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Neurological System. Symptom Overview HeadacheHeadache Dizziness and vertigoDizziness and vertigo ConfusionConfusion Memory/mental status changesMemory/mental.

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Presentation on theme: "Neurological System. Symptom Overview HeadacheHeadache Dizziness and vertigoDizziness and vertigo ConfusionConfusion Memory/mental status changesMemory/mental."— Presentation transcript:

1 Neurological System

2 Symptom Overview HeadacheHeadache Dizziness and vertigoDizziness and vertigo ConfusionConfusion Memory/mental status changesMemory/mental status changes ParesthesiaParesthesia TremorsTremors

3 Common Symptoms HeadacheHeadache –Inflammation/Constriction Dizziness and vertigoDizziness and vertigo –Irritation Confusion/memory/mental status changesConfusion/memory/mental status changes –Executive Function ParesthesiaParesthesia –Nerve Inhibition TremorsTremors –Nerve Excitation

4 Basis of Neurological Problems Autoimmune/DegenerativeAutoimmune/Degenerative –Pathologic excitation/inhibition nerve fibers –Degeneration/Destructions nerve fibers CirculatoryCirculatory –Ischemia/hypoxemia Decreased blood flow/decreased oxygen levelsDecreased blood flow/decreased oxygen levels GeneticGenetic –Mutations causing abnormal biochemistry Infection/TraumaInfection/Trauma –Abnormal pathology through injury

5 Degenerative Conditions Parkinson’s diseaseParkinson’s disease Multiple sclerosisMultiple sclerosis Brain tumorsBrain tumors

6 Circulatory TIA/CVATIA/CVA AneursymAneursym AV MalformationAV Malformation HeadachesHeadaches –Migraine –Tension –Cluster Peripheral neuropathyPeripheral neuropathy

7 Infection/Trauma Meningitis and encephalitisMeningitis and encephalitis Viral meningitisViral meningitis Seizure disorders/ epilepsySeizure disorders/ epilepsy Bell’s palsyBell’s palsy Trigeminal neuralgiaTrigeminal neuralgia

8 Nerve Fibers

9 Pressure/Ischemia = Neuropathy Peripheral (extremity)Peripheral (extremity) Radiculopathy (“root”)Radiculopathy (“root”) Myelopathy (muscle/nerve)Myelopathy (muscle/nerve)

10 Small myelinated axons are responsible for light touch, pain temperature.Small myelinated axons are responsible for light touch, pain temperature. Small unmyelinated axons are also sensory and subserve pain and temperature.Small unmyelinated axons are also sensory and subserve pain and temperature. Neuropathies involving these are called small fiber neuropathiesNeuropathies involving these are called small fiber neuropathies

11 Nerves have a limited number of ways to respond to injuryNerves have a limited number of ways to respond to injury Damage can occur at the level of the axon— this generally results in degeneration of both the axon and the myelin sheathDamage can occur at the level of the axon— this generally results in degeneration of both the axon and the myelin sheath Damage at the motor neuron or dorsal root ganglion is often incompleteDamage at the motor neuron or dorsal root ganglion is often incomplete Damage at the level of the myelin sheath are often inflammatory or hereditary—these can yield a rapid recovery or a progressive diffuse course of illnessDamage at the level of the myelin sheath are often inflammatory or hereditary—these can yield a rapid recovery or a progressive diffuse course of illness

12 Severed = Paralysis

13

14 Results of Neuropathy PainPain –Burning ParathesiaParathesia –Numbness HyperasthesiaHyperasthesia –Sensitivity ParalysisParalysis –Loss of movement

15 Various Neuropathy Conditions Back painBack pain –Radiculopathy –Sciatica –Myelopathy Neuralgia/ParathesiaNeuralgia/Parathesia –Trigeminal –Palsy (Bell’s, Ulnar) –Migraine (?) DegenerativeDegenerative –Multiple Sclerosis –Amyotrophic Lateral Sclerosis

16 Radiculopathy/Myelopathy

17 Radiculopathy/Myelopathy Burning pain along nerveBurning pain along nerve Loss of muscle strengthLoss of muscle strength –Atrophy –Injury

18 Trigeminal Neuralgia Cranial Nerve V Tic douloureux 5 TH Decade (V!) Young age ? MS Multiple Cause Paroxysmal Unilateral Trigger

19 Bell’s Palsy/Nerve Palsy Nerve paralysisNerve paralysis Facial Nerve (VII)Facial Nerve (VII) Motor not SensoryMotor not Sensory Sir Charles BellSir Charles Bell IdiopathicIdiopathic Altered TasteAltered Taste Hyper LacrimationHyper Lacrimation

20 Nerve Palsies Neuropathy “Saturday Night Palsy” Nerve pressure causing paralysis Sleeping standing up Hours to Months

21 EPS

22 Testing Neuropathies Electromyography (EMG)Electromyography (EMG) –Needles into the muscle –Measures muscle action potentials –A surface EMG (SEMG) is not accurate Nerve Conduction Velocity (NCV)Nerve Conduction Velocity (NCV) –Usually done at the same time as EMG Evoked potentialEvoked potential –Basis for EMG, can be auditory, visual

23 EMG

24 Treatment for Neuropathies First treat the underlying cause then symptom managementFirst treat the underlying cause then symptom management –TCAs –Muscle relaxants –SSRIs –Antiseizure meds –Vitamin B12 –Lidocaine patch –Analgesics –TENS unit, acupuncture, Biofeedback

25 Headache

26 Headaches MigrainesMigraines Cluster HeadachesCluster Headaches –“Cluster cycle” Tension HeadachesTension Headaches –“Stress”, muscle tension, neck pain

27 Migraines

28 Migraine Headaches TypesTypes –Simple or Classic –Complex HemiplegicHemiplegic Possible Aggravating factors (“triggers”) –Stress / Emotion –Glare –Alcohol –Exercise –Stimulants: Excess Caffeine, cocaine, amphetamines –Foods –Analgesic rebound –Estrogen

29 Migraines Trigeminal Nerve Symptoms Several Criteria –Photophobia –Nausea/Vomiting –Aura Recurrent MRI of a Migraine

30 Diagnostic Requirements of Migraine At least two of the following features:At least two of the following features: –Unilateral location –Throbbing character –Worsening pain with routine activity –Moderate to severe intensity At least one of the following features:At least one of the following features: –Nausea and/or vomiting –Photophobia and phonophobia International Headache Society Classification of Headache International Headache Society Classification of Headache

31 Acute Migraine Treatment ErgotamineErgotamine –- Unknown –“Abortive” or “rescue” tx –Dosage forms – oral, sublingual, rectal, parenteral –Contraindications Cardiac diseaseCardiac disease Peripheral vascular diseasePeripheral vascular disease Cerebrovascular diseaseCerebrovascular disease SepsisSepsis Advanced Liver and Kidney diseaseAdvanced Liver and Kidney disease Pregnancy, Breast FeedingPregnancy, Breast Feeding Caffeine –Increases intestinal absorption of ergotamine –Potentiates vasoconstriction and pain relief when combined with ergotamine and analgesics –Adverse effects GI disturbances Nausea Vomiting Anorexia

32 Acute Migraine Treatment- Triptans SumatriptanSumatriptan –Dosage Forms Subcutaneous injectionSubcutaneous injection Oral tabletOral tablet Nasal SprayNasal Spray –Adverse effects Oral - nausea and vomiting, malaise, dizzinessOral - nausea and vomiting, malaise, dizziness Intranasal – bitter, unpleasant tasteIntranasal – bitter, unpleasant taste Subcutaneous Injection - mild pain, redness, rebound HASubcutaneous Injection - mild pain, redness, rebound HA Drug Interactions –Ergot alkaloids –Lithium –Serotonin-specific reuptake inhibitors –Other triptans –Monoamine Oxidase Inhibitors - use with these products may precipitate serotonin syndrome

33 Acute Migraine Treatment Second Generation triptansSecond Generation triptans Eli-, zolma-, nara-, frova-Eli-, zolma-, nara-, frova- Acute treatment of migrainesAcute treatment of migraines Comparison to sumatriptanComparison to sumatriptan –Similar pharmacologic features –Improved oral bioavailability –Able to cross blood brain barrier Possible reasons for treatment failures –Medication administration too late –Swallowing Sublingual products –Vomiting tablet prior to absorption –Rebound headache due to overuse –Dehydration/ ketosis/acidosis –Analgesic rebound –Diagnosis?

34 Intractable migraines Sumatriptan subcutaneous injectionSumatriptan subcutaneous injection Parenteral form of ergot derivativesParenteral form of ergot derivatives IV antiemeticIV antiemetic Corticosteroid - oral or parenteralCorticosteroid - oral or parenteral Hydration!Hydration! Parenteral Narcotic analgesicsParenteral Narcotic analgesics

35 Migraine Adjunctive therapy AntiemeticsAntiemetics –Systemic relief of nausea and vomiting –Increased absorption of other medications, prokinetic NSAIDSNSAIDS –Not approved by FDA for migraine headache indication –Selected NSAIDS effective as abortive therapy

36 Migraine Prophylactic therapy GoalsGoals –Reduces frequency –Reduces severity CriteriaCriteria –Headaches that occur twice monthly or more often –Disabling headache that occurs less frequently but are unresponsive to usual abortive therapy –Abortive agents contraindicated –Headaches that occur in unpredictable patterns

37 Migraine Prophylactic therapy- cont’d. TopomaxTopomax Use in low dose of 25 to 50 mg at hs to prevent migrane Valproic AcidValproic Acid –1000mg po q HS prophylaxis

38 Cluster Headaches Gender - males>femalesGender - males>females Onset - second and fourth decade of lifeOnset - second and fourth decade of life Intensity of Headache PainIntensity of Headache Pain Same side of head, tearing, flushSame side of head, tearing, flush Severe throbbing/stabbingSevere throbbing/stabbing Not preceded by auraNot preceded by aura Last minutesLast minutes

39 Cluster Headache Abortive Therapy Oxygen inhalationOxygen inhalation ErgotamineErgotamine

40 Tension Type Headaches Gender - women 88%, males 69%Gender - women 88%, males 69% Intensity of headache painIntensity of headache pain No auraNo aura No nausea, vomitingNo nausea, vomiting No photophobiaNo photophobia

41 Tension Headache Therapy Abortive-Abortive- –NSAID’s –Muscle relaxants –Anxiolytics –Analgesics ProphylacticProphylactic –Antidepressants Non-drug techniques –Massage –Hot bath –Acupuncture –Biofeedback

42 Seizures VFib of the brainVFib of the brain Various ReasonsVarious Reasons –Electrical –Ischemic –Chemical

43 Seizure Disorders- Pharmacologic Treatment Optimization of drug therapyOptimization of drug therapy Choice of appropriate AEDChoice of appropriate AED Individualization of dosingIndividualization of dosing ComplianceCompliance

44 Therapeutic endpoints: Patient response Seizure frequency and severitySeizure frequency and severity Presence and severity of symptoms of dose related toxicityPresence and severity of symptoms of dose related toxicity

45 Serum drug concentrations Indications for useIndications for use –Uncontrolled seizures despite greater than average doses –Seizure recurrence in a previously controlled patient –Documentation of intoxication –Assessment of compliance –Dose change –Assessment of therapy in patients with infrequent seizures When dosage changes are made –Interpretation of serum concentrations –Laboratory variability –Interindividual variability –Active metabolites of AED’s may not be measured –Binding of serum proteins Therapeutic blood levels useful for: –Phenytoin –Valproate –Carbamazepine –Phenobarbital

46 Idiopathic Grand Mal Epilepsy DrugsDrugs –Phenytoin (hydantoins) (Dilantin) –Valproic Acid=Depakote –Carbamazepine (Tegretol) –Phenobarbital (barbiturates) –Topiramate (Topomax) Duration of therapyDuration of therapy –Seizure free for 2-5 years or may be lifetime Withdrawal of AED’sWithdrawal of AED’s –Two to three months withdrawal schedule –Multiple therapy - each drug tapered separately

47 Complex Partial Seizures with secondary generalization Carbamazepine (Tegretol)Carbamazepine (Tegretol) Lamotrigine (Lamictal)Lamotrigine (Lamictal) Gabapentin (Neurontin)Gabapentin (Neurontin) Tiagabine=GabitrilTiagabine=Gabitril Levatiracetam=KeppraLevatiracetam=Keppra Oxcarbazepine=TrileptalOxcarbazepine=Trileptal Pregabalin=LyricaPregabalin=Lyrica

48 Absence Seizures Valproate when secondary tonic/clonic alsoValproate when secondary tonic/clonic also ClonazepamClonazepam

49 Febrile Seizures Fever controlFever control Anticipatory management in the futureAnticipatory management in the future

50 Testing Seizures EEG

51 Circulation Problems Think Vascular

52 CVA/TIA Vascular insultVascular insult DyslipidemiaDyslipidemia Clotting/emboliClotting/emboli Risk FactorsRisk Factors –Age –Family history –Smoking –Dyslipidemia –Diabetes

53 Two kinds of CVA HemorrhagicEmbolic

54 Hemorrhage

55 Embolic Multiple causes –Fat –Air –Blood ‘Brain attack’ Destroys nerves ‘Cuts the wires’

56 Testing for Vascular Problems MRAMRA AngiographyAngiography UltrasoundUltrasound

57 Consequences of wrong test

58 Medications for embolic CVA IV tissue plasminogen activator tPA 0.9mg/kg in highly selected cases within 3 hours of ischemic strokeIV tissue plasminogen activator tPA 0.9mg/kg in highly selected cases within 3 hours of ischemic stroke ECASAECASA Dipyridamole-aspirin (Aggrenox) extended release, 200mg/25mg capsule PO BIDDipyridamole-aspirin (Aggrenox) extended release, 200mg/25mg capsule PO BID Clopidogrel (Plavix) 75mg/dayClopidogrel (Plavix) 75mg/day Warfarin INR adjusted doseWarfarin INR adjusted dose

59 Surgical Measures Carotid endartectomy (CEA) is indicated for stenosis of 70-99%Carotid endartectomy (CEA) is indicated for stenosis of 70-99% CEA is of modest benefit for carotid stenosis of 50-69% and depends on risk factorsCEA is of modest benefit for carotid stenosis of 50-69% and depends on risk factors No benefit <50%No benefit <50%

60 Risk Factor Management Blood PressureBlood Pressure –130/80 –JNC 7 –Starting antihypertensive drug therapy after TIA/Stroke –ACE Inhibitors

61 Risk Factor Management SMOKINGSMOKING “the risk of stroke in persons of either sex and all ages was 50 percent higher in smokers than in nonsmokers” –Smoking cessation

62 Risk Factor Management Blood lipid levelsBlood lipid levels –Statin Diabetes mellitusDiabetes mellitus –Increases the overall risk by 25 to 50% Antiplatelet therapyAntiplatelet therapy –clopidogrel (Plavix), ticlopidine (Ticlid), and aspirin-dipyridamole (Aggrenox) AspirinAspirin mg/day50-325mg/day

63 Degenerative Disease Think progressive

64 Parkinsons Reduction of Dopamine productionReduction of Dopamine production Causes resting tremorsCauses resting tremors

65 Dopamine/Acetylcholine

66 Testing for Parkinson’s

67 Parkinson’s Symptoms Symptom spectrumSymptom spectrum –Bradykinesia/ akinesia –Rest tremor –Mask facies –Progressive dementia –Depression (functional?)

68 Parkinson’s Disease Non-pharmacologic Interventions ExerciseExercise Physical activityPhysical activity NutritionNutrition Psychologic supportPsychologic support

69 Parkinson’s Pharmacologic Interventions: Dopamine Agonists AmantadineAmantadine –Mechanism of action ? – ↑ dopamine release from presynaptic nerve terminals Initiation of therapyInitiation of therapy –Twice daily, Morning and lunch Adverse effects –Anticholinergic Gastrointestinal Cardiovascular CNS –Mild elevations of BUN and alkaline phosphatase Monitoring Parameters –GI and CNS complaints –BUN, Cr every 3 months

70 Parkinson’s- cont’d. Dopamine agonists- besides amantidineDopamine agonists- besides amantidine –Pramipexole (Mirapex) –Bromocriptine (Parlodel) –Pergolide (Permax) –Ropinirole (Requip) Monoamine Oxidase-B Inhibitors: Selegiline (Eldepryl))Monoamine Oxidase-B Inhibitors: Selegiline (Eldepryl)) Antioxidant Therapy- questionable efficacyAntioxidant Therapy- questionable efficacy

71 Serotonin Syndrome Symptoms Associated with Serotonin Syndrome Mental status changes Confusion (51%) Agitation (34%) Hypomania (21%) Anxiety (15%) Coma (29%) Cardiovascular Sinus tachycardia (36%) Hypertension (35%) Hypotension (15%) Gastrointestinal Nausea (23%) Diarrhea (8%) Abdominal pain (4%) Salivation (2%) References 2, 4 Motor Abnormalities Myoclonus (58%) Hyperreflexia (52%) Muscle rigidity (51%) Restlessness (48%) Tremor (43%) Ataxia/incoordination (40%) Shivering (26%) Nystagmus (15%) Seizures (12%) Other Diaphoresis (45%) Unreactive pupils (20%) Tachypnea (26%) Hyperpyrexia (45%) (Nolan, 2005)

72 Anticholinergics Mechanism of actionMechanism of action –Blocks excitatory neurotransmitter Ach in substantia nigra Aids treatment of tremorAids treatment of tremor – less effective than levodopa/carbidopa or dopamine agonists DrugsDrugs –trihexyphenidyl (Artane) –benztropine (Cogentin) Adverse effects –Increased intraocular pressure –Confusion –Impairment of recent memory –Hallucinations –Delusions –Dry mouth –Blurred vision –Constipation –Urinary retention

73 Parkinson’s Tremor Symptoms may be controllable with BenadrylSymptoms may be controllable with Benadryl Dopamine Precursors (Levodopa - Sinemet – Stalevo)Dopamine Precursors (Levodopa - Sinemet – Stalevo) –Initiation of therapy E.g. sinemet 10/100 t.i.d., increase q 2-3 days as tolE.g. sinemet 10/100 t.i.d., increase q 2-3 days as tol –Adverse effects DyskinesiasDyskinesias Mental changesMental changes Levodopa Drug interactions –Neuroleptic drugs – (Phenothiazine, Prochlorperazine, Fluphenazine, Chlorpromazine) –Butyrophenones: Haloperidol –Antihypertensives – (Reserpine and Methyldopa) –MAOi ’ s- serotonin syndrome –Other: Metoclopramide, Pyridoxine, Ferrous sulfate, Phenytoin, Benzodiazepines

74 Adjunctive Treatment of Parkinsonian Tremor B-adrenergic blockersB-adrenergic blockers ClozapineClozapine SurgerySurgery Deep brain stimulationDeep brain stimulation Potential dietary/nutritional interactionsPotential dietary/nutritional interactions –Tryptophan, tyramine, melatonin

75 Multiple Sclerosis DemyelinationDemyelination –Energy Diffusion –Reduced conduction –Nerve degeneration

76

77 Types of MS Relapsing-remitting (80%)Relapsing-remitting (80%) –Periods of relapse, when symptoms flare up –Periods of remission, when symptoms improve Secondary progressiveSecondary progressive –Develops from Relapsing/Remitting –shorter periods of remission and worse symptoms during relapses. –50% to the secondary progressive stage in first 10 years Primary progressive (3 in 20)Primary progressive (3 in 20) –no periods of remission –This causes increasing disability, and can reduce life expectancy

78 MS Testing MRI Brain and spinal cordMRI Brain and spinal cord –Remember MS is CNS –White matter “Demyelination” Lumbar PunctureLumbar Puncture –WBCs, Antibodies EMG StudiesEMG Studies

79 MS Treatment Options - General Considerations ExerciseExercise Appropriate exercise program is beneficialAppropriate exercise program is beneficial Simple exercises such as normal walking, swimming, using exercise bikeSimple exercises such as normal walking, swimming, using exercise bike strongly advise against overheating (saunas, hot tubs, sunbathing, etc.) to prevent declines in neurologic function. Exercising in a cool, well aerated environment is strongly encouraged.strongly advise against overheating (saunas, hot tubs, sunbathing, etc.) to prevent declines in neurologic function. Exercising in a cool, well aerated environment is strongly encouraged.

80 MS Treatment Cont. Physical TherapyPhysical Therapy PT/OT including ankle braces and devices that provide assistance with walking, personalized exercise program and counseling on work and daily activities.PT/OT including ankle braces and devices that provide assistance with walking, personalized exercise program and counseling on work and daily activities.

81 NutritionNutrition MS Society recommends low fat, low cholesterol dietMS Society recommends low fat, low cholesterol diet Obese patients appear to lose any reserve muscle strength they may have left because of their weight.Obese patients appear to lose any reserve muscle strength they may have left because of their weight. Some patients with medullary lesions and difficulty swallowing may require feeding tubes to prevent aspiration and resulting pneumonia.Some patients with medullary lesions and difficulty swallowing may require feeding tubes to prevent aspiration and resulting pneumonia.

82 Treatment of Infections and Elevated Body TemperaturesTreatment of Infections and Elevated Body Temperatures Increased body temperature may lead to transient increase in neurologic symptoms or even precipitate exacerbation.Increased body temperature may lead to transient increase in neurologic symptoms or even precipitate exacerbation. If a fever is due to an infection, infection needs to be identified and treated, and antipyretics need to be administered.If a fever is due to an infection, infection needs to be identified and treated, and antipyretics need to be administered. UTI’s are commonUTI’s are common

83 Treatment of Relapses Solu-Medrol (Methylprednisone) is often used for treatment of severe exacerbations.Solu-Medrol (Methylprednisone) is often used for treatment of severe exacerbations. Typical doses range from 500 to 1000 mg/day for 3 to 5 daysTypical doses range from 500 to 1000 mg/day for 3 to 5 days

84 Prevention of Relapses recombinant interferon-ß'srecombinant interferon-ß's –Betaseron –Avonex CopaxoneCopaxone RebifRebif

85 Treatment Options - Symptomatic Therapy FatigueFatigue VertigoVertigo Spasticity and Muscle SpasmsSpasticity and Muscle Spasms Psychological ProblemsPsychological Problems Urinary DysfunctionUrinary Dysfunction Sexual ProblemsSexual Problems Tremor and IncoordinationTremor and Incoordination PainPain Cognitive DysfunctionCognitive Dysfunction

86 Huntington’s Disease Degenerative Disease of the BrainDegenerative Disease of the Brain –Tremors –Progressive dementia Genetic InheritanceGenetic Inheritance 5 in 100,000 cases5 in 100,000 cases Diagnosed at symptom onsetDiagnosed at symptom onset –Usually after 30 –Usually after children are born

87 Compare…

88 Testing Huntington’s Disease CT/MRI (Specific finding)CT/MRI (Specific finding) –loss of a normally convex bulge of the caudate nucleus into the lateral ventricles –Enlarged lateral ventricles LabsLabs –Genetic testing

89 Dementia Think Multi-causal degeneration

90 DR SEUSS ON AGING I cannot see I cannot pee I cannot chew I cannot screw Oh, my God, what can I do? My memory shrinks My hearing stinks No sense of smell I look like hell My mood is bad -- can you tell? My body's drooping Have trouble pooping The Golden Years have come at last The Golden Years can kiss my ass

91 Overview of Dementia Population is agingPopulation is aging Dementia increases with ageDementia increases with age AmnesiaAmnesia –Isolated memory loss –may be the first sign of dementia Delirium is a deficit of attentionDelirium is a deficit of attention

92 Diagnostic Criteria for Dementia Impaired social or occupational functionImpaired social or occupational function Impaired memory + 1 or more changes in:Impaired memory + 1 or more changes in: –Abstract/problem solving –Judgment –Language –Personality

93 Depression vs. Dementia DepressionDepression –Fast onset –Depressed before demented –Patient complains more than family Dementia –very slow onset –Demented then depressed –Patient denies

94 Depression vs. Dementia DepressionDepression –Appears depressed –Response of "I don't know" –Inconsistent Cognitive impairment –antidepressant works Dementia –May not appear depressed –Tries to answer –Consistent Cognitive impairment –Antidepressant may not work

95 Causes of Dementia Alzheimer's diseaseAlzheimer's disease –Most common cause in the elderly –Incidence: new cases/100,000 population/ year123.3 new cases/100,000 population/ year –Prevalence: 10% over age 65, 47% over age 8410% over age 65, 47% over age 84

96 “Probable” Alzheimer's Dementia Abnormal clinical examAbnormal clinical exam Abnormal Mini Mental status ExamAbnormal Mini Mental status Exam Deficits in 2 or more areas of cognitionDeficits in 2 or more areas of cognition Progressive declineProgressive decline No disturbance of consciousnessNo disturbance of consciousness Absence of other causeAbsence of other cause

97 PET Scan NORMALALZHEIMERS DISEASE

98 MMSE - The Clock (1:45)

99 Risk Factors for Alzheimer's Family History of Alzheimer's diseaseFamily History of Alzheimer's disease APO GenotypeAPO Genotype Aging and estrogen deficiencyAging and estrogen deficiency Head injuryHead injury Low educationLow education

100 Brain Iron Distribution DementiaNormal

101 Psychotic & Affective disturbance Delusions: (false beliefs)Delusions: (false beliefs) –30-70% of patients (Usually simple delusions HallucinationsHallucinations –Not common. If present usually visual. DepressionDepression –very common, difficult to diagnose. –Suicide is rare. –Severe depression more in vascular dementia.

102 Behavior problems Personality change:Personality change: –apathetic or more impulsive Anxiety:Anxiety: –apprehension over upcoming events Aggression:Aggression: –physical or verbal WanderingWandering ScreamingScreaming Sleep disruption & “Sundowning”: very commonSleep disruption & “Sundowning”: very common

103 Multi-infarct Dementia Abrupt onset with stepwise deteriorationAbrupt onset with stepwise deterioration Fluctuating course: improvement between strokesFluctuating course: improvement between strokes Relative preservation of personalityRelative preservation of personality Nocturnal confusionNocturnal confusion Depression and Somatic complaintsDepression and Somatic complaints Emotional incontinenceEmotional incontinence Cardiovascular Hx/SignsCardiovascular Hx/Signs –History of hypertension –Evidence of atherosclerosis (PVD, MI) –Focal Neurological symptoms (TIA) –Focal neurological sign

104 Normal Pressure Hydrocephalus 3 main symptoms:3 main symptoms: –Dementia, Gait Apraxia, Incontinence Language functions preservedLanguage functions preserved Most common cause of gait abnormality plus Dementia is multiinfarct dementiaMost common cause of gait abnormality plus Dementia is multiinfarct dementia Progressive (months-years) with plateauProgressive (months-years) with plateau MRI shows large ventriclesMRI shows large ventricles LP may result in temporary improvementLP may result in temporary improvement Treatment is VP or LP shuntTreatment is VP or LP shunt

105 HIV dementia Younger patientYounger patient Memory lossMemory loss Frontal lobe dysfunction, personality change, social withdrawFrontal lobe dysfunction, personality change, social withdraw Progresses over monthsProgresses over months Sometimes initial symptoms of AIDSSometimes initial symptoms of AIDS May have other brain infection/tumorMay have other brain infection/tumor

106 Other causes of Dementia Toxic/Metabolic/Nutritional:Toxic/Metabolic/Nutritional: –Alcohol or drugs –Vitamin deficiencies –Hormonal disturbances Primary progressive Aphasia:Primary progressive Aphasia: –progressive aphasia without true dementia Jacob Creutzfeld Disease:Jacob Creutzfeld Disease: –progressive dementia with seizures, myoclonus, ataxia, visual disturbance, motor neuron dysfunction

107 Other Dementias Chronic infections, vasculitis:Chronic infections, vasculitis: –Cryptococcal, fungal. Progressive multifocal leukoencephalopathyProgressive multifocal leukoencephalopathy Bilateral Subdural hematomaBilateral Subdural hematoma Brain tumor:Brain tumor: –especially frontal glioma Neurodegenerative DisordersNeurodegenerative Disorders –Parkinson's disease –Lewy body dementia –Progressive supranuclear palsy –Frontotemporal dementias (e.g., Pick's disease, primary progressive aphasias)(e.g., Pick's disease, primary progressive aphasias) –Cortical-basal degeneration Hippocampal sclerosis

108 Infections Think bug!

109 Meningitis/Encephalitis Inflammatory processInflammatory process Driven by foreign invaders (usually)Driven by foreign invaders (usually) Fungal, Bacterial, Viral, or ParasiticFungal, Bacterial, Viral, or Parasitic SymptomsSymptoms –Caused by increased pressure/edema –Pressure on nerve fibers –Temperature changes

110 Strep Pneumo Meningitis

111 Testing for Meningitis Lumbar PunctureLumbar Puncture Clinical ExamClinical Exam Labs/Blood culturesLabs/Blood cultures


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