Neurological Disorders: Assessment Techniques

Neurological Disorders: General Approaches

• Neurological disorders range from chronic to acute and lethal.
• All patients with suspected neurological disorders need a neurological exam.
• Mental status assessment includes LOC, orientation, memory, cognitive function, and language.
• Motor skills assessment involves checking body position, involuntary movements, muscle tone, and strength.
• Sensory function assessment includes light touch, pain, and position sense.
• Reflexes include deep tendon reflexes (DTRs), abdominal reflexes, and Babinski reflex.
• Cerebellar function assessment should be done based on history.
• Gait, rapid alternating motion, point-to-point movement, and Romberg test are part of the assessment.
• Cranial nerves (1-12) should be checked for motor and sensory components.

Neurological Disorders: Mini-Mental Status Exam

• If abnormalities are found in the above areas, conduct a mini-mental status exam.
• Further sensory testing (stereognosis & two-point discrimination).

Neurological Disorders: Older Adults

• Blood flow to the brain decreases by 20% with age.
• Autoregulation changes can contribute to orthostatic hypotension.
• Slower response time and processing speed in older adults.
• Increased incidence of sensory deficits with age and chronic illness.
• Consider cardiac, metabolic, or medication adverse reactions for global complaints.

Neurological Red Flags (Adult Patients)

• Focal findings (weakness, change in cognition)
• Acute, sudden onset of headaches, weakness, aphasia or visual changes.
• Immediate neurologist referral and/or consult with supervising physician.
• Refer patients with unusual or confusing presentations to neurologist.

Headaches: General Approaches

• Assess headache patterns to understand the etiology.
• Use SNOOP mnemonic for red flags.
• S: Assess for systemic signs and secondary risk factors(fever, rash, fatigue, weight loss, neck stiffness, personality changes, HIV status, cancer).
• N: Check for neurologic symptoms(LOC changes, personality changes, focal deficits, CNS infections).
• O: Examine onset(sudden/new/changed), severity and duration(thunderclap headaches, intense).
• O: Examine the onset and if it fits the pattern.
• P rule out changes in presentation.
• Assess for presence or precipitating factors.
• Evaluate family history of headaches.
• Review of systems.
• Assess for medication overuse.

Headaches: Diagnostic Testing

• If headache is consistent, and PE is normal, no further diagnostics needed.
• Brain CT needed if sudden severe headache, progressive headache, headache with exertion, or changes in mental status or fever.
• Sed rate to rule out temporal arteritis (age 50+).

Types of Headaches (Primary)

• Tension Headaches: Bilateral, occipital, or frontal tightness/fullness; waves of aching pain; 70-90% in adults, more common in women, family history common, muscle tension, stress, anxiety, depression. No neurological symptoms.
• Migraines: Common in women (30-45 years), strong genetic component, risk factors include age, gender, stress, Alcohol, caffeine; triggers include menses, alcohol, food, sleep changes, weather, emotional stress, medications, vascular disruption, neurochemicals; throbbing, aura possible, nausea, vomiting, abdominal pain, relieved by sleep, fluorescent lights.
• Cluster Headaches: Rare, seasonal, unilateral, excruciating pain, short duration, possile neurochemical imbalance

Types of Headaches (Secondary)

• Subarachnoid Hemorrhage: Thunderclap headache, sudden and severe, immediate CT.
• Head Trauma: Secondary headache.
• Brain Tumors: Holocranial headache, morning onset, projectile vomiting.
• Giant Cell Arteritis (Temporal Arteritis): 50+ years, bilateral temporal headaches, malaise, muscle aches, low-grade fever, immediate referral for temporal biopsy, prednisone.
• Meningitis: Severe headache, sudden onset, neck stiffness, fever, lumbar puncture.
• Medication Overuse/Rebound Headaches: Medication overuse, withdrawal.

Headache Treatments

• Tension headaches: analgesics, avoid opioids; preventive if more than twice weekly
• Migraines: analgesics, abortive therapy (triptans, ergot), treat nausea/vomiting, review headache guidelines, neurology referral if multiple treatments ineffective
• Cluster headaches: similar to migraine, consult/hospitalization as needed
• Refer if unable to manage symptoms, symptoms worsen, increased intracranial pressure, possible aneurysm/tumor, severe/unresponsive migraines/cluster headaches,
• Referral to pain clinic for chronic pain (psychotherapy, relaxation, stress, anxiety treatment)

Trigeminal Neuralgia

• Compression of fifth cranial nerve root
• Common in middle-aged to older women
• Pain triggered by touch, movement, cold air, chewing
• Possible association with multiple sclerosis.
• Thorough history of pain characteristics, triggers, and management.
• LOCATES mnemonic for neuro deficits.
• Unilateral, stabbing, surface pain in lower face, lasting seconds to minutes, recurring.
• Physical exam is usually normal, except potential for poor dentition/lack of shaving or makeup application.
• Diagnostic: CT/MRI if neuro deficits. Sed rate, if generalized cell arteritis suspected.
• Treatments: Avoid triggers, surgical decompression of fifth cranial nerve -Tegretol (first-line). Oxcarbazepine and lamotrigine (second-line), Neurontin(third-line)

Bell's Palsy

• Unilateral facial paralysis/paresis. Sudden onset, unilateral facial droop.
• Affects seventh cranial nerve VII.
• Discomfort behind the ear or jaw.
• Possible hearing loss, taste changes.
• Transient pain. Possible cause is herpes simplex reactivation.
• Associated with prior URI, Lyme,
• Symptoms progress for 7-10 days, Full recovery over six months.
• Risk factors include trauma, diabetes, hypothyroidism, AIDS, Lyme disease.
• Thorough history and physical exam. Establish time frame of complaint, past medical history.
• Facial asymmetry, inability to raise eyebrow/close ipsilateral eye, flattening of nasal labial fold, inability to puff out cheek/smile/frown.
• Other cranial nerves typically normal; check thyroid, lymph nodes. Erythema migrans (possible Lyme).
• Labs: CBC, chem panel, syphilis, HIV, Lyme (if suspected). ESR if temporal arteritis suspected. Lumbar puncture if meningitis suspected
• Treatments include prednisone, famciclovir, artificial tears.

Parkinson's Disease

• Bradykinesia, rigidity (cogwheeling), resting tremor, loss of postural reflex, flexed posture. Unknown cause-possibly genetics, environmental toxins.
• Risk factors: age, heredity. Detailed history, complete neuro assessment, past medical history (neuro symptoms, toxin exposures).
• Family history of Parkinson's, movement disorders, or dementia.
• Medication review (including OTC meds, anticholinergics, antihistamines).
• Functional assessment (instrumental ADLs, stairs, rising from chair). Falls history.
• Autonomic dysfunction (incontinence, constipation, postural hypotension). Assess for depression (geriatric depression scale).
• Time frame, progression of symptoms, aggravating/alleviating factors.
• Physical exam: manner, affect, dress, hygiene, soft/monotone speech. Cranial nerves typically normal, possible fourth cranial nerve palsy(progressive supranuclear palsy). Motor exam: no weakness, cogwheeling, rigidity. Bradykinesia and tremor assessment.
• Management: non-pharmacological (PT, OT, speech therapy, fall precautions, encourage walking). Surgical intervention. Pharmacological (dopamine agonists, MAO-B inhibitors, anticholinergics). Careful dosing; close collaboration with neurologist.

Alzheimer's Disease

• Gradual, progressive decline; no neurological deficits. Unknown cause, possibly genetic. Three stages.
• Stage 1: Short-term memory impairment.
• Stage 2: Increasing social/cognitive loss, behavioral changes.
• Stage 3: Cognitive disability, physical disability.
• Physical exam: mental status (FAQ, Mini-mental status exam, scores <26). Neuro exam.
• Diagnostic tests: CBC, chem panel, thyroid, B12, UA, CT, pulse oximetry, drug tox screen.
• Treatment: treat contributing conditions (agitation w/ Haldol), cholinesterase inhibitors, depression treatments (SSRIs). Sleep deprivation treatments (Ambien/Desyrel). Non-pharmacological, support, behavioral therapy, home/driving safety assessment, advance directives.

Delirium

• Acute, fluctuating onset of inattention, disorganized thinking, altered awareness. Unlike dementia, which is slow and progressive.
• Elderly, 70% initially hypoactive. Underlying medical cause. Deleriums mnemonic (drugs, emotions, low PaO2, infection, retention, ictal, undernutrition, metabolic, subdural, sensory, pain.)
• Thorough history of HPI, including cognition; time frame and progression of symptoms. Complete review of systems, validate with family or caregiver.
• Physical exam: LOC, deficits, hearing/vision, CV/pulmonary, infection signs.
• Diagnostic: CBC, chem panel, UA, thyroid, B12, CT (infarcts/lesions), HIV, Syphilis (indicated). EKG, chest X-ray (cardiopulmonary).
• Treat underlying cause. Important differences between delirium, dementia and depression(onset, course, duration, consciousness)

Stroke and TIA

• 600,000 annual US strokes, risk increases with age; 1/4 die, 50% survivors have disability. Interruption of blood flow causing neuronal death, ischemic/hemorrhagic (less than 10%).
• Thrombotic: symptom onset during sleep, progressing. Hemorrhagic/embolic: sudden onset with activity.
• TIA: temporary interruption, <24 hours, no tissue death, symptoms include weakness, slurred speech, vision loss, gait changes, temporary.
• Stroke deficits include visual, aphasia, motor weakness, paresthesia.
• Stroke causes: ischemic (thrombotic, embolic, lacunar); hemorrhagic (spontaneous bleeds).
• History: duration of symptoms, locates mnemonic for symptom review, review system and past medical history(risk factors).
• Risk factors include age, vascular disease (hypertension, diabetes, hyperlipidemia, smoking), emboli (A fib, cardiomyopathy, CAD)

Stroke and TIA: Physical Exam

• Complete neurologic exam.
• LOC, cognitive ability, motor and sensory function, cranial nerves, fundoscopy, complete CV exam, hypertension, A fib, murmurs, bruits, abdominal aneurysm.
• Diagnostic: CT, MRI, carotid Doppler, angiography, halter monitor.
• Labs: CBC, sed rate, coagulation studies, chem panel, lipid panel.
• Management(acute): TPA (stroke), individualized treatment based on severity, co-morbidity. PCP collaboration.

Stroke and TIA: Prevention

• Follow JNC guidelines for hypertension. Review week four recording and week four cardiology. Follow ADA guidelines for diabetes. Screen for bruits. Smoking cessation.

Other Neurological Disorders

• Epilepsy: Abnormal electrical discharges in neurons, recurrent seizures. Risk factors: previous seizures, family history, trauma, withdrawal from seizure meds. Diagnostic: brain CT, EEG. Medications: anti-convulsants (Dilantin, Phenobarb).Teaching patients about medication.
• Multiple Sclerosis: Progressive neuro-degenerative disease, inflammation in neuronal sheath/brain/spinal cord. Autoimmune disease, 1-3% in women. Careful history, physical exam. MRI, lumbar tap. Treatment is to delay progression, neurologist collaboration.
• Neurofibromatosis: Genetic disorder affecting nerve cell formation. Diagnosis: two or more of: 6+ café au lait spots, 2+ dermal neurofibromas, family history, armpit/groin freckles.
• Peripheral Neuropathy: Damage to peripheral nervous system. Causes: diabetes, hypothyroidism, B12 deficiency, peripheral arterial disease. Treatment based on causative factor.