Adult Neurological Disorders PDF

7046 Adult Neurological Disorders Dr. Kim Ballone, FNP-BC  Cerebral Function Performs higher functions, interpretation of touch, vision and hearing a well as speech, reasoning, emotions, learning and fine control of movement Four lobes of the brain Frontal...

7046 Adult Neurological Disorders Dr. Kim Ballone, FNP-BC  Cerebral Function Performs higher functions, interpretation of touch, vision and hearing a well as speech, reasoning, emotions, learning and fine control of movement Four lobes of the brain Frontal lobe: cognitive function, control of voluntary movement Parietal lobe: processes information about temperature, taste, touch and movement Occipital lobe: primarily responsible for vision Temporal lobe: processes sound, auditory language, and speech comprehension  Cerebellar Function The cerebellum is responsible for balance and coordination Assessment techniques to evaluate cerebellar function: Romberg Test Evaluates proprioception and cerebellar function Ask patient to stand feet together, eyes closed and arms at the side, looking for a sway Finger to nose test (FNT) The patient alternately points from his nose to the examiner’s finger to assess correct vision and perception (correctly placing finger to nose) Heel to shin test The patient runs the heel of one foot along the shin of the opposite leg  Review of 12 Cranial Nerves CNI Olfactory Smell Sensory CNII Optic Vision (Snellen Chart) Sensory CNIII Oculomotor EOMs, pupillary reaction Motor CNIV Trochlear Down and In Eye movement Motor CNV Trigeminal Mastication, sensation scalp/face/cornea/nose Both CNVI Abducens Lateral eye movement Motor CN VII Facial Moves face, close mouth, tear & saliva secretion Both CNVIII Acoustic Hearing and equilibrium Sensory  Review of Cranial Nerves CNIX Glossopharyngeal 1/3 Phonation, gag, swallowing, Both taste (posterior). Say Ah CNX Vagus Talking, swallowing, carotid reflex Both CNXI Spinal Accessory Shrug shoulders Motor CNXII Hypoglossal Moves the tongue Motor CN III, IV, VI test extraocular movements (tested together)  Short cut to remembering Cranial Nerves https://www.youtube.com/watch?v=FtJtYMRVw7A “Oh Oh Oh To Touch And Feel A Girl’s Vagina So Happy” TYPE OF NERVE Some Say Marry Money But My Brother Says Big Business Matters Most  Review of Headaches Tension Headaches Most common type of headache- 90% Signs & Symptoms Vise-like or tight sensation (band like pain that is dull) Usually generalized around the neck or back of the head, stiff shoulder No associated focal neurological symptoms Usually lasts for several hours Affects adults more Triggered by emotional/physical stress, mental tension, head and neck movements Management: Over the counter analgesics (Naproxen BID, Ibuprofen QID, Aspirin q 4-6 hr, Tylenol) Combo Ibuprofen + Aspirin Relaxation  Headaches Migraine Headaches- Related to dilation and excessive pulsation of branches of the external carotid artery. Lasts 2-72 hours following the trigeminal nerve pathway. Classic migraines (with aura): see spots/lights, numbness/tingling , prodrome several days before attack (irritable, no energy food cravings), sense of doom/fatigue Common migraines (without aura): most common: throbbing pain behind one eye, photophobia, phonophobia, nausea/vomiting Onset usually in adolescence or early adult years, often have a family history. Individual appears ill. More females than males. Have variety of triggers: physical stress, missed meals, change in weather/season, nitrates in food (processed meats), aspartame, sleep disturbance, alcohol (wine), menstruation, use of birth control. Signs & Symptoms: Unilateral, lateralized pounding/throbbing headache, occurs episodically Builds gradually, last for hours, visual disturbances ar common, aphasia, numbness and tingling, nausea and vomiting, photophobia (light sensitivity), phonophobia (fear of loud sounds) Laboratory/Diagnostics: CBC, BMP, ESR, VDRL, CT scan of the head Management for Acute Attack: Rest in dark room, Simple analgesics (ASA), antiemetic if n/v Sumatriptan (Imitrex) 6 mg SQ at onset, may repeat in 1 hr (max 3x per day). Good choice with severe n/v Sumatriptan (Imitrex) 25 mg orally at onset of headache Prophalactic daily therapy if attack occurs more than 2-3 times per month Treximet (NSAID-triptan)  Headaches Cluster headaches- Very painful, abrupt, unilateral, ice pick, periorbital pain occurs daily for several weeks. Months or weeks between attacks. Affects middle-aged men. Usually occurs at night, awakens from sleep or same time daily, from alcohol consumption, tobacco use, history of head trauma Ipsilateral nasal congestion, rhinorrhea, and eye redness may occur (Horner’s syndrome) Diagnostics: MRI (AVM, aneurysms, macroadenoma, meningiomas) Management: Sumatriptan (Imitrex) 6mg SQ may be effective Inhalation of 100% O2 may help (10-15 L nonrebreather) Ergotamine tartrate aerosol (Ergostat), lidocaine, octreatide may be effective Prophylaxis: Verapamil 240 mg daily, glucocorticoids  Review of Seizures A transient disturbance of cerebral function due to an abnormal paroxysmal neuronal discharge or hyperexcitability in the brain Causes / Incidence Congenital abnormalities and perinatal injuries Metabolic disorders: hypocalcemia, hypoglycemia, renal failure Trauma in adolescents Tumors and lesions Infectious diseases: Bacterial meningitis, herpes encephalitis, neurosyphilis Seizure threshold is lowed with fever  Review of Seizures International Classifications of Seizures Certain medications like Carbamazepine and pregabalin treat focal but not generalized. Partial Focal origin: one hemisphere, localized abnormalities on eeg (Only on one side of brain is affected – unilateral). Simple partial seizures (focal seizure with retained awareness) No loss of consciousness Motor, autonomic and sensory symptoms (Will present with an aura (epigastric rising, stomach sensation) Complex partial seizures (focal seizure with impaired awareness) Impaired consciousness- appears awake, staring more than 20 seconds before, during, or after symptoms, lip smacking, picking Most common type in adults with epilepsy  Review of Seizures Generalized: Involves both hemispheres- (both sides) Tonic-clonic (Grand Mal)- Most common generalized seizure. Begins with abrupt LOC (confusion), violent/generalized contractions, stiff extremities, cyanosis. Muscles jerk and twitch, tongue may be bitten Tonic: sudden muscle stiffening, often with impaired consciousness and falling Clonic: rhythmic jerking muscle contractions usually involving neck, arms, face Absence (Petit Mal)- in childhood, daydreaming. Lasts 5-10 sec, onset marked by behavioral arrest Atonic- Drop seizure: Sudden loss of muscle control (usually in legs) that causes collapse to ground Status Epilepticus- incontinence, injury, tongue biting, postictal confusion, lateralized weakness, severe headache  Types of Generalized Seizures Absence (Petit Mal) Brief staring episodes (daydreaming) lasts 10-20 seconds (infant of child blinking, smacking lips over and over) Onset and termination are brief Usually begins in childhood (ADHD) Tonic Sudden increase in muscle tone producing characteristic postures Consciousness is usually partially or completely lost Postictal alteration of consciousness is brief, lasts several minutes (confusion)  Types of Generalized Seizures Tonic-clonic (Grand Mal seizure) Sudden loss of consciousness with arrested respirations Clonic phase involves increased muscle tone followed by bilateral jerks lasts 2-3 minutes followed by flaccid coma Urinary and or fecal incontinence may occur and is common with a tonic clonic Postictal state characterized by deep sleep for up to an hour, headache, disorientation, muscle discomfort and nausea, can last minutes to hours (common with a tonic clonic) Status Epilepticus- Series of grand mal seizures of > 10 minutes, refer to ED  Management of Seizure Labs/ Diagnostics Identify cause CBC with diff for infection/low electrolytes (Ca, Mg, Ph), Glucose, renal function tests, liver function tests and serologic test for syphilis, tox screen Other tests to rule out suspected etiology (MRI of head (tumor), LP (meningitis) for all new onset seizures) EEG – Most important test to determine seizure classification  Management of Seizures Maintain open airway, protect patient from injury, administer blow by oxygen if cyanotic, do not force artificial airway or object between teeth Initiate antiseizure medication with two or more unprovoked seizures Parenteral anticonvulsants (initial): Lorazepam (Ativan), Benzodiazepine (Valium) to stop convulsive seizures Broad Spectrum (Both focal and generalized): Keppra, Lamictal, sodium valproate, topiramate Managing seizures: Phenytoin (Dilantin), Fosphenytoin (Cerebyx) is more common Seizure prevention maintenance doses of long-acting anticonvulsants: Carbamazepine (Tegretol), Valproic acid (Depakene), Primidone (Mysoline), Clonazepam (Klonopin)- always taper and never abruptly withdraw (can induce a seizure) Referrals to Neuro: if seizures continue, regression of developmental skills, regression of cognitive function, side effects worsen  Bell’s Palsy An acute, unilateral, full facial palsy of unknown etiology that can progress within 24 hours. Most commonly diagnosed peripheral facial nerve condition. Assumed to be initiated by a triggering event that causes stress on the body (URI or nerve ischemia) Accounts for 50% of all cases of lower facial motor neuron paralysis Cranial nerve VII: facial nerve Herpes Simplex Virus (HSV) believed to be the cause in most cases Men and women equally affected, most common in young, middle-aged adults Either side of face affected, recent respiratory tract infection reported Higher incidence for women in last trimester or first week post partum/preeclampsia  Image of Bell’s Palsy Affects trigeminal (facial) nerve. Scared they may have stroke, but usually both the eye and mouth is affected and cannot move forehead in Bell Palsy. A stroke usually has one or the other affected and can move forehead  Clinical Presentation Typical onset is acute, rapid and progressive. Maximum paralysis occurs within 48-72 hours Report of pain behind the ipsilateral ear preceding the facial paralysis Face feels stiff and pulled to one side; unable to move forehead (Unlike with CVA can move forehead) Unable to close eyelid, smooth forehead, flattened nasolabial fold, widened palpebral fissure, asymmetric smile Tearing, drooling, tinnitus, post-auricular pain, mild hearing deficit Dysgenusia (altered taste) and hypersensitivity to sound (Hyperaucusis)  Diagnostics Laboratory CBC with diff, TSH, Angiotensin-converting enzyme, Serum glucose, Pregnancy test (HCG), Lyme titer with tick exposure or in epidemic areas Imaging- MRI to rule out CVA if necessary, but not common Differential diagnoses Otitis media Meningitis Lyme disease Leukemia  Management of Bell’s Palsy Protect the eye is the single most important goal (cannot blink)- prn artificial tears q 1-2 hours. Exposure keratitis can result in blindness and cornea must be protected from dust/debris Protective eyeglasses/moisture chambers (mineral oil and white petrolatum ointment), close and tape eyelids at night Massage of weakened muscles Oral glucocorticosteroids- prednisone 60-80 mg/day for 1 week then taper the 2nd week (start within 72 hours of symptom onset) Antivirals coadministered with glucocorticoids if severe palsy- Valacyclovir 1000mg 3x/day for 1 week or acyclovir 400 mg five times daily NSAIDs or Tylenol  Trigeminal Neuralgia Nerve disorder that causes a stabbing, electric (shock like) unilateral pain in maxillary and mandibular distributions of trigeminal nerve (below eyes to chin, close to nasal border/cheeks) Causes: Common in women > 50, Multiple Sclerosis, pressure on the trigeminal nerve from a swollen blood vessel or tumor, talking, chewing, shaving, brush teeth, hot/cold food, cold wind. Affects older adults/elderly most Findings: Facial spasms, possible diminished sensation over affected side, otherwise normal exam Signs & Symptoms: Painful spasms that last seconds to 2 minutes but can happen up to hundreds of times daily, pain is unilateral Labs/Diagnostics: Neuro/CN exam, MRI (tumor pressing on nerve), Trigeminal reflex testing Management: Anti-seizure drugs: Carbamazepine (Tegretol) and oxcarbazepine (gold standard for initial treatment), muscle relaxants (baclofen), Tricyclic antidepressants, gabapentin, pregabalin, lamotrigine, phenytoin, microvascular decompression  Multiple Sclerosis (MS) Autoimmune disease marked by numbness, weakness, loss of muscle coordination, and problems with vision, speech and bladder control, with exacerbations and remissions The immune system attacks myelin, a key substance that serves as a nerve insulator and helps in the transmission of nerve signals Affects young adults (more females), between 20-50 years of age Signs & Symptoms: weakness, numbness, tingling or unsteadiness in a limb that may progress to all limbs, spastic paraparesis, diplopia (double vision), disequilibrium, urinary urgency, optic atrophy, nystagmus Labs & diagnostics: Elevated CSF protein, IgG, MRI of brain to assess MS lesions, Mild lymphocytosis and protein in CSF are common Management: Immunomodulatory therapy (IMT) reduces relapses and slows progression, Interferon therapy, Immunosupression, Plasmaphoresis Images of Multiple Sclerosis Longstanding multiple sclerosis plaques are areas of permanent damage and can be seen as “black holes” on MRI.  Myasthenia Gravis Autoimmune disorder resulting in the reduction of the number of acetylcholine receptor sites at the neuromuscular junction Affects 20-40 yr old may occur at any age. Especially females in their 30s + males in 50-60s. Signs & Symptoms: weakness worse after exercise and better with rest, ptosis, diplopia, dysarthria, dysphagia, fatigue, extremity weakness, respiratory difficulty Labs/Diagnostics: Antibodies to acetylcholine receptors are found in the blood in 85% pts, Edrophonium (Tensilon) test to help diagnose (muscles get stronger after being injected with Tensilon, it’s indicative of myasthenia gravis) Management: Neuro referral, Anticholinesterase drugs: pyridostigmine bromide (Prostigmin) to block the hydrolysis of acetylcholine are used for symptomatic improvement, Immunosupressives, Plasmapheresis, Ventilator support during crisis  Acute Cerebral Vascular Syndrome (ACVS) or Transient Ischemic Attack Periods of acute cerebral insufficiency lasting less than 24 hours without any residual deficit (infarct) as seen in stroke Causes Ischemic due to atherosclerosis, thrombus, arterial occlusion, embolus, intracerebral hemorrhage Rupture in artery primarily from hypertension Cardio-embolic events (atrial fib, acute MI, endocarditis, valve disease) TIA is indicative of an impending stroke. The longer the TIA, the higher the risk for ischemic brain damage Approximately 13% of pts with TIA will experience cerebral infarction within 5 years Risk factors: age > 60, history of TIA/stroke within 30 days of event, diabetes, BP > 140/90, TIA duration > 10 min  Signs and Symptoms of TIA Altered vision in one eye: Ipsilateral monocular blindness (amaurosis fugax). Painless loss of vision described as a shade descending over the visual field Altered speech: Dysphagia- slurred speech, Transient aphasia/dysarthria: temporary inability to speak/speech problems Motor impairment: Paresthesias of contralateral arm, leg, or face Sensory deficits: Hemiparesis, Hemisensory loss Cognitive and behavioral abnormalities Vertigo Nystagmus  Diagnostics & Management for TIA Laboratory/Diagnostics CT is best for distinguishing between ischemia, hemorrhage and tumor (within 24 hours of event). MRI is superior to CT in detecting ischemic infarcts Carotid Doppler/Ultrasound/Echo for cardioembolic source Cerebral angiography CBC, coag panel, CMP, glucose, lipid panel, Hgb A1C, ESR, CRP Management Aspirin 81-325 mg daily and Plavix to reduce the incidence of stroke and death Assess for hypertension (maintain BP < 140/90). Labetalol or nicardipine, intense statin therapy Carotid endarterectomy decreases the risk of stroke and death in pts with recent TIAs if they have an occluded carotid artery  ABCD Score for Acute Cerebral Vascular Syndrome (Transient Ischemic Attack) Criteria Points if positive Age> 60 years 1 point BP > 140 systolic/>90 diastolic 1 point Unilateral weakness with or without speech changes 2 points Speech changes, no unilateral weakness 1 point Duration > 60 minutes 2 point Duration < 59 minutes 1 point Diabetes 1 point  Guide to ABCD Scores ABCD Score 48 hr stroke risk Comment 1-3 points 1% Obtain Neuro consult to evaluate asap 4-5 points 4.1% Hospitalization Justified 6-7 points 8.1% Hospitalization Beneficial Low risk TIA if < 4: Aspirin alone (162-325 mg/day) High risk TIA if > or equal to 4: Hospital + Dual antiplatelet therapy using aspirin (160-325 mg loading dose, followed by 50-100 mg daily, plus clopidrogel (Plavix) 300-600 mg loading dose, then 75-100 mg daily for first 21 days  Tips to remember! Immediate ED referral or physician consultation is indicated for all patients with suspected cerebral vascular accident.  Parkinson’s Disease Parkinson’s Disease (PD) is a slowly progressive neurodegenerative disease with an insidious onset of the cardinal features of an asymmetric resting tremor, bradykinesia, and rigidity, commonly with postural changes. PD develops after widespread depletion of dopamine in the substantia nigra nigrostriatal pathway to the caudate putamen  Subtypes of Parkinson’s Disease  Primary (idiopathic- most common)  unknown origin but not induced by obvious stimulus  Secondary (parkinsonism)  related to drugs, stroke, or trauma, other stimuli  Familial  genetically linked  accounts for < 20% of the diagnosed cases  Parkinson’s Disease  Considerable dopamine loss must occur before the disease is apparent  clinical diagnosis is usually made after  80% loss in basal ganglia dopamine content  symptoms may emerge after a 60% reduction in basal ganglia dopamine content  The disease is probably present > 20 years before diagnosis  Incidence  Onset usually appears after age of 40 years  but can begin at any time including childhood when it is termed juvenile parkinsonism  affects 1% aged 50 years and over  10% aged 60 years and over may have undiagnosed, early stages of the disease  about 1½ times more common in men than in women  Symptoms of Parkinson’s Disease  Flexed posture (postural instability)  Bradykinesia: Difficulty initiating movement  Shuffling gait with decreased arm swing  “Cogwheel” or muscular rigidity (early sign that can help diagnosis Parkinson’s)  Asymmetrical tremor at rest (pill rolling is an early sign that increases when walking)  Advanced stages may include psychiatric complications  depression  hallucinations  Paranoia  Cognitive decline  Physical exam for the Patient with PD Postural reflexes- firm pull on the shoulders from behind Rigidity – Cogwheeling: test by flex/extend elbow or supine/pronate the forearm Walking marked by festination- walks with fast short steps with flexed center core Freezing- transient inability to perform motor movements (ie. feet glued to ground) Bradykinesia- immobile pt may move with sudden burst motor movement The Gold Standard for diagnosis is post mortem neuro-pathologic examination of the brain.  Treatment Selegiline (Eldepryl) is a monoamine type B inhibitor May delay the destruction of the nigral neurons and inhibit the breakdown of dopamine Levodopa (L-dopa) therapy (L-dopa is a dopamine precursor). Sinemet (Levodopa/Carbidopa 25/100 TID with meals) Generally, very effective for the first 2 to 5 years of treatment after which the on-off effect develops Direct-acting dopamine receptor agonists Ropinirole, pramipexole, bromocriptine with Levodopa Take at night (cause orthostatic hypotension) Anticholinergics/Amantadine Benztropine (Cogentin) and phenidyl (Artane)- in young patients for bad tremor and rigidity Experimental brain surgery- Deep Brain Stimulation lesions of nuclei that inhibit basal ganglia remove inhibition of dying neurons, they may be more active = motor control neural tissue implants (e.g., fetal dopamine cells) Comparison of the Brain of Patient with Parkinson’s Disease No signs of stroke or brain tumor, most MRI/CAT scans of people with Parkinson's is normal. If there is a normal scan but have symptoms of Parkinson’s, then has Parkinson's. PET scan can detect low levels of dopamine in the brain A 20 year old patient has recently been diagnosed with migraines. The NP is educating the patient about factors that are known to trigger migraine headaches. Which of the following is incorrect advice? A. Avoid foods high in tyramine content B. Avoid foods with high potassium content C. Get enough sleep D. Avoid fermented foods  The correct answer is: B. Avoid foods high in potassium Rationale: Foods that are high in potassium are not associated with migraines. Foods high in tyramine content (blue cheese, smoked meats, salami, beer, soy) and change in sleep, and fermented food all possibly trigger migraines.  You are examining a patient diagnosed with Bell’s palsy. Bell’s palsy is characterized by all of the following except: A. Drooling B. Inability to swallow C. Inability to close the eye on the affected side D. Drooping of the corner of the mouth of the affected side  The correct answer is: B. Inability to swallow Rationale: Bell’s Palsy (acute idiopathic facial nerve palsy) is caused by inflammation of cranial nerve VII (Facial nerve). CN VII does not innervate the throat, so swallowing is not affected. All other answers are symptoms of Bell’s palsy  8. A quality of a partial seizure is: 1. Status epilepticus. 2. Tonic movements. 3. Fluttering eyelids. 4. Clonic movements.  A child who had a seizure one hour ago is exhibiting signs of paralysis on the left side of the body. The nurse understands the child is exhibiting signs of: 1. Lethargy due to previous seizure activity. 2. Postictal paralysis. 3. Permanent paralysis of the left side of the body. 4. Major brain damage that is going to have long-term effects  An 18 month old is having a seizure when the nurse is assessing him. The nurse notes that the child is fluttering his eyes and smacking his lips. The nurse should document this seizure as: 1. An absence seizure. 2. A tonic-clonic seizure. 3. A myoclonic seizure. 4. A febrile seizure.  A 9 month old is admitted to the pediatric unit for seizures of unknown origin. The child has an EEG performed for several hours. The EEG notes several seizures occurring at different intervals. The nurse knows this child: 1. Will develop at the same rate as his peers. 2. May have severe mental and physical challenges due to the frequent seizure activity. 3. May exhibit a slight cognitive delay as he grows. 4. Will grow out of having seizures.  A child has been status epileptics for the last 20 minutes. The child has Depakote, Valporic Acid, and Diazepam gel ordered. The nurse should prepare which medication for administration at this time? 1. Depakote 2. Valporic acid 3. Diazepam 4. None of the medications. The child will stop on his own.. Care for a child during status epilepticus should include all of the following except: 1. Turn the patient to the right side. 2. Loosen tight clothes. 3. Move toys out of the area to prevent injury. 4. Stay with the patient until the seizure has stopped  The nurse is identifying the difference between primary headaches to secondary headaches. Secondary headaches can occur: 1. Because of stress. 2. In relation to low blood pressure. 3. Because of concussions. 4. Because of migraines.  The assessment a nurse performed on a 12-year-old boy demonstrated a positive Kernigs sign and a Brudzinskis sign. Identify the priority for the nurses next action. 1. Document the findings and note as normal. 2. Further assess the neurological function of the child and call the doctor with a report. 3. Explain to the patient that the assessment was abnormal and there is no a cause for concern. 4. Prepare the child for a lumbar puncture  Results from cerebrospinal fluid that was tested for meningitis have been received by the nurse. The results indicate bacterial meningitis. The nurse knows this because the results show: 1. A low protein count and a low glucose count. 2. A low red blood cell count. 3. An elevated protein count and a low glucose level. 4. A normal protein count and a high glucose count  A 10 year old is hit in the head with a baseball during practice and is diagnosed with concussion, even though no loss of consciousness occurred. The primary care pediatric nurse practitioner is evaluating the child 2 weeks after the injury and learns that the child is still experiencing some sleepiness every day. The neurological exam is normal. The child and the parent are adamant that the child be allowed to return to play baseball. What will the nurse practitioner recommend? A. Continuation of cognitive rest only B. Continuation of physical and cognitive rest C. Continuation of physical rest only D. Returning to play