NURS 497 W25: Neurological System

• The slides are about the Neurological System for NURS 497 W25, by Justin Burkett MN RN CHSE, adapted from Sealock & Tillier.

How the Brain Affects the Body

• The topic of this slide deck is neurological conditions and diseases.
• Pathophysiology and chronic diseases affect the brain.
• The goal is to use acquired knowledge to assess and care for patients.
• Neurological conditions covered in this deck include:
  • Dementia
  • Parkinson's Disease
  • Multiple Sclerosis
  • Headaches
  • Guillain Barré
  • Myasthenia Gravis
  • Amyotrophic Lateral Sclerosis
  • Brain Tumors

Memory and Aging

• Most people will not experience memory problems as they age.
• About 40% experience some memory loss after age 65.
• Between 5% to 8% of people will live with dementia after age 60.

Understanding Dementia

• Dementia: An extremely low condition of mental functioning, mental incapacity.
• The word dementia comes from the Latin "dementia" (madness, insanity), and literally translates to "a being out of one's mind" from 1806.
• The word dement is derived from the stem of demens, meaning "mad, raving."

Pathophysiological Mechanisms of Dementia

• Brain cell connections can be damaged by disease and other factors.
• Symptoms and disease progression depend on the type, location, and extent of the damage.
• Common causes of damage include:
  • Abnormal protein deposits (e.g., Alzheimer's, Lewy body).
  • Impaired blood flow (e.g., vascular, mixed).
  • Genetic mutations or defects (e.g., Huntington's, frontotemporal).
  • Infections or inflammation (e.g., Creutzfeldt-Jakob, HIV).
  • Traumatic brain injury or repeated head trauma (e.g., chronic traumatic encephalopathy, dementia pugilistica).
  • Alcohol abuse or nutritional deficiencies (e.g., Wernicke-Korsakoff, alcoholic).

Dementia in Alberta

• More than 45,800 Albertans lived with dementia as of March 31, 2018.
• 10%, or 4,435, of Albertans with dementia are between 40 and 65 years old.
• Almost half (21,410) of Albertans with dementia are between 65 and 84 years old.
• 44%, or 19,960, of Albertans with dementia are age 85 or older.

Clinical Manifestations of Dementia

• Early (Mild) symptoms include:
  • Mild forgetfulness and misplacing items.
  • Short-term memory impairment.
  • Taking longer than usual to accomplish tasks.
  • Difficulty recognizing what numbers mean, handling money.
  • Loss of initiative and interests.
  • Poor judgement.
  • Finding the right word is difficult.
  • Confusion about the location of familiar places (lost).
  • Anxiety.
• Middle (Moderate) symptoms include:
  • Increasing memory loss.
  • Impaired attention.
  • Anxiety, mood swings, suspiciousness, jealousy, and irritability.
  • Flat affect.
  • Difficulty recognizing family members and friends.
  • Difficulty with language and understanding, problems with reading.
  • Difficulty with logic and organizing thoughts.
• Late (Severe) symptoms include:
  • Loss of most memories, inability to process new information.
  • Inability to understand words.
  • Responding to short and simple communication.
  • Difficulty eating and swallowing.
  • Repetitious words or sounds.
  • Inability to perform self-care activities.
  • Loss of social skills, sexual disinhibition.
  • Hallucinations, delusions, and agitation.
  • Aggressive behaviors.
  • Loss of appetite and weight loss.
  • Seizures.

The 7 A's of Dementia Symptoms

• Anosognosia: Loss of insight or awareness of one's own condition.
• Amnesia: Loss of memory, especially for recent events.
• Aphasia: Loss of language skills, such as speaking, understanding, reading, or writing.
• Agnosia: Loss of recognition of faces, objects, sounds, or smells.
• Apraxia: Loss of purposeful movement, such as dressing, eating, or using tools.
• Altered Perception: Loss of perceptual acuity, such as depth, distance, or color.
• Apathy: Loss of initiation, motivation, or interest

Overview of Dementia

• Dementia is an umbrella term.
• The term describes the loss of memory and of other thinking abilities which is severe enough to interfere with daily life.

Types of Dementia

• Alzheimer's disease:
  • Abnormal deposits of proteins form amyloid plaques and tau tangles throughout the brain.
• Frontotemporal dementia:
  • Abnormal amounts of tau and TDP-43 proteins accumulate inside neurons in the frontal and temporal lobes.
  • Symptoms include: Behavioral and emotional problems, movement problems, language problems
• Lewy body dementia:
  • Abnormal deposits of the alpha-synuclein protein, and Lewy bodies, affect the brain's chemical messengers.
  • Symptoms include: Cognitive decline, movement problems, sleep disorders, visual hallucinations.
• Vascular dementia:
  • Conditions, like blood clots, disrupt blood flow in the brain.

Understanding Lewy Body Dementia

• It is a common progressive dementia second to Alzheimer's.
• The precise cause is unknown, it is related to abnormal deposits of alpha-synuclein in the brain.
• Lewy Bodies overwhelms normal functions, causing the cell to die.
• Lewy body dementia diagnosis includes Parkinson's disease and dementia with Lewy bodies (DLB).
• DLB tends to have more prominent cognitive concerns, those with Parkinson's exhibit motor concerns first.
• Visual hallucinations.
• Difficulties with movement.
• Dysregulation of body functions.
• Confusion and memory loss.
• Sleep disorders.
• Changes in mood.
• Risk factors include: Age, gender, family history.

Huntington's Disease

• Genetic disease that causes atrophy of basal ganglia and enlargement of lateral ventricals.

Reversible Dementia

• Reversible dementia can affect younger people.
• Some causes and examples include:
  • Infections: meningitis, encephalitis, syphilis, Lyme disease, or HIV.
  • Brain injuries: subdural hematomas, normal pressure hydrocephalus, or traumatic brain injury.
  • Metabolic disorders: hypothyroidism, hypercalcemia, or liver failure.
  • Nutritional deficiencies: vitamin B12, folate, or thiamine deficiency.
  • Drug effects: alcohol, opioids, benzodiazepines, or anticholinergics.
  • Tumors: brain and pituitary tumors, or paraneoplastic syndromes.

Irreversible Dementia

• Irreversible dementia is a progressive and degenerative condition, affecting mainly older people.
• Causes and types include:
  • Neurodegenerative disorders: Alzheimer's disease, Lewy body dementia, frontotemporal dementia, Pick disease, Huntington disease, or Parkinson disease.
  • Vascular disease: vascular and mixed dementia, or stroke.
  • Infection: Creutzfeldt-Jakob disease or prion disease.

Special Considerations

• Includes childhood dementia, Wernicke’s encephalopathy, and Korsakoff’s syndrome.
• Wernicke’s encephalopathy:
  • A sudden and life-threatening reaction.
  • Causes bleeding and damage in the lower parts of the brain.
  • Symptoms: confusion, poor coordination, coma, involuntary eye movements, low BP, and hypothermia.
  • Is potentially reversible with early thiamine, hydration, nutrition, and medication.
• Korsakoff’s syndrome: - Is a chronic, degenerative condition. - Causes damage in the middle parts of the brain. - Symptoms include: severe memory loss, difficulty learning new information, confabulation, lack of insight, hallucinations, and repetitive behavior and speech. - Irreversible and progressive, may stabilize or improve with thiamine supplements, abstinence from alcohol, cognitive rehabilitation, and supportive care.

Alzheimer's Disease (AD)

• AD is a type of dementia that causes progressive degeneration of brain cells and their connections.
• It affects memory, thinking, behavior, and mood.

Molecular and Cellular Mechanisms of AD

• Includes metal ions imbalance, genetic risk factors, immune system, and Tau.

Hallmarks of Alzheimer's in the Brain

• Amyloid plaques: Extracellular deposits of a toxic protein called amyloid-beta, which interferes with cell communication and function
• Neurofibrillary tangles: Intracellular aggregates of a protein named tau, disrupts cell structure and transport

Pathogenesis of Alzheimer’s and Vascular Dementia

• Pathogenesis progresses from a neuro-inflammatory response and the release of toxic levels to the disruption of neurotransmitter to neuronal loss and function
• Process creates a cascade of excitotoxicity affecting areas such as the hippocampus and synaptic plasticity, impacting performing everyday asks.

Types of Alzheimer's

• Sporadic AD:
  • Most common with no clear family history or inheritance.
  • Influenced by susceptibility genes and risk factors.
• Early Onset AD:
  • Occurs before age 65, regardless of cause.
  • Affects about 5% of all people with Alzheimer's disease.
• Familial AD (FAD):
  • Rare type, with a strong family history and inheritance pattern.
  • Caused by deterministic genes and mutations.

Alzheimer's Disease and Neurotransmission

• Alzheimer's damages and kills neurons.
• Reduction in the production and release of neurotransmitters.
• Acetylcholine is the most affected, and is crucial for memory, attention, and learning.
• Other neurotransmitters, such as glutamate, serotonin, and dopamine, are also reduced.

Diagnosing Dementia

• To diagnose dementia requires:
  • Cognitive and neurological tests
  • Brain scans
  • Psychiatric evaluation
  • Genetic tests
  • Cerebrospinal fluid (CSF) tests
  • Blood tests

Core Proteins in Alzheimer's

• Tau and amyloid proteins are abnormal products of the brain.
• These accumulate and form clumps and tangles that damage nerve cells and their connections.

Cognitive Screening Tests for Dementia

• Mini-mental state examination (MMSE):
  • 7-10 minutes
  • Cut-off score/Total score: ≤23-26/30
• Modified mini-mental state examination (MMSE):
  • 10-15 minutes
  • Cut-off score/Total score: ≤77-86/100
• Hopkins verbal learning test – total recall: 5 minutes Cut-off score/Total score: ≤14-18/36
• Memory impairment screen:
  • 4 minutes
  • Cut-off score/Total score: ≤4/8
• Clock drawing test:
  • 1-3 minutes
  • Scoring methods varied
• Cambridge cognitive examination:
  • 20 minutes
  • Cut-off score/Total score: ≤80/107
• Community screening interview for dementia:
  • 30 minutes
  • Formula used
• Montreal cognitive assessment (MoCA):
  • 10 minutes
  • Cut-off score/Total score: ≤25/30
• Behavioural neurology assessment (Long form):
  • 40-50 minutes
  • Cut-off score/Total score: ≤182/250
• Behavioural neurology assessment (Short form):
  • 20-30 minutes
  • Cut-off score/Total score: ≤82/114
• Canadian Indigenous Cognitive Assessment:
  • 10 minutes

Principles For A Dignified Diagnosis

• Talk directly to the person.
• Tell the truth about the diagnosis.
• Test early.
• Take concerns seriously.
• Deliver news gently, with sensitivity.
• Coordinate care with other providers.
• Explain the purpose of tests and what you hope to learn.
• Give tools for living with the disease.
• Work with people to create healthy living plans.
• Recognize each person and experience is unique.
• Dementia is a journey, not a destination.

Scales for Measuring Progression of Alzheimers

• Stage 1: No Cognitive Decline
  • Experiences no problems in daily living.
• Stage 2: Very Mild Cognitive Decline
  • Forgets names and locations of objects.
  • Trouble finding words.
• Stage 3: Mild Cognitive Decline
  • Difficulty travelling to new locations.
  • Difficulty handling problems at work.
• Stage 4: Moderate Cognitive Decline
  • Difficulty with complex tasks.
• Stage 5: Moderately Severe Cognitive Decline
  • Needs help to choose clothing.
  • Needs prompting to bathe.
• Stage 6: Severe Cognitive Decline
  • Loss of awareness of recent events and experiences.
  • Requires assistance bathing or has a fear of bathing.
  • There is decreased ability to use the toilet or incontinence.
• Stage 7: Very Severe Cognitive Decline
  • Vocabulary declines to single words.
  • Loses ability to walk and sit.
  • Requires help with eating.

Reducing Risk Factors For Dementia

• Includes modifiable risk factors such as
  • Minimizing diabetes.
  • Lowering hypertension.
  • Preventing head injury.
  • Stop smoking.
  • Reducing air pollution.
  • Avoid obesity.
  • Frequent exercise.
  • Reduce depression.
  • Avoid alcohol.
  • Treat hearing impairment.
  • Social contact.
  • Obtain higher levels of education.

Nursing Assessment for Possible Dementia Includes

• D = Drugs
• E = Eyes and Ears
• M = Metabolic and Endocrine Disorders
• E = Emotional Disorders
• N= Neuro disorder and Nutritional Deficiency
• T= Tumors and Trauma
• I= Infection
• A= Alcohol

Subjective Data Collection For Assessing Dementia

• Includes:
  • History of present illness.
  • Past medical history.
  • Family history.
  • Social history.
  • Mood and affect.
  • Functional status:
  • Safety concerns

Objective Data For Assessing Dementia

• Includes:
  • Vital signs.
  • General appearance.
  • Neurological examination.
  • Cognitive tests.
  • Laboratory tests.
  • Neuroimaging.

General Info about Parkinson’s Disease

• It is a progressive neurological disease.
• Tenet #1: there is no one size fits all description.
• Affects the basal ganglia, which assists with movement
• Changes the protein structure leading to neurotransmitter dysregulation that inhibits dopamine production

What are Lewy bodies?

• Lewy bodies are clumps of alpha-synuclein proteins.
• Alpha-synuclein helps to release and maintain nerve endings which regulate activity.
• The changes to the protein in PD interfere with the normal function, and the cells begin to die.

Main Symptoms of PD

• Four main symptoms include: • Tremor • Rigidity • bradykinesia, • postural instability
• Causes other health problems, such as depression, anxiety, vision problems, digestive issues, and loss of smell.
• Produces cognitive changes, such as memory loss, problems solving, and hallucinations.

How is Parkinson's Tremor Different

• The primary indicator is tremor as well as the rate of movement.

Nonmotor Symptoms of PD

• Sleep disturbances
• Restless leg syndrome
• Mood disturbances
• Depression
• Anxiety
• Cognitive impairment
• Sleepiness

Atypical Parkinsonism Disorders

• It is a group of progressive neurological disorders.
• Can include multiple system atrophy and dementia with Lewy bodies.
• Advanced symptoms tend to occur within 1-3 years.
• Typically progresses faster than Parkinson's disease.

Risk Factors For Parkinson's

Increases with age and average age at diagnosis is 65.

• Higher risk for the male gender.
• Envirnomental, and lifetime exposure to well water.
• Family history.
• Sleep disorder.
• Head trauma.

PD Stages

• Stage 1: Mild and limited to one side of the body, with no physical impairment.
• Stage 2: Mild, but on both sides of the body.
• Stage 3: Moderate with slow movements and loss of balance are common; may still live independently.
• Stage 4: Needs help with daily activities and can no longer live alone.
• Stage 5: Bedbound or unable to walk requires constant care.

Assessment for Parkinson's

• Gathering info about medical history.
• Physical exams.
• Assessing functional mobility and any environmental factors.
• Completing a cognitive and emotional assessments.

Associated Terms In Movement

• Dyskinesias: abnormal or impaired movements.
• Akinesia: absence or loss of voluntary movements.
• Akathesia: feelings of inner restlessness and an urge to move.
• Dystonia: abnormal muscle tone or tension.
• Ataxia: lack of coordination or accuracy of movements.
• Chorea: rapid and jerky movements.
• Myoclonus: twitching, jerking, or shaking movements.
• Tics: repetitive movements.
• Tremor: rhythmic movements.

Understanding MS

• MS, or la sclérose en plaques, is an autoimmune disease of the CNS, characterized by periods of relapse and remission.
• It leads to inflammatory processes and scarring.

Canadian Data for MS

• Canada is known to have of the highest rates of MS in the world.
• The country has 90,000 people living with MS, 1 in every 400 people.
• Approximately 4,377 people are diagnosed with MS each year.
• Diagnosed typically by age 43.
• MS is more prevalent with women.

Symptoms of MS

• MS symptoms vary widely
• Vision problems are common.
• Weak limbs.
• Tingling.
• Dizziness.
• Fatigue.
• Impaired sensation.
• Incontinence.
• Cognitive and mood changes.

Main Classifications of MS

• MS have 4 categories:
• CIS- Clinically isolated syndrome are single episode neurological symptoms.
• RRMS- Relapsing-remitting MS- is a more common type.
• SPMS- The slow worsening of symptoms over time
• PPMS - The increase of symptoms from onset.

Understanding Damage of MS

• The immune system attacks and destroys the myelin and the fibers.
• Causes localized areas of demyelination.
• Plaques interfere with transmissions.

Multiple Sclerosis Plaque

• B Cells: Immunoglobulins Produced by the CNS.
• T Cells: Anti-Inflammatory cytokines released.
• Microglia: Stimulate Interferon production.
• Macrophages: Damaging agents.

General Info about MS

• MS, or Multiple Sclerosis, is a disease attacking the brain and spinal cord.
• Key identifiers for diagnoses are IgG, CSF, oligoclonal.
• Diagnoses can lead to permanent or transient deficits (Uhthoff Sign).

Signs and Symptoms of MS

• Sensory abnormalities
• Autonomic abnormalities
• UMN signs affect motor function.
• Coordination.
• Cognitive impairment.
• Optic neuritis.

MS Nursing Considerations

• Identify symptoms.
• Track flares-ups.
• Manage symptoms.
• Educate patients about the condition.
• Promote safety and emotional support.
• Promote independence.
• Manage bowel issues.

Myasthenia Gravis

• It is an antibody-mediated autoimmune disease.
• Symptoms- Bulbar and respiratory muscles, the limb.
• The age peaks in adulthood when women are younger, and men are older.
• MG is linked to a tumor known as thymoma of the thymus gland.

MG Pathogenesis

• IgG antigens lead to end-organ damage or antibody damage against key substances.

Neuromuscular Junction - Contraction

• Neuromuscular junction: The process for immune dysregulation in MG.
• Muscles don't react as strongly to nerve signals.

Manifestations

• Key symptoms include: muscle weakness that worsens with movement.
• Early signs include a double vision.
• Generalization: most progress occur from muscle weakness to more widespread.
• Bulbar involvement.
• Limb weakness.
• Trouble breathing.

Understanding MG Crisis

• It a clinical diagnosis defined by respiratory failure from MG.
• Crisis occurs as a small portion of patient cases.
• MC can be caused by an infection.

Exam for MC Patients

• Extraocular muscles and pupil reactivity assessment.
• Sensation extremity assessment.
• Strength assessment.
• Evaluate for ptosis and fasciculation.

Conditions

• Includes examination features, neuromuscular and neurologic components.

Explanation of GBS

• GBS means Guillain-Barré Syndrome.
• Is immune system damaging the peripheral nerves.

Understanding Phases of GBS

• Includes: Preceding infection, autoimmune responses, Acute weakness, treatment, monitoring, and recovery.

GBS Pathophysiology

• A humoral immune disorder that causes progressive phases.

Needed Actions for GBS in Practices

• GBS requires awareness in the legs and arms.

GBS Symptoms/ Assessment

• In GBS, rapid symptoms, and are mostly symmetrical.
• Includes assessment, and monitoring.

ALS Description

• ALS- Amyotrophic Lateral Sclerosis.
• Is lower and upper cord motor neurons.

Progressive Muscle Weakness ALS

• Muscles wasting is a common occurrence.

• Genetic factors affect the muscles.

ALS Patho Processes

• Mutant proteins interfere with cellular function and processes.

Characteristics of ALS

• Characterized by damage, affecting cell components.
• The damage is typically in the motor region.

ALS Classification

• In classical forms, is in both motors.
• There are upper and lower regions that affect function.

Types of Brain Tumors

• Origin: Start to develop within tissue or nearby around cranial nerves.
• Cell Mutation: Where DNA leads to cell growth with death.
• Formation: is where it accumulates.
• Naming: Is named after cells being involved.
• Risk factors include: Exposure.

Brain Tumor Symptoms

• Headaches.
• Seizures.
• Nausea.
• Affect thinking, behavior, and physical ability.
• Issues in coordination.

The General Definition of Headaches.

• Types of headaches broadly with over 150 disorders as recognized.
• Over activity includes such items may include tension, and cluster.
• Originate in relation to surrounding nerves.

Types of Headaches

• Migraine causes throbbing or pulsing pains.
• There are frequent forms of migraine

Nursing Process Assessment - Headaches

• Onset of headaches.
• Frequency
• Level, of frequency.

Evaluations of Headaches Patients

• Includes: Imaging reports.
• Develop all care, plus record findings.