Neurological Disorders Lecture PDF - Vanderbilt School of Nursing

NURS 6030 – Advanced Practice Nursing in Primary Care of the Adult Neurological Disorders Melissa Glassford, DNP, FNP-C Learning Objectives At the end of this lecture, students will be able to: ü Describe strategies for evaluation and management of common neurological complain...

NURS 6030 – Advanced Practice Nursing in Primary Care of the Adult Neurological Disorders Melissa Glassford, DNP, FNP-C Learning Objectives At the end of this lecture, students will be able to: ü Describe strategies for evaluation and management of common neurological complaints ü Develop differential diagnoses based on history and physical exam findings ü Identify appropriate treatment and indications for referral Common neuro complaints in primary care Headaches Dizziness Weakness Paresthesia Memory TIA or CVA Syncope Seizures loss Headache ► Primary Migraine Women > men Tension-type Cluster *Not symptomatic of an underlying condition* ► Secondary Headache Differentials ► Infectious Sinusitis Meningitis Abscess Earache Lyme Disease COVID-19 Headache Differentials ► Inflammatory RA Temporal arteritis Trigeminal neuralgia SLE Headache Differentials ► Structural Tumor Hemorrhage Aneurysm Subdural hematoma Headache Differentials ► Metabolic Thyroid dysfunction Pheochromocytoma Sleep apnea ► Other Pseudotumor cerebri Trauma Migraines Epidemiology Affects 12% of general population women > men Genetics account for 40-50% of individual susceptibility Migraine without aura accounts for 75% Migraine Presentation ► Disorder of recurrent attacks ̶ 4 phases ̶ Prodrome ̶ Aura ̶ Headache ̶ Postdrome Migraine POUND ► Migraine 92% likely if 4 or more present § Pulsatile § One day duration § Unilateral § Nausea or vomiting § Disabling intensity Migraine Triggers Hormones in Sleep Emotional Not eating Weather women (65 disturbances stress (80%) (57%) (53%) %) (50%) Neck pain Alcohol Odors (44%) Lights (38%) Smoke (36%) (38%) (38%) Sleeping late Exercise Sexual Heat (30%) Food (27%) (32%) (22%) activity (5%) Migraine WITHOUT Aura Criteria A. At least 5 attacks fulfilling criteria B through D B. Headache lasting 4-72 hours C. Headache has at least 2 of following: Unilateral location Pulsating quality Moderate or severe pain intensity Aggravation by or causing avoidance of physical activity D. During headache at least 1 of the following nausea, vomiting or both Photophobia or phonophobia ICHD-3 Criteria Migraine WITH Aura Criteria A. At least 2 attacks fulfilling criteria B through C B. 1 or more of the following fully reversible aura symptoms Visual, sensory, speech/language, motor, brainstem, retinal C. At least 2 of the following 4: 1 aura symptom spreads >5 min and/or 2 auras occur in succession Each individual aura symptoms lasts 5 to 60 min At least 1 aura symptom is unilateral Aura is accompanied or followed within 60 min by headache ICHD-3 Criteria Physical Exam ► Vital signs ► Fundoscopic ► Palpation of head, neck and sinuses ► Palpate TM joint ► Cardiopulmonary ► Examination of cranial nerves ► Evaluation of motor and balance ► Mental Status Work Up ► Labs ̶ CBC with diff ̶ ESR ̶ Thyroid function ̶ Lyme titer ̶ RH factor ► Imaging ̶ CT or MRI? Diagnostics ► Choose wisely ̶ Don’t perform imaging in patients with stable headaches who meet criteria for migraine ̶ Consider in patient’s with a red flag or focal neuro deficit ̶ Ask yourself if you should refer instead Abortive Pharm Management ►Mild to moderate attacks § NSAIDS § Acetaminophen § Aspirin ►Warn about rebound*** ►Can add antiemetic Abortive Pharm Management ► Moderate to severe attacks ̶ Imitrex® (sumatriptan) ̶ Maxalt ® (rizatriptan) ̶ Relpax® (eletriptan) ̶ Zomig ® (zolmitriptan) ► *Can combine triptan with NSAID* ̶ Treximet® (sumatriptan + naproxen) Are Triptans Safe? Absolute Contraindications ►Cardiovascular risk? § Selective for cranial arteries Hemiplegic migraine § Should not be given to patients with Basilar migraine known vascular dz ►Drug interactions Ischemic stroke § Contraindicated with ergotamines & MAO inhibitors Ischemic heart disease ►Pregnancy? Prinzmetal’s angina § Not studied but sumatriptan considered low risk Uncontrolled HTN (Roberto et al., 2015); (Dodick, Martin, Smith, & Silberstein, 2004); (Hall, Brown, Mo, & MacRae, 2004); (Jamieson, 2002) In Office Options Sumatriptan Ketorolac Diphenhydramine Dexamethasone 6mg subq 30-60mg IM 12.5-25mg IM 12-25mg IM Non Pharm Management § Relaxation training § Biofeedback § Acupuncture § Cognitive behavioral therapy Preventive Pharm Management ►Goal is to ↓ headache intensity and frequency § When to consider? ►Examples: § Beta blockers: propranolol § Antidepressants: SSRIs or tricyclic (amitriptyline) § Anticonvulsants: topiramate, valproate § Calcitonin gene related peptide Alternatives for Prevention Butterbur Coenzyme Q10 150mg 100mg BID TID Feverfew Magnesium 6.25mg 600mg TID QD (Diener, Pfaffenrath, Schnitker, Friede, & Henneicke-von Zepelin, 2005); (Holland et al., 2012); (Teigen & Boes, 2015) Medication Overuse Headaches ►Common culprits § Opioids § Butalbital combos § Caffeine combos § NSAIDs ►Prevention § Do not take these meds more than 10 days/month § Consider prophylactic med for primary headache disorder Approach to Treatment ► Educate patient about condition ► Use migraine specific agents ► Use non-oral route with early nausea/vomiting ► Consider self administer rescue med ► Guard against medication overuse headaches ► Know that headache types can overlap Headache Misconceptions ► Sinus headache? ► Eye strain? ► Hypertension?? Tension Type Headaches ► Classified by frequency ► Etiology § Multifactorial § Heightened sensitivity § Precranial muscle tenderness ► Precipitating factors § Stress and mental tension ► Relationship with migraine? Tension Type Criteria ►At least 2 of the following 1. Bilateral location 2. Pressing or tightening (non-pulsing quality) 3. Mild to moderate intensity 4. Not aggravated by physical activity ►Both of the following § No nausea or vomiting § No photophobia or phonophobia Differentials ►Brain tumor ►Sinus headache ►Medication overuse headache ►Migraine ►Arthritis ►TMJ ►Non-ergonomic work station Acute Treatment Options ►Simple analgesics § NSAIDs § Aspirin ̶ *Combine with caffeine* ► ►Caution about medication overuse headache ►Triptans may be effective for patients with co-existing migraine Preventive Treatment Options ► Pharm Best Evidence Limited Evidence Effexor® (venlafaxine) Topamax® (topiramate) Elavil® (amitriptyline) Neurontin® (gabapentin) ► Behavioral/complementary § Biofeedback, relaxation § Acupuncture provides modest benefit § Trigger point injections § Botulinum toxin injections Cluster Headache ► Trigeminal autonomic cephalalgias § Unilateral severe headache attacks with autonomic symptoms § Men > women ► Differentials § Trigeminal neuralgia § Alternate headache syndrome § Meningioma § Nasopharyngeal carcinoma § AVM ► Neuroimaging suggested to rule out secondary diagnosis Cluster Criteria A. At least 5 attacks fulfilling criteria B through D B. Severe unilateral orbital, supraorbital or temporal pain C. Either or both of the following ̶ 1. At least 1 of the following ipsilateral symptoms Conjunctival Nasal Lacrimation Rhinorrhea injection congestion Forehead and Eyelid facial Sensation or Miosis or edema sweating or ear fullness pitosis ̶ flushing ̶ 2. A sense of restlessness or agitation ICHD-3 Criteria Cluster Treatment ► Acute episode § 100% oxygen § Subq Sumatriptan ► Preventative § Verapamil (240-320mg QD but may go up to 480-960mg QD) § Glucocorticoids during initiation of verapamil § Topiramate can be effective add on to verapamil § Nerve blocks for refractory cases ► Refer Case Study ► 24 year old female ► HPI: Headaches x3 months, unilateral, pulsing/throbbing. Lasts for a day. Better with sleep. Feels nauseated, has to close eyes against pain. Pain 7/10. Worse prior to menstrual cycle. NSAIDs help some. ► ► Exam: normal Case Study ► 24 year old female ► HPI: Headaches off and on, worse around finals time. Hurts all over head, feels like a vice grip, sometimes has pain in neck. Headache usually lasts for a few hours. Pain 5/10. No associated symptoms. NSAIDs help some. ► ► Exam: normal Cranial Nerve Disorders ►Bell’s Palsy § Acute unilateral peripheral facial palsy § Viral causation most popular theory § More common in young and middle aged adults ►Risk factors 1st week 3rd Hypo- Recent Family post Diabetes Obesity trimester thyroid URI History partum Presentation ► Onset § Acute and progressive § Paralysis usually by 48 hours ► Symptoms Sparing of § Smooth forehead forehead § Flattened nasolabial fold muscles on § Asymmetric smile affected side is § Tearing, drooling, post-auricular pain suggestive of a § Tinnitus central lesion § Dysgeusia § Hyperacusis Diagnostics Differentials ►Lab: Consider Lyme titer Stroke, Tumor, MS Lyme, Guillian-Barre ►Imaging: Only in atypical Otitis media, mastoiditis presentation or bilateral nerve palsies Ramsay-Hunt, Zoster Pregnancy ►Degree of facial paralysis Diabetes, hypothyroidism § House-Brackmann scale § Photographic record Trauma Management ► Refer for atypical presentation, pregnancy, corneal abrasion, CNS involvement ► Prednisone 60mg for 5 days § Co-administer acyclovir 400mg QD for 7 days ► Eye care § Lubricating eye drops § Protective glasses § Tape closed at night ► Complications § Depression § Loss of vision § Hearing loss Cerebral Vascular Events ► Ischemic and hemorrhagic stroke § TIA or ACVS ► Symptom recognition § Weakness § Numbness § Paralysis § Severe headache § Impairment in cognition, speech, EOM, LOC § Emotional lability, aphasia, alexia, agraphia Differentials ►Migraine ►Arrhythmia ►Seizure ►Hyperventilation ►Tumor ►Drug overdose ►Syncope ►Cardiac arrest ►Transient global amnesia ►Conversion disorder ►Subdural or epidural hematoma ►Panic attack ►Systemic or neurologic infection ►Hypoglycemia Cerebral Vascular Events ► Prevention § Risk factor reduction § Stroke symptoms recognition and emergency treatment ► Follow-up § Address each physical impairment § Assess motor, sensory, perceptual, cognitive, speech Dizziness and Vertigo What is it? Causes Physical exam TiTrATE True vertigo Vestibular HEENT Timing Lightheadedness/ Neuro Cardiac Triggers syncope Cardiovascular Neuro Targeted exam Imbalance Psych Labs: CBC, TSH, B12, RPR, electrolytes, basic metabolic screen, glucose Dizziness and Vertigo Imaging? Audiometry Holter Management Abnormal neuro Performed if any If any suggestion Fall risk findings hearing loss of cardiac Antiemetics Progressive etiology Vestibular rehab unilateral hearing Refer loss Dizziness and Vertigo 40% Peripheral vestibular dysfunction Presyncope or Disequilibrium 25% Multicausal In older adults, 15% Psychiatric stroke is the most common 10% Central cause cause of Stroke dizziness 10% Unclear etiology Seizures ► 2.2 million with epilepsy in US § Men > women § Genetic predisposition § Seizure can be isolated event where neurons produce excessive electrical charges in brain ► Common causes in adults § Medications, trauma, infections, brain lesions § Strokes common cause of epilepsy in elderly ► Diagnosis § Primarily historical, look for post-ictal signs Seizure Differentials Cardiac Syncope Neuro Arrhythmias Migraine Metabolic TIA/CVA Transient amnesia Toxic ingestion Other AVM Movement Alcohol use or Infections of CNS disorder withdrawal Tumor Febrile seizure Hyperventilation Head trauma Psychogenic Sleep deprivation Parkinson’s Disease ► When to suspect § Tremor, rigidity, bradykinesia, postural disturbances ► Neuro referral § Neuroprotection § Symptom management § Meds, surgery ► Primary care management § Fall risk, home safety issues, health promotion Parkinson’s Disease ►Consider alternate diagnosis § Falls at presentation § Poor response to levodopa § Symmetric motor signs § Rapid progression § Lack of tremor § Dysautonomia early in dz course Meningitis ► Risk factors § Prior skull fracture or neurosurgery § Sickle cell disease § Asplenia, alcoholism, HIV ► Presentation Nausea, Altered 44% Fever, vomiting, consciousnes headache, photophobia s, seizures, stiff neck are common hypotension ► Prevention § MCV4 and MPSV4 § Pneumovax Multiple Sclerosis ►Chronic progressive inflammatory dz of CNS § Low vitamin D? § Exposure to Epstein-Barr? § Smoking? ►Presentation § Focal neural deficit § Eye pain or visual disturbance § Paresthesias or weakness of limbs ►Differentials B12 Disc Somatiza Alcohol Lyme Lupus Migraine Deficien Disease tion Use cy Delirium ►Presentation § Disturbance in attention, consciousness, cognition § Develops over hours to days ►Diagnosis § Distinguish between organic and psychiatric symptoms ►Management § Identify underling medical condition Delirium ► Diagnostics ̶ Differentials § Complete blood count § Infections § Basic metabolic panel § MI § Thyroid function § Anemia § Blood and urine tox screens § CVA/TIA § Medication levels § Dehydration § Urinalysis and culture § Vitamin deficiency § Anticholinergics § Chest x-ray § Narcotics § MRI or CT? Dementia Differentials ► 5 million people in US § Alzheimer’s is 6th leading cause of death in US Depression ► Presentation § Memory loss Hypothyroidism § Personality changes § Language disturbances § Difficulty with independent living Medication ► Classification Liver § Mild cognitive impairment (MCI) § Alzheimer's disease § Vascular Dementia Vitamin § Lewy Body deficiency Dementia Prevention ► Multimodality risk factor reduction § Physical exercise § Cognitive training § Vascular risk factor reduction § Control hypertension ► What has not been proven? § Omega-3 fatty acids § Mediterranean diet* § Alcohol § Vitamin supplementation (Livingston et al., 2017) Case Study ► You have a 31 year old male with onset of a severe headache in the past day, he has difficulty turning his head. He has been vomiting and can’t keep any food or fluids down. He has no significant medical history other than seasonal allergies. He has never had headaches in the past. ► What are you most concerned he has? Case Study ► You have a 78 year old female who has sudden onset confusion within the past 6 hours and was found by her daughter after falling in her home. She takes blood pressure medication and has a history of breast cancer. ► What are your differentials? Fibromyalgia ► Widespread musculoskeletal pain and fatigue § Disorder or pain regulation, central sensitization § Tenderness in anatomic areas ► Management § Exercise program § Pharm therapy: tricyclics, SNRI’s, muscle relaxors, anticonvulsants Fibromyalgia Work Up ►History of chronic widespread pain for > 3 months ►Rule out other conditions ►Physical exam: neuro, sleep and mood ►Labs: CBC, ESR, CRP, TSH ►Confirm presence of tender points (? Need 11 of 18) ►Confirm diagnosis (Goldenberg, Burckhardt, & Crofford, 2004 Shingles Zostavax Prevention! For adults > 60 years old. Given even if history of shingles Clinical Pain usually precedes rash along dermatome diagnosis Antiviral agents: famciclovir, acyclovir, valcyclovir Management Acute pain relief: prednisone 60mg/day with taper over 3wk Post herpetic Pain that is present 3 months after disease neuralgia Gabapentin is best agent Paresthesia and Neuropathy ► Differentials § Arterial disease § B12 deficiency § Nerve entrapment § TIA § Shingles § Exclude non diabetic etiologies ► Management § Treat underlying cause § Tricyclics, anticonvulsants § Consider pain referral Monofilament Testing ►Quantitative measurement of simple sensation § A foot able to sense monofilament is protected § Apply monofilament to skin with enough force for it to buckle § Generally test 6 sites Neuro Exam Components: Mental status Cranial nerves Motor/coordination Sensory system Reflexes References ► Diener, H. C., Pfaffenrath, V., Schnitker, J., Friede, M., & Henneicke-von Zepelin, H.-H. (2005). Efficacy and safety of 6.25 mg t.i.d. feverfew CO2-extract (MIG-99) in migraine prevention--a randomized, double-blind, multicentre, placebo-controlled study. Cephalalgia : An International Journal of Headache, 25(11), 1031–41. https://doi.org/10.1111/j.1468-2982.2005.00950.x ► Dodick, D. W., Martin, V. T., Smith, T., & Silberstein, S. (2004). Cardiovascular tolerability and safety of triptans: a review of clinical data. Headache, 44 Suppl 1(s1), S20-30. https://doi.org/10.1111/j.1526-4610.2004.04105.x ► Goldenberg, D. L., Burckhardt, C., & Crofford, L. (2004). Management of Fibromyalgia Syndrome. JAMA, 292(19), 2388. https://doi.org/10.1001/jama.292.19.2388 ► Hall, G. C., Brown, M. M., Mo, J., & MacRae, K. D. (2004). Triptans in migraine: the risks of stroke, cardiovascular disease, and death in practice. Neurology, 62(4), 563–8. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/14981171 ► Holland, S., Silberstein, S. D., Freitag, F., Dodick, D. W., Argoff, C., Ashman, E., & Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. (2012). Evidence-based guideline update: NSAIDs and other complementary treatments for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology, 78(17), 1346–53. https://doi.org/10.1212/WNL.0b013e3182535d0c References ► Jamieson, D. G. (2002). The safety of triptans in the treatment of patients with migraine. The American Journal of Medicine, 112(2), 135–40. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/11835952 ► Kelman, L. (2007). The triggers or precipitants of the acute migraine attack. Cephalalgia : An International Journal of Headache, 27(5), 394–402. https://doi.org/10.1111/j.1468-2982.2007.01303.x ► Livingston, G., Sommerlad, A., Orgeta, V., Costafreda, S. G., Huntley, J., Ames, D., … Mukadam, N. (2017). Dementia prevention, intervention, and care. Lancet (London, England). https://doi.org/10.1016/S0140-6736(17)31363-6 ► Pawłowicz, M., Birkholz, D., Niedźwiecki, M., & Balcerska, A. (2009). Difficulties or mistakes in diagnosing type 1 diabetes in children?-- demographic factors influencing delayed diagnosis. Pediatric Diabetes, 10(8), 542–9. https://doi.org/10.1111/j.1399-5448.2009.00516.x ► Roberto, G., Raschi, E., Piccinni, C., Conti, V., Vignatelli, L., D’Alessandro, R., … Poluzzi, E. (2015). Adverse cardiovascular events associated with triptans and ergotamines for treatment of migraine: Systematic review of observational studies. Cephalalgia, 35(2), 118–131. https://doi.org/10.1177/0333102414550416 ► Teigen, L., & Boes, C. J. (2015). An evidence-based review of oral magnesium supplementation in the preventive treatment of migraine. Cephalalgia : An International Journal of Headache, 35(10), 912–22. https://doi.org/10.1177/0333102414564891