NEURO-FOR-THE-NOT- SO-NEURO-MINDED Barb Bancroft, RN, MSN, PNP CPP Associates, Chicago, IL

THE FRONTAL LOBES… Prime real estate of the brain Comprises one-third of the cerebral cortex This is your “Mother” “No, negative, don’t, stop…” She is inhibitory.. Socialization

“Mom” and socialization Frontal lobes are not mature in babies and young children…it actually takes about years for full maturity of the frontal lobes “Don’t scratch, don’t pick, don’t dig..” Judgment Insight

FRONTAL LOBES… Alcohol and socialization Loss of inhibitions with.05 blood alcohol levels Baso-orbital region and the loss of inhibitions in patients with dementia

Acetylcholine…cognitive function Alzheimer’s disease—90% of acetylcholine is lost with destruction of brain tissue Amyloid plaques and neurofibrillary tangles BAP v.s. TAU Tumeric (cucurmin) and beta amyloid Acetylcholinesterase inhibitors

Alzheimer’s… The Alzheimer’s brain Cortical atrophy Sulcal widening Atrophy of gyri Brain weight

Quick mental status check… Time and Change Test Clock with hands—What time is it? 3 quarters, 7 dimes, 7 nickels—Can you give me change in the amount of $1.00? 97% negative predictive value if correct on both parts of the test

Clock drawing…global function

Frontal lobes… Voluntary speech center Dr. Pierre Paul Broca Broca’s aphasia Non-fluent aphasia—telegraphic, staccato speech

Frontal lobes… Pre-central gyrus (motor cortex—upper motor neurons) Voluntary movement center

Upper Motor Neurons/CS tract Contralateral hemiparesis Pronator drift Hemiparalysis (spastic paralysis) Head injury, stroke,tumors

“And that’s why we always stand to the side when we check reflexes…” Hyperreflexia Babinski—extensor plantar reflex

TEMPORAL LOBES… Wernicke’s area—reception of speech Do you understand what I am telling you? Interpretation of speech and sounds Coins jingling in pocket Auditory agnosia

TEMPORAL LOBES… Cranial Nerve VIII (Acoustic Nerve) “hears” for you…(primary sensory modality) The Superior Temporal Gyrus (STG) interprets what you are hearing (higher cortical function) What am I hearing?

TEMPORAL LOBES… Cranial Nerve I “smells” for you (primary sensory modality) The uncus interprets what you are smelling (higher cortical function) The uncus is connected to the hippocampus (memory)

TEMPORAL LOBES… Inferior surface of frontal and temporal lobes--a meningioma displacing the olfactory nerve (cranial nerve 1) Loss of smell Loss of inhibitions (baso-orbital frontal lobe)

TEMPORAL LOBES… An “aura”—the beginning of a temporal lobe seizure with a funny taste or smell (rotten eggs) Anosmia—loss of smell or the loss of the ability to interpret smell may be the first sign of a neurodegenerative disease (PD, DAT)

TEMPORAL LOBES… Déjà vu—feeling like you’re been there before Jamais vu—familiar place becomes totally unfamiliar Hallucinations—seeing or hearing something that is not there Illusions—distortion of an ongoing stimuli Drugs and hallucinations—boosting dopamine triggers hallucinations—drugs for Parkinson’s disease, hallucinogenic drugs and mushrooms, ETOH withdrawal, Herpes encephalitis Marijuana and illusions

TEMPORAL LOBES… Self-preservation and preservation of the species—the autonomic nervous system The 4 F’s…fight, flight Feeding activities And….

And… Sexual Function

Sexual function in the brain and dopamine… SSRIs increase serotonin and you’re happy, but… When serotonin goes up, dopamine goes down

TEMPORAL LOBES… Self-preservation and preservation of the species—The other 2 F’s Flight—Fright (epi, NE) Episodic dyscontrol syndrome—TBI patients

TEMPORAL LOBES… Recent memory (hippocampus) Remember 3 items… Red ball, clock, tennis shoe Repeat them after me… Red ball, clock, tennis shoe Continue with exam for 10 minutes and ask them to repeat those 3 items Post-traumatic stress disorder (cortisol receptors) Depression and neurogenesis

Loss of hippocampal cell function Loss of recent memory This is the first neurologic function to go with the aging process When does this process begin? When do you reach your peak mental capacity?

TEMPORAL LOBES… Partial complex seizures—altered state of consciousness; most common cause is a closed head injury; also consider a history of shaken baby syndrome; mid-forceps delivery Automatisms Semi-purposeful behavior

PARIETAL LOBES… Integration of tactile sensations—touch, pressure, vibration, and proprioception (do you know where your left buttocks is, right now?)

PARIETAL LOBES..testing Double simultaneous stimuli—kids vs. adults Touch two areas at the same time.. Kids will always neglect their body and will recognize touch on the face The neglect syndrome in adults

PARIETAL LOBES..testing Ability to localize stimuli Sharp vs. dull Tests for proprioception Graphesthesia Apraxia—example: a dressing apraxia ideomotor apraxia constructional apraxia

Abstraction… What does “Don’t cry over spilled milk” mean? HUH? How are a car, plane and boat alike? Cow, horse, and pig?

OCCIPITAL LOBES… Visual integration—problems manifest as cortical blindness (visual agnosia) Do you see this object? If they can see it, CN2 (the optic nerve) What is it? The occipital cortex

QUIZ… What were those 3 items I asked you to remember?

The BASAL GANGLIA… The 2 nd area of the motor “triad”

The basal ganglia… Paired nuclei at the base of the brain 50:50 balance between acetylcholine and dopamine All dopamine is made in the substantia nigra from melanin Gamma-amino butyric acid (GABA) keeps dopamine in check Substantia nigra Subthalamic nucleus Globus pallidus Caudate nucleus

Dopamine Dopamine levels decrease with aging gradually—we all slow down (loss of 45%) Dopamine loss of greater than 80% results in signs and symptoms of Parkinson’s disease

The BASAL GANGLIA The functions of the basal ganglia depend on a balance between various neurotransmitters GABA-- ↓ dopamine:acetylcholine 50:50 When this balance is disturbed, movement disorders occur

The BASAL GANGLIA… Control of movement, initiation and cessation of movement Postural reflexes—the righting reflex

Clinical symptoms Resting tremor (70%)—unilateral or bilateral (unopposed acetylcholine in Parkinson’s patients) Rigidity (decreased dopamine) (vs. spasticity of stroke patients) Loss of voluntary movements (spontaneous) Bradykinesia (decreased dopamine) (check gait) Postural instability (sternal push) Presence of severe seborrheic dermatitis suggests PD (unopposed acetylcholine) Anosmia

Huntington’s chorea…chromosome #4 Excess dopamine due to the loss of GABA- minergic input from the degeneration of the caudate nucleus Chorea—rapid, jerky movements of muscle groups Dementia Neuroleptic drugs to block dopamine

Other movement disorders Tourette’s syndrome Athetoid Cerebral Palsy Tardive dyskinesia

The cerebellum—the 3 rd area of the motor “triad”

The cerebellum… Coordination Synergy Balance Equilibrium

The cerebellum… Romberg test—stand up with your feet together and close your eyes Tandem walk Close your eyes and touch your finger to your nose Rapid alternating movements

The cerebellum… Truncal ataxia—wide, staggering gait Dysdiadochokinesia—inability to make rapid alternating movements Dysmetria—inability to light on an object (touching nose with finger, for example) Dysarthria Puppet-like movements

The cerebellum… THINK BOOZE and the CEREBELLUM

The CEREBELLUM… Multiple sclerosis Down syndrome Spinocerebellar ataxia (The cerebellum is not “strictly” motor—it also monitors sensory input from “the outside”—may play a role in autism and schizophrenia)

Small cell carcinoma of the lung with mets to the cerebellum

The BRAINSTEM…(the “bulb”) Cardiorespiratory center—C2, C3 “Hangman’s fracture) ARAS (Ascending reticular activating system) Cranial Nerves III – XII (I and II are not located in the brainstem)

The BRAINSTEM…(the “bulb”) II (Optic) and III (Oculomotor)—light reflex, accommodation, and the optic disk (papilla)

The BRAINSTEM…(the “bulb”) II (Optic) and III (Oculomotor)—light reflex, accommodation, and the optic disk (papilla) The Argyll Robertson pupil—it will accommodate but not react (to light)

The BRAINSTEM… CN III, IV, VI—follow my finger (extraocular movements)

The BRAINSTEM… V (Trigeminal) and VII (Facial) Corneal reflex—touch cornea with a cotton wisp and the patient blinks VII (Bell’s palsy)—paralysis of facial muscles – smile, puff cheeks, frown

The BRAINSTEM… IX (Glossopharyngeal) and X (Vagus) The gag reflex The uvula Closing off nasopharynx—say “K, K, K” Cleft palate

The BRAINSTEM… CN XII (Hypoglossal)— tongue movement and strength

The PERIPHERAL NERVOUS SYSTEM Dermatome chart Stocking-glove distribution with peripheral neuropathy The reflex arc—S1,2 (Achilles), L3,4(Patellar), C5,6 (Biceps), C7,8 (Triceps)

Know your dermatome chart…

OR draw your own…

Neuromuscular junction Disease of the neuromuscular junction— myasthenia gravis Muscle weakness—consider thyroid disease, drug-induced myopathy, polymyositis, inherited muscular dystrophies

The reflex arc… Sensory information into the spinal cord Synapses in same spinal cord segment Sent right back out via lower motor neuron to Peripheral motor nerve S1,2 (Achilles); L3,4 (Patellar); C5,6 (Biceps); C7,8 (Triceps) 50% of the elderly (over 75) do NOT have an Achilles reflex

Disease of the lower motor neuron or it’s pathway to the peripheral nervous system Diabetes, alcoholism (thiamine deficiency), trauma, B12 deficiency Heavy metals Chemotherapy others

Thanks. Barb Bancroft, RN, MSN, PNP CPP Associates, Inc. Chicago, IL.