tremors
Because they could be caused by demyelinating diseases or hereditary degenerative diseases

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3
Q

Define TREMOR

A

Regular oscillation of a body part

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4
Q

What kind of tremor is typical of early parkinsonism?

A

Resting tremor, often a pill rolling tremor

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5
Q

Some drugs that can accentuate a normal physiologic tremor

A

SSRIs
TCAs
Beta agonists
Antiepileptics
High dose corticosteroids
Lithium
Sympathomimetics

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6
Q

Define DEMENTIA

A

Acquired decline in cognitive ability that impairs ADLs

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7
Q

What portion of the lipid panel contributes to stroke risk?

A

High LDL

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8
Q

What is NPH?

A

Normal pressure hydrocephalus

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9
Q

Name the classic triad associated with normal pressure hydrocephalus

A

Dementia
Gait disturbance
Urinary incontinence

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10
Q

What is seen on CT or MRI that indicates the possibility of normal pressure hydrocephalus?

A

Large ventricles without prominent vascular disease or widening of cortical sulci

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11
Q

Possible symptoms of mass lesions in the brain

A

Change in personality
New neurologic deficit
Progressive unilateral headache

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12
Q

Risk factors for dementia

A

Sleep deprivation
Diabetes
Vascular disease
Chronic exposure to strong anti-cholinergics, like bladder agents
Opiates
Hypothyroidism, hypothyroidism
Infection: HIV, neurosyphilis
High-dose corticosteroids
Thiamine deficiency
Learning disabilities
Depression
Alcohol abuse
Frailty
Low education
Social isolation
Never being married
Head trauma

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13
Q

Goal of dementia work up

A

Distinguish dementia from other causes of mental impairment

Identify the cause as either a primary neurologic condition or condition secondarily affecting the brain

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14
Q

HHS diagnostic criteria for Alzheimer’s Disease

A

Presence of dementia established by clinical exam and documented by a standardized assessment like MMSE

Evidence of deficits in two or more areas of cognition

Progressive worsening of memory

No disturbance of consciousness

Absence of systemic disorders or other brain disease that could account for the deficits

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15
Q

A stepwise pattern of cognitive decline raises suspicion of what?

A

Possibility of multiple infarcts

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16
Q

A patient who seems like he has dementia, and also has vivid visual hallucinations, should we suspected of having what?

A

Lewy body dementia

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17
Q

Who is at risk for normal pressure hydrocephalus?

A

Those with a history of meningitis or subarachnoid hemorrhage

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18
Q

MMSE performs best with what type of patients

A

White patients with at least a high school education

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19
Q

Define ASTERIXIS

A

Flapping tremor, the inability to maintain posture and

Think: flapping tremor of the hands

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20
Q

Define CHOREA

A

Jerky involuntary movements, especially affecting the shoulders, hips and face

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21
Q

What test should be ordered for a patient who is suspected to have dementia

A

CBC
CMP
ESR
TSH
Serum vitamin B12
RPR (to check for syphilis)
Urinalysis
Formal depression screening
CT or MRI of the head
HIV testing (of risk factors indicate)

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22
Q

What can patients do to prevent cognitive decline?

A

Cognitive training
Blood pressure management
Increase physical activity
Good diet (Mediterranean style)
Not smoking
Modest alcohol use (1 to 6 drinks per week – – more benefit than abstention)

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23
Q

Name a cause of sleep deprivation that increases the risk of dementia

A

Obstructive sleep apnea

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24
Q

Pharmacologic therapy is not always helpful with dementia. What condition needs to be treated–possibly with drugs–to help treat dementia?

A

depression

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25
What B vitamins are important for neurologic health?
folate vitamin B12
26
What to tell patients and families who inquire about CSF study or PET scanning for early diagnosis of dementia?
At this time, testing is for research purposes only; if interested, can be referred to a research center conducting the studies.
27
Name some signs of advanced dementia
pneumonia febrile illnesses eating problems
28
What is the typical prognosis once dementia is advanced?
6 months
29
How to assess driving ability in patients with dementia? What are some key indicators of abilities?
caregiver's subjective rating as "marginal" history of crashes or citations MMSE \<= 24 can also use Clinical Dementia Rating Scale
30
A family member of a patient with advanced dementia asks you about tube feeding; what do you share?
there is no evidence that tube feeding therapy prolongs survival or improves quality of life
31
What percentage of MS patients develop severe disability?
30%
32
A patient with MS expresses hesitation about getting the flu vaccine. How do you provide counsel?
no evidence that vaccines increase risk of developing MS
33
Where do MS lesions primarily occur?
in the white matter of the brain and the spinal cord
34
Is demyelination of MS reversible?
in some cases; after an attack, some remyelination occurs --\> partial resolution of symptoms
35
What can exacerbate MS? Why?
infection and stress fatigue partially demyelinated axons are more susceptible to dysfunction at this time
36
What is the definition of a MS attack?
produces symptoms lasting \> 24 hours
37
Most common initial presentation of MS
transient sensory deficits
38
What is the name for the acute monocular visual loss associated with MS?
optic neuritis
39
characteristic features of optic neuritis
pain on eye movement central scotoma (partial loss of vision or blind spot) Marcus Gunn pupil (decreased pupillary reaction to light)
40
besides optic neuritis, what other visual issue can herald MS?
diplopia
41
Signs of cerebellar involvement of MS
intention tremor ataxia
42
what finding in the lower extremities can indicate the presence of MS?
Babinski sign
43
What MS patients exhibit a relapsing-remitting course?
younger patients
44
What characterizes relapsing-remitting MS?
attacks followed by complete or nearly complete remission
45
What is secondary progressive MS?
after years of initial relapsing-remitting MS, a secondary progressive course develops; gradual worsening happens
46
What percentage of patients develop secondary progressive MS?
50%
47
What is relapsing-progressive MS?
patients have progressive disease exacerbated by acute attacks with little remission
48
What is neuromyelitis optica (NMO)?
demyelinating disease patients sustain recurring attacks of optic neuritis
49
Why is it important to differentiate neuromyelitis optica from other demyelinating conditions?
disease-modifying treatments are different
50
What influence does pregnancy have on risk of relapse?
decreases risk; risk is increased in postpartum period
51
Your newly-diagnosed MS patient doesn't want to start DMT (disease-modifying therapy); what do you tell him?
5-10% of patients can have a very benign course, but it is difficult to predict which patients can safely forego disease-modifying therapy; it is recommended to start therapy early to protect neurologic function
52
Name some treatable conditions on the differential with MS
Lyme disease vitamin B12 deficiency syphilis HIV infection sarcoidosis systemic lupus erythematosus (SLE) vasculitides
53
What confirms the diagnosis of MS?
McDonald criteria
54
most sensitive diagnostic test for MS
MRI
55
Why would one order a spinal MRI if a MS is suspected?
spinal cord abnormalities are common, even in early-stage MS these abnormalities are less likely to be confused with other diagnostic entities (as happens with the hyperintense white matter lesions found on brain MRIs)
56
When MS is suspected, what tests should be done to rule out other causes?
Lyme serology RPR vitamin B12 ANA HIV testing
57
What are the goals of MS treatment?
prevent and treat relapses treat persistent symptoms (e.g. pain and spasticity) retard progressive worsening
58
Why start MS treatment early?
evidence that inflammatory process is active during periods of clinical remission irreversible axonal injury accumulates during this time, even with relapsing-remitting disease
59
What are some complications of MS?
urinary incontinence impotence debilitating fatigue depression paroxysms of pain and spasticity
60
Your MS patient asks about pregnancy. What do you tell her?
* pregnancy can bring about a **relapse-free period** * **DMTs are either completely contraindicated, or are pregnancy category C**, so they likely (or definitely) need to be stopped * **postpartum: temporary increased risk of relapse** * pregnancy has **no detrimental long-term effect** * *breastfeeding is contraindicated** during immunomodulating therapy
61
What is the challenging thing about Alzheimer's Dementia?
no disease-modifying therapy available
62
What is the prognosis when Alzheimer's Dementia is diagnosed?
* 2-20 years from onset to death * average is 8-10 years * progressive disease * rate of progression usually follows initial rate; slowly progressive onset suggests a slowly progressive future; rapid onset suggests a rapid course
63
Independent predictors of rapid progression of Alzheimer's Dementia
* hallucinations * paranoia * delusions * misidentification syndromes * extrapyramidal signs * low score on initial psychometric testing
64
define MCI
* mild cognitive impairment: decline in at least 1 domain of cognitive function more than expected for age * overall functional capacity remains intact
65
initial clinical features of Alzheimer's Dementia
* memory loss * language impairment * visuospatial deficits
66
early signs of dementia
patients report concerns: * poor concentration * memory loss or confusion * coworkers notice relatively poor performance * inability to learn/remember new information
67
symptoms of intermediate stage Alzheimer's Disease
* complex tasks are impossible * wandering/getting lost is common * orientation can be maintained * traveling to/from familiar places is possible * difficulty w/ speech/language more pronounced * denial can become more pronounced
68
key features of later-stage Alzheimer's Dementia
* patients cannot survive w/o assistance * unable to recall major relevant aspects of current life * delusions/hallucinations common * disorientation to time/place is common
69
What are typical causes of death in Alzheimer's Dementia?
* total debilitation * infection
70
What are some things patients can do to prevent dementia?
* regular exercise (walking 1.5 hours per week is beneficial; more frequent and intense exercise is better) * cognitively stimulating leisure and social activities * Mediterranean style diet * managing atherosclerotic risk factors (diabetes, hypertension, smoking, hypercholesterolemia)
71
What is a Mediterranean style diet?
* high in fruits and vegetables * high in nuts, oily fish, olive oil * low in animal fat and red meat
72
What should you tell a patient who wants to use vitamins to decrease homocysteine levels in hopes of decreasing their risk of Alzheimer's Dementia?
* elevated levels of homocysteine are associated with Alzheimer's Dementia * some of these vitamins do lower levels of homocysteine * they do not lower cardiovascular risk in controlled trials * have been found to increase rates of adverse vascular events
73
A patient with Alzheimer's Dementia presents for care in your clinic. She is on the cholinesterase inhibitor Tacrine. What do you need to check?
Liver function as there is a risk for liver toxicity
74
Why are cholinesterase inhibitors used to treat Alzheimer's Dementia?
* patients were found to have depletion of acetylcholine-synthesizing enzyme * and cholinergic neuronal degradation
75
What Alzheimer's patients can receive cholinesterase inhibitors to improve cognitive function?
mild to moderate dementia
76
What are the side effects of cholinesterase inhibitors?
* gastrointestinal (nausea, vomiting, diarrhea) * somnolence, headache, insomnia * orthostatic hypotension * bradycardia
77
contraindications to use of cholinesterase inhibitors in Alzheimer's Dementia
* sick sinus syndrome * left bundle branch block * angle-closure glaucoma * poorly controlled asthma
78
Aside from cholinesterase inhibitors, what other class of drugs is used to treat Alzheimer's Dementia? Why?
* NMDA antagonists = memantine (Namenda) * overstimulation of NMDA by glutamate is believed to play a role in neurodegeneration
79
Side effects of NMDA antagonists
* nausea, diarrhea * dizziness * agitation
80
What is the rule of thumb for the use of antipsychotics, benzodiazepines, and sedative-hypnotics in treating patients with Alzheimer's Dementia?
lowest possible dose for the shortest possible time
81
What is the black box warning regarding antipsychotic use in elderly patients with dementia?
* prolongation of QT interval on EKG * increased risk of sudden cardiac deaths (increased risk, but the absolute risk is small)
82
For depression in an elderly patient with Alzheimer's dementia, why is a TCA with marked anticholinergic activity problematic?
may: * worsen memory * cause agitatioin * trigger cardiac dysrhythmias
83
Name a TCA with strong anticholinergic activity
amitriptyline
84
Name some TCAs with few anticholinergic side effects
* nortriptyline * desipramine
85
How can an NP treat a patient with Alzheimer's Dementia how has prominent apathy and lack of motivation unrelated to comorbid depression?
stimulants: * methylphenidate * dextroamphetamine * modafinil
86
What anticipatory guidance do families need when caring for a patient with dementia, particularly regarding later stages?
* how to recognize symptoms of later stages early (deterioration of behavior and gait) * how to approach the patient * importance of communication with HCP
87
Incontinence is a (LATE/EARLY) sign of Alzheimer Disease
LATE
88
Incontinence presenting early in Alzheimer Disease should prompt what?
careful search for other causes, including: * UTI * atrophic vaginitis * constipation * mobility problems (r/t arthritis) * other causes of dementia
89
A patient is diagnosed with Alzheimer Disease; the family is concerned about possible inappropriate sexual behavior. What is your response?
* not common in Alzheimer Disease * self-stimulation is the usual form it takes * not sexually aggressive toward children
90
Symptoms typical of the onset of Alzheimer's disease include memory loss; what is the symptom typical of onset of Lewy body Dementia?
psychosis (visual hallucinations)
91
Patients with Lewy body eventual often have psychosis; what caution needs to be in place when pharmacotherapy is considered?
* can have extreme sensitivity to antipsychotics * can have worsening of extrapyramidal symptoms with little improvement in mental status * increased risk of neuroleptic malignant syndrome

NURS 871: NP Role in Illness (10 decks)

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