Management of Neurological_Disorders.pdf

7/14/2023 NURS 5524 – Primary Care of the Adult/Elderly The Management of Neurological Disorders • July 19, 2023 • G. M. Rose, PhD, NP-C, FNP-BC Cranial Nerves • • • • • • CN I CN II CN III CN IV CN V CN VI Olfactory Optic Oculomotor Trochlear Trigeminal Abducens Cranial Nerves • • • • • • C...

7/14/2023 NURS 5524 – Primary Care of the Adult/Elderly The Management of Neurological Disorders • July 19, 2023 • G. M. Rose, PhD, NP-C, FNP-BC Cranial Nerves • • • • • • CN I CN II CN III CN IV CN V CN VI Olfactory Optic Oculomotor Trochlear Trigeminal Abducens Cranial Nerves • • • • • • CN VII CN VIII CN IX CN X CN XI CN XII Facial Acoustic Glossopharyngeal Vagus Spinal accessory Hypoglossal 1 7/14/2023 Headache • Headache is a common reason for primary care office visits and is a complaint in more than 1 percent of patient visits • Tension HA most common type • Migraine HA most frequently treated HA in primary care • About 45 million individuals in the US experience recurrent headaches annually International Headache Society (IHS) Classification System • Assists in diagnosis • Establishes standard of care for headache • Divides headaches into two general categories – Primary Headache – Secondary Headache Primary and Secondary Headache • Primary Headaches •Migraine with and w/o aura •Tension •Cluster 2 7/14/2023 Headache • Secondary • Associated with specific disorder, illness or lesion –Trauma –Cranial or cervical vascular disorder –Nonvascular intracranial disorders –Substance use/withdrawal –Infection –Disorders of homeostasis –Psychiatric disorders Headache: Primary Versus Secondary Primary Secondary • Not associated with other diseases • Likely complex interplay of genetic, developmental, and environmental risk factors • Associated with or caused by other conditions, generally does not resolve until specific cause is diagnosed and addressed • Migraine, tension-type, cluster • Intracranial issues or any condition that causes increased intracranial pressure Determining - Differential Diagnosis • Begins with the history – – – – – – Age of onset Location Frequency Duration Intensity and character Associated symptoms • Triggers and ameliorating factors • Medications • Associated with physical and neurological symptoms • Impact on work and family • Psychological symptoms • History of head trauma • Previous imaging and results • Family history 3 7/14/2023 Headache Red Flags • Thunderclap headache • Sudden onset of severe head pain with neck stiffness that may be associated with altered consciousness or focal neurological deficits; suggests – subarachnoid hemorrhage • Acute onset severe headache • Worst headache ever • Late onset of new headache (> 50 yrs.) • Associated w/ fever, rash, stiff neck • Progressively worsening Headache Red Flags (cont’d) • Associated with exertion, sexual activity, coughing or sneezing • Headache starting after exertion or Valsalva's maneuver • Headache awakens patient at night • Change in well-established headache pattern • New-onset headache in patient who has HIV infection or previously diagnosed cancer • Associated with focal signs and symptoms Headache “Red Flags” (cont’d) • • • • • • • Systemic symptoms Neurological signs/symptoms Onset Onset (age at onset of headache) Previous headache history Positional Papilledema 4 7/14/2023 Diagnostic Tests • Diagnostic test are usually not warranted when history is consistent w/ typical primary type headache (migraine, tension, cluster) and normal physical exam • The presence of ominous warning signs and/or focal symptoms warrants further diagnostic tests and referral to a neurologist Preferred Diagnostic Tests • • • • • • • • • • Noncontrast computed tomographic (CT) scanning Magnetic resonance imaging (MRI) Cerebrospinal fluid (CSF) Lumbar Puncture Sinus series CBC, CMP and TSH Cervical x-rays EEG Sedimentation rate RPR Algorithm of Differentiating Primary and Secondary Headache Detailed History Physical Examination Ominous Warning Signs Focal Signs and Symptoms Present? YES Rule out secondary HA Order appropriate diagnostic tests NO Follow IHS Differential Diagnosis Primary Headache Disorders 5 7/14/2023 Some Characteristics of Headache Disorders by Cause Cause Suggestive Findings Diagnostic Approach Cluster Multiple unilateral orbitotemporal attacks, often at the same time of day Deep, severe, lasting 30–180 minutes Often with lacrimation, rhinorrhea, facial flushing, or restlessness Clinical evaluation Migraine Unilateral or bilateral and pulsating, lasting 4–72 hours Occasionally with aura Usually nausea, photophobia, sonophobia, or osmophobia Worse with activity, preference to lie in the dark, resolution with sleep Clinical evaluation Tensiontype Frequent or continuous, mild, bilateral, and viselike occipital or frontal pain that spreads to entire head Worse at end of day Clinical evaluation Migraine Headache • Comparatively common disorder with great disability burden • Present with or without aura • Occurs 3 x more often in women than men • >80% of individuals with migraine have a family history • Can begin in childhood – (2 -5%) of all children in the US – Incidence increases to 10-20% during the second decade Migraine Headache • • • • Common: >30 million U.S. residents More common in women (17.1%) than men (5.6%) 1 in 6 women will experience migraine Peaks between early and middle adulthood, then declines • After age 40, severity and frequency decline, except in perimenopausal women • Onset after age 50 is rare 6 7/14/2023 Etiology – Migraine Headache • Etiology not clearly understood • Growing evidence supports the role of serotonin and dopamine • Initiate an inflammatory cascade – release of endothelial cells, mast cells, and platelets. • Inflammation causes vasodilation and a perivascular reaction • The serotonin receptor (5-HT) is believed to be the most important receptor in the headache pathway • Some of the symptoms associated with migraine headaches, such as nausea (80%), vomiting (50%), yawning, irritability, hypotension, and hyperactivity, can be associated dopamine receptor activation IHS- Diagnostic Criteria for Migraine Headache • Diagnosis of migraine w/o aura requires five attacks with the following criteria: – HA lasting 4 to 72 hours – HA with at least 2 of the following: • • • • Unilateral location Pulsating quality Moderate or sever intensity Aggravated by physical activity – During HA at least one of the following occurs: • Nausea and vomiting • Photophobia and phonophobia Migraine Headaches • Triggers – Emotional or physical stress – Lack or excessive sleep – Missing meals – Specific foods – Alcohol – Menstruation – Use of contraceptives – Nitrate containing foods 7 7/14/2023 Migraine Migraine without Aura A. At least 5 attacks meeting criteria B-D B. Attacks lasting 4-72 hours C. Has at least two of the following characteristics 1. Unilateral location 2. Pulsating quality 3. Moderate or severe pain intensity D. During headache at least one of the following: 1. Nausea or vomiting 2. Photophobia or phonophobia E. Not better accounted for by another headache classification Migraine Migraine with Aura A. At least 2 attacks of criteria B-D B. One or more of these fully reversible symptoms of aura: Visual – Sensory – Speech and/or language – Motor Brainstem – Retinal C. At least 2 of the following 4: 1. At least one aura symptom spreads gradually > 5 minutes, and/or two or more symptoms occurring in succession 2. Each individual aura symptoms lasts 5-60 minutes 3. At least one aura symptom is unilateral 4. The aura is accompanied or followed within 60 minutes, by headache D. Not characterized by another headache classification. Transient ischemic attack has been excluded 8 7/14/2023 Migraine Headaches • Phases – Prodrome – Aura – Headache – Termination of Headache – Postdrome Medical Management of Migraine Headache • Acute analgesia – OTC and prescriptive medications • Pharmacologic prophylaxis – abortive therapy – Guided by severity, response to analgesic medication, and frequency of attacks • Nonpharmacologic therapy – Avoidance of triggers Acute Analgesia • Goal - reduce disability and maintain quality of life • Guided by severity of symptoms • Tailor therapy with the patient – Certain medications for mild attacks – Other medications for severe attacks 9 7/14/2023 Symptoms Guided Therapy • Mild Attacks – combination therapy – OTC medications • Aspirin • NSAID • Acetaminophen + Caffeine – (Excedrin migraine) • Moderate to Severe – – – – Triptans * the current DOC Dihydroergotamine (DHE) Other ergotamine compounds Antiemetics Prophylactic Therapy • Determined by – Frequency of occurrence – Potential for overuse of acute therapies • Liver and kidney damage with chronic use of NSAID and Acetaminophen • Rebound and tolerance with chronic use of ergotamines and triptans • Habituation with butalbital – Severity of HA • Acute therapy ineffective Prophylactic Agents for Migraine • Beta-blockers – Propranolol, Timolol • Calcium channel blockers – Verapamil • Selective serotonin reuptake inhibitors – Ciproheptadine • Tricyclic antidepressants – Amitriptyline, Nortriptyline • Anticonvulsants – Divalproex sodium, Gabapentin 10 7/14/2023 Tension Type Headache • • • • • Most common type of headache Both episodic and chronic Slightly higher incidence in females Prevalence correlated with socioeconomic status May progress to migraine headache if chronic Key Presenting Complaints and Findings • • • • • Band like squeezing Tight pressure – dull, vice-like, throbbing Temporal and occipital region Associated with depression/anxiety and stress No neurologic abnormalities found on neurological exam • Migraine-type features (unilateral, throbbing pain, nausea, photophobia) are not present. 11 7/14/2023 IHS Diagnostic Criteria • IHS – subdivided into Tension HA with and w/o pericranial tenderness. • Classified by cause – Temporamandibular joint TMJ dysfunction – Psychosocial stress – Analgesic overuse ISH- Diagnostic Criteria for Episodic Tension Headache • Include at least 10 previous headache episodes with the following characteristics: • • • • Pressing or tightening (non-pulsating) quality Mild or moderate intensity Bilateral location No aggravation by walking, climbing stairs, or similar routine physical activity • Both of the following • No nausea or vomiting • Photophobia and phonophobia – Both absent – Or only one present Infrequent Episodic Tension-Type Headache • A. At least 10 episodes occurring <1 day/month and fulfilling criteria B-D • B. Duration 30 minutes-7 days • C. At least two of the following: 1. Bilateral location 2. or tightening (nonpulsating) quality. 3. Mild or moderate intensity 4. Not aggravated by routine physical activity • D. Both of the following: 1. No nausea or vomiting 2. Not more than one of photophobia or phonophobia 12 7/14/2023 ISH- Diagnostic Criteria for Chronic Tension Headache • Same criteria for episodic tension headache + • Pain present for 15 days a month for more than 3 months Pharmacologic Management Tension Headache • NSAID, Acetaminophen + Caffeine – Be on guard for analgesic overuse and abuse • Chronic daily headache • Withdrawal • Amitriptyline • Muscle Relaxants – use short term – with neck, shoulder pain • Complimentary Alternative Medicine (CAM) – Acupuncture, meditation, yoga Chronic Daily Headache • Present with the typical pain characteristics of tension-type headache but have symptoms that occur daily or almost daily. • The progression of either migraine or tension-type headache into chronic daily headache can occur spontaneously but often occurs in relation to frequent use of analgesic medication. 13 7/14/2023 Headache Management • Repeated use of analgesics, especially ones containing caffeine or butalbital, can lead to “rebound” headaches – as dose wears off -- patients then take another round of medication – starts rebound cycle • Medications containing butalbital with either acetaminophen/aspirin/caffeine, are most commonly prescribed medications for the relief of many types of headache – Fiorinal®, Fioricet®, Esgic®, Medigesic®, Phrenilin®, and others. Headaches • Common features of chronic daily headache associated with frequent analgesic use: – early morning awakening with headache – poor appetite, nausea – restlessness, irritability – memory or concentration problems – depression. • Screened for psychiatric co morbidity. – anxiety, depression, and psychosocial stress are prevalent in patients with tension-type headaches. Withdrawal – Rebound Headache • Secondary to prolonged use of analgesics • Develop pharmacologic tolerance – Rebound headache • Described as diffuse or pulsating • Onset occurs several hours after taking the analgesic • Discontinue use of analgesics – – – – – – Sumatriptan (Imatrex) Educate patient on rebound HA Prophalaxis (i.e. amitriptyline) Dietary changes Relaxation therapy Headache diary 14 7/14/2023 Etiology – Cluster Headaches • Etiology is poorly understood • The basic pathophysiology is in the hypothalamic gray matter • May be genetic component - autosomal dominant gene • Implications for a disorder of circadian rhythm – Attacks often begin during sleep • An increased incidence of sleep apnea in patients with cluster headache suggests that periods of reduced oxygenation may trigger an attack Cluster Headache • Less common than migraine and tension headaches • 80% male vs. 20 % female • “Suicide headache" because of its severity and "alarm clock" headache because of its periodicity Cluster Headache • Unilateral excruciating pain (a hot-poker or stabbing sensation) in the ocular, frontal, or temporal areas • Pain often radiates to the upper teeth, jaw, and neck • Associated signs include ptosis, ipsilateral lacrimation, conjunctival injection, and rhinorrhea. • Pain usually unilateral 15 7/14/2023 Key Presenting Complaints and Findings – Cluster HA • Unilateral pain – Orbital or periorbital region – w/ watering of the eye • Pain described as sharp and incapacitating • Last from 5 min. to 3 hrs. • Cyclic pattern – occur similar time of day or night lasting 4 to 12 weeks • May be triggered by alcohol IHS Diagnostic Criteria Cluster Headache • Include at least five attacks with the following elements: – Severe Headache associated with at least one of the following ipsilateral signs in addition to the headache • • • • • • • Conjunctival infection Lacrimation Nasal congestion Miosis, ptosis Eye edema Forehead and facial sweating Sense of restlessness or agitation – Frequency from every other day to eight times a day 16 7/14/2023 Medical Management Cluster Headache • Treatments of choice for acute cluster headache attacks are oxygen, sumatriptan, or a combination of these treatments • Also may respond to other migraine medications – Triptans, DHE, ergotamines, and aqueous lidocaine • Prophylaxis recommended – Intense severity w/o response to abortive therapy Headache • Hypnic Headache – Rare – Occurs at nights – Pain – range from mild to moderate • Treatment – Aspirin – Atenolol – Melatonin Trigeminal Neuralgia • Piercing, sudden, severe pain in the area of the cheek or jaw --unilateral • Last for seconds or minutes • Aggravated by chewing or talking • Pain elicited by touch, changes in temperature, or light breeze on the cheek 17 7/14/2023 Trigeminal Neuralgia • • • • • • Treatment includes: Carbamazepine – first line, Oxcarbazepine Baclofen and gabapentin Dilantin Sometimes surgery is needed. Headaches in Older Adults • Giant cell / Temporal Arteritis – – – – – – Diffuse bilateral or unilateral temporal pain Moderate to severe Persistent - often worse at night Associated with joint pain/tenderness Aggravated with jaw movement ESR usually elevated • Medical Emergency – blindness w/o treatment • If suspect – Treat immediately with high dose steroids (prednisone) • Refer for temporal artery biopsy 18 7/14/2023 Other Headaches • Ophthalmic Zoster – Burning, constant, piercing , “shock like” pain – Region of trigeminal nerve – Anticonvulsants (carbamazepine or gabapentin). • Glaucoma – Migraine-like headache with severe pain around affected eye Syncope • Vasovagal – Due to decreased cardiac output – Fear, anxiety or sudden emotion may precipitate episode – Sudden onset of weakness, sweating and nausea • Orthostatic Hypotension – Due to medications or hypovolemia – Occurs when patient stands Syncope • Situational – Due to coughing, micturition or defecation – May be precipitated by swallowing and any of the above • Cardiac – Due to sudden decrease in cardiac output – Usually abrupt without warning – Related to physical activity 19 7/14/2023 Syncope • Cardiac Sinus Syncope – Due to manual pressure/stimulation of the carotid arteries • Cerebrovascular Disease – Due to decreased perfusion of the vertebrobasilar system • Neurological – Seizures, TIA • Other causes – Depression – Alcohol – Drug abuse Syncope • Assessment Findings – Feelings of lightheadedness, weakness, nausea, vomiting, diaphoresis • Diagnostic Studies – Goal is to identify life-threatening conditions Syncope • Nonpharmacology – Elevate patient’s leg – vasovagal or hypotension – Change position slowly, especially to an upright position • Pharmacology – Depends on underlying cause – Beta-blockers may prevent recurrent vasovagal symptoms – Antiarrhythmic drugs – Adrenergic agonists 20 7/14/2023 Stroke Brain Attack Incidence & Burden • • • • • >795,000 strokes occur annually 200,000 are recurrent 5th leading cause of death in US Leading cause of disability in US 5%- 14% of stroke survivors have their 2nd stroke within 1 year Stroke Classifications • Classified into two general types –Ischemic stroke • Approximately 80% of strokes –Hemorrhagic stroke • Approximately 20% of all strokes 21 7/14/2023 Transient Ischemic Attack (TIA) • Stroke symptoms of < 24 hours • Blood supply to part of the brain is briefly interrupted. • Symptoms occur suddenly and are similar to stroke – Most symptoms disappear within an hour – May persist for up to 24 hours to be classified as TIA Presenting Symptoms Ischemic Stroke/TIA • SUDDEN ON SET -------• Numbness or weakness in the face, arm, or leg, especially on one side of the body • Confusion • Difficulty speaking or understanding speech • Trouble seeing in one or both eyes • Difficulty with walking • Dizziness • Loss of balance and coordination • Headache 22 7/14/2023 Common Patterns of Neurological Impairments • Left Hemisphere Stroke – Aphasia – Right hemiparesis – Right sensory loss – Right spatial neglect – Right hemianopia – Impaired right conjugate gaze • Right Hemisphere Stroke – Left hemiparesis – Left sensory loss – Left spatial neglect – Left hemianopia – Impaired left conjugate gaze Common Patterns of Neurological Impairments • Deep (subcortical) hemisphere or brainstem – Hemiparesis (pure motor stroke) or Sensory (pure sensory stroke) – Dysarthria (slurred speech) – Ataxic-hemiparesis (lack of coordination combined with weakness or partial paralysis) Common Patterns of Neurological Impairments • Brainstem – – – – – – – Motor sensory loss in all four limbs Crossed signs Dysconjugate gaze Nystagmus Ataxia Dysarthria Dysphagia • Cerebellum – Limb and/or gait ataxia 23 7/14/2023 Hemorrhagic Stroke • Intracerebral hemorrhage – Diseased artery within the brain ruptures, flooding the surrounding brain tissue with blood – The major risk factor is hypertension. • Subarachnoid hemorrhage (bleeding into the skull or cranium that occurs when a blood vessel on the surface of the brain ruptures and bleeds into the meninges) Risk Factors for Ischemic Stroke Nonmodifiable • • • • • • Increased age Being male Race (e.g., African-Americans) Prior stroke/transient ischemic attacks Family history of stroke Asymptomatic carotid bruit Risk Factor For Stroke: Modifiable • Major – – – – – Hypertension Diabetes Heart disease, esp. atrial fibrillation Cigarette smoking Transient ischemic attacks • Secondary – Increased serum cholesterol / lipids – Physical inactivity – Obesity • Less Well Documented – Excessive alcohol intake / drug abuse 24 7/14/2023 Diagnosis • • • • • • • • History Physical Exam – classic symptoms CT Carotid Duplex MRA CTA Trans Cranial Doppler Angiogram Stroke Primary Prevention • Multifactorial approaches with intensive treatments to control – Hyperglycemia – Hypertension – Dyslipidemia • Appropriate medications for tight glycemic control, statin, ACEI, ARB, and antiplatelet drug as appropriate • Included behavioral measures – Diet, exercise, smoking cessation, limit EtOH American Heart Association/American Stroke Association (AHA/ASA) • Guidelines for Prevention of Stroke in Patients With Ischemic Stroke or Transient Ischemic Attack – Provide comprehensive and evidence-based recommendations on the prevention of second ischemic stroke among survivors of ischemic stroke or TIA. – Many of the guidelines are identical for primary prevention 25 7/14/2023 Bells Palsy • A mononeuropathy (involvement of a single nerve) that damages the seventh cranial (facial) nerve. The facial nerve controls movement of the muscles of the face. Bell’s Palsy • Etiology –Idiopathic –Viral –Exposure to cold –Facial trauma Bell’s Palsy • Risk Factors – – – – – Lyme Disease 3rd trimester pregnancy Family history Diabetes Mellitus Herpes Zoster • Assessment Findings – – – – Numbness on affected side Sagging of eyebrow Mouth drawn to affected side Inadequate tearing or excessive tearing 26 7/14/2023 Bell’s Palsy – Partial or total face paralysis – Hypersensitivity to sound – Excessive tearing – Inadequate tearing – Ipsilateral loss of taste – Ipsilateral ear pain, cheek pain – Loss of nasolabial fold – House-Brackmann Facial Nerve Grading Scale Bell’s Palsy - Diagnostic Studies • Based on clinical presentation • Must first rule out other possible causes of facial paralysis (STROKE) • No specific laboratory test to confirm diagnosis of the disorder. • Examine the individual for upper and lower facial weakness Diagnostic Studies (Cont’d) • Electromyography (EMG) can confirm the presence of nerve damage and determine the severity and the extent of nerve involvement. • An x-ray of the skull can help rule out infection or tumor. • A magnetic resonance imaging (MRI) or computed tomography (CT) scan can eliminate other causes of pressure on the facial nerve 27 7/14/2023 Nonpharmacologic Management • Keep the eye moist and protect the eye from debris and injury with lubricating eye drops, such as artificial tears or eye ointments or gels, and eye patches. • Physical therapy to stimulate the facial nerve and help maintain muscle tone may be beneficial to some. • Facial massage and exercises may help prevent permanent contractures. Moist heat applied to the affected side of the face may help reduce pain. Bell’s Palsy • Nonpharmacologic Management – – – – Patient education Eye drops to maintain lubrication Close and patch affected eye Warm, moist heat to affected side of face • Pharmacologic Management – Tapered dosage of corticosteroids – Possible benefit of oral anti-viral agent Brain Infection 28 7/14/2023 Overview • There are many organisms, viruses, fungi and parasites which can cause infection in the brain and spinal cord. Some of the most commonly seen brain infections include: • Meningitis- is an inflammation of the membranes of the brain or spinal cord. – Caused by a virus or by bacteria. • Bacterial meningitis is a very serious disease. • Encephalitis- is an inflammation of the brain itself. – many forms from many causes. • Myelitis- means an inflammation of the spinal cord • Abscess- a collection of pus appearing in an acute or chronic localized infection and associated with tissue destruction. Meningitis • Description – Inflammation of the brain and spinal cord caused by infection with bacteria, viruses, and fungi – Occasionally parasites are responsible Meningitis • Etiology • Bacterial meningitis – Group B or D streptococcus – Streptococcus pneumoniae – Neisseria meningitidis • Viral and fungal organisms • Parasitic 29 7/14/2023 Meningitis • Viral meningitis – Enterovirus – includes Coxsackie A and B, polioviruses, echoviruses • Fungal meningitis – Candida species – Aspergillus – Cryptococcus neoformans Meningitis • Incidence • Bacterial – – – – Predominant age – extremes of age 80% occur under 24 months Males = females 3-10/100,000 in U.S. • Viral – Most common in young adults – Affects all ages Meningitis • Fungal – Cryptococcal meningitis – most common in immunocompromised adults – Candida species most common in premature infants and other immunocompromised adults 30 7/14/2023 Meningitis • Risk factors • Bacterial – Immunocompromised hosts – Alcoholics – Neurosurgical patients • Viral – Immunocompromised hosts • Fungal – Imminocompromised hosts – Exposure to pigeon or bird droppings Meningitis • Bacterial – – – – – Recent URI Neck pain/stiff neck Headache, fever Nausea and vomiting Decreased level of consciousness, seizures Meningococcemia rash Positive Kernig and Brudzinski signs Meningitis • Viral – – – – Headache Stiff neck Rash Illness lasts 2-6 days Fever Photophobia Seizures • Fungal – Worsening headaches over a period of days – Vomiting for days or weeks 31 7/14/2023 Meningitis • Differential diagnosis – Bacterial vs. viral vs. fungal vs. tuberculosis meningitis – Meningitis caused by other infectious agents – Seizure disorder – Encephalopathy – Brain abscess Meningitis • Diagnostic studies – Lumbar puncture – CSF – CSF Gram stain and cultures – CBC – Blood cultures – Consider CT/MRI Meningitis • Prevention – Strict aseptic technique during neurosurgical dressing changes – Treat URI infections promptly – Administer meningococcal immunization • Nonpharmacologic management – – – – Vigorous supportive care Measures to prevent dehydration Good hand washing Anticipatory guidance for family 32 7/14/2023 Meningitis • Pharmacologic Management – Antibiotic specific for culture if available – Empiric treatment with ampicillin PLUS third-generation cephalosporin; may need to add aminoglycoside – Dexamethasone may decrease morbidity and mortality – Antipyretics Meningitis – Analgesics for headache – Antiemetics – Antiviral agents not recommended – Depending on etiology: prophylaxis for contacts • Consultation/Referral – Refer to ER/neurologist immediately Meningitis • Expected Course • Bacterial – Overall fatality is 14% – Afebrile by 7-10 days – Headache and other symptoms may persist intermittently for 2 weeks 33 7/14/2023 Meningitis • Viral – Recovery in 2-7 days – Headache and other symptoms may persit intermittently for 2 weeks • Fungal – Poor prognosis usually related to overall health of patient Movement Disorders Parkinson’s Disease • Etiology – Gradual loss of neurons in the substantia nigra • Incidence – 90,000 cases annually in the U.S. (2022) – Males > Females (1.4:1) – Mean age at onset – 60 years 34 7/14/2023 Parkinson’s Disease • Idiopathic, neurodegenerative movement disorder characterized by 4 prominent features: – Bradykinesia – Muscular rigidity – Resting tumor – Postural instability Parkinson’s Disease • Risk factors – Family history – Unknown – Ingestion of toxins, drugs, may produce a secondary PD • Assessment findings – “Pill-rolling” tremor – Tremor maximal at rest Parkinson’s Disease – Bradykinesia – Cogwheel rigidity with tremor – Stooped posture – Gait disturbance – Festination – Mask-like facial apperance – Constipation – Drooling, Dysphonia, Depression 35 7/14/2023 Parkinson’s Disease • Differential Diagnosis – Benign essential tremor – Other movement disorders • Diagnostic Criteria – Clinical diagnosis – CT or MRI Parkinson’s Disease • Nonpharmacologic Management – Patient and family education – Anticipatory guidance – Encourage medication compliance – PT, OT, ST – Adjustment in home environment Parkinson’s Disease • Pharmacologic Management – Dopamine Agonist – Dopaminergic Agents – MAO Inhibitors – Anticholinergics 36 7/14/2023 Multiple Sclerosis • Description – Disease of the CNS which is slow and progressive – Characterized by demyelination of nerve cells in the brain and spinal cord that produces varied neurologic symptoms, frequent remissions, and exacerbations Multiple Sclerosis • Etiology – – – – Cause is unknown Viral origin Immunologic Environmental • Incidence – Age at onset 20-45 years – Female > Male – Approximately 25,000 new cases each year Multiple Sclerosis • Risk Factors – Family history – Northern European descent • Assessment Findings – Onset is insidious – CNS complaints are intermittent with remissions and exacerbations. – Paresthesias in extremities, weakness or clumsiness of a hand or leg 37 7/14/2023 Multiple Sclerosis – – – – – – – Stiffness or unusual fatigability of a limb Transient blindness or pain in an eye Nystagmus common Scanning speech Mild emotional disturbances Difficulty with bladder control may be present Deep tendon reflexes increased; superficial reflexes diminished – Charcot’s triad common in later stages of disease Multiple Sclerosis • Differential Diagnosis – Spinal cord or brain stem tumors – Amyotrophic lateral sclerosis – CNS infection – Compressed/ruptured intervertebral disk – Multiple cerebral infarcts Multiple Sclerosis • Diagnostic Studies – No specific tests confirms diagnosis – CSF – Evoked potentials – MRI or CT – Syphilis serology 38 7/14/2023 Multiple Sclerosis • Nonpharmacologic Management – – – – – – – Avoid factors which precipitate attack Maintain independence Patient and family education Emotional support Monitor for depression OT and PT High fiber diet Multiple Sclerosis • Pharmacologic Management – Immunomodulators – IV prednisone – Central muscle relaxants – Stool softeners – Propantheline, tofranil, ditropan – NSAIDs, Neurontin, Tegretol – Antidepressants as needed Seizure Disorders – Transient alteration in behavior with or without loss of consciousness – Due to excessive rate of neuronal discharges • Etiology • • • • • • • • • Idiopathic Brain tumor Alcohol intoxication or withdrawal Hypoxia Brain attack Head injury Fever Meningitis Hyperthermia 39 7/14/2023 Seizure Disorders • Types of Seizures • Classified by the location of their onset • Partial – Jacksonian-type (focal) – Simple partial Seizure Disorders • Generalized – Absence – Myoclonic – Clonic – Tonic – Atonic – Tonic-clonic – Other types Seizure Disorders • Incidence – Highest incidence in children – 1.5 million people in the U.S. – 10% general population has isolated seizures • Risk Factors – – – – – Previous history of disease Family history Brain tumor History of neurological insult Withdrawal from anticonvulsant medications 40 7/14/2023 Seizure Disorders • Assessment Findings – Seizure with or without loss of consciousness • Diagnostic Clues – – – – – Fever Headache Meningismus Papilledema Focal neurologic findings Seizure Disorders • Diagnostic Studies – CMP – Toxology screens – CBC – Anticonvulsant levels – MRI or CT of brain – EEG – Lumbar puncture Seizure Disorders • Nonpharmacologic Management – Monitor anticonvulsant levels – Patient education – Provide safe environment during seizure – Discussion regarding driving, swimming, other activities 41 7/14/2023 Seizure Disorders • Pharmacologic Management – Phenytoin – Carbamazepine – Phenobarbital – Valproic acid – Ethosuximide 42