_________ _____ is a more profound deficit that includes disorientation, bewilderment, and difficulty following commands.
A. Confusional State B. Lethargy C. Obtundation D. Stupor E. Coma
A. Confusional State
________ is a state similar to lethargy in which the patient has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states.
A. Confusional State B. Lethargy C. Obtundation D. Stupor E. Coma
C. Obtundation
______ is a state of unarousable unresponsiveness
A. Confusional State B. Lethargy C. Obtundation D. Stupor E. Coma
E. Coma
________ consists of severe drowsiness in which the patient can be aroused by moderate stimuli and then drift back to sleep.
A. Confusional State B. Lethargy C. Obtundation D. Stupor E. Coma
B. Lethargy
____ means that only vigorous and repeated stimuli will arouse the individual, and when left undisturbed, the patient will immediately lapse back to the unresponsive state
A. Confusional State B. Lethargy C. Obtundation D. Stupor E. Coma
D. Stupor
______-__ syndrome is a rare form of paralysis due to injury to the anterior brainstem with sparing of the RAS.
These patients will be awake and aware, but limited in their ability to communicate.
Locked-In Syndrome
A ______ state, or severe ______, are both syndromes that inhibit the patients ability to respond appropriately due to limited brain impairment
Catatonic State
Abulia
In locked-in syndrome, patients will often have a ________ gaze.
Vertical
T/F: Abulic patients will have occasional spontaneous purposeful movements.
True
Which portion of the neurological examination is helpful when evaluating and differentiating coma, catatonic state, or neurologically brain dead?
Cranial Nerves
Should a comatose patient be capable of pushing the examiner’s hand away when they’re introducing painful stimuli?
No, this reaction would not be consistent with coma
In what clinical settings are patients most likely to experience delirium?
- ICU Admission (70%)
- Post-Op (10-50%)
- Hospice (42%)
- SNF (16%)
- ED (10%)
Delirium is often secondary to _________.
Infection
What common conditions result in delirium?
- Dehydration, Electrolyte Imbalance
- Infection (UTI)
- Withdrawal
- Hypoglycemia
- Post-op states
Would you expect to see focal neurological findings in a patient with delirium?
No, typical they have non-focal neurological findings
T/F: Excited Delirium is the lest common type of delirium
False
It is the most common..
Other than lab work, what tests/procedures could you preform if there was no obvious or determined cause of the patient’s delirium?
What may these things rule out?
- EEG (r/o seizures)
- LP (r/o meningitis)
- MRI (Infarcts, Leptomeningeal Disease)
How is delirium managed?
Treat Underlying Cause
Supportive Care
What ‘method’ is used to diagnose and evaluate delirium?
Confusion Assessment method (CAM)
What are preventative measures taken to help prevent or limit delirium?
- Orientation Protocols
- Stimulation
- Sleep Aids
- Early Mobilizations (limit Restraint Use)
- Avoid Problematic Medications
How can you differentiate delirium from dementia?
Delirium: Rapid Onset, Reversible
Dementia: Gradual decline and deterioration of cognitive function
When taking a good history and physical on a patient being worked up for dementia, it is important to establish what?
A baseline cognition
What is the most common form of dementia?
Second most common form?
First: Alzheimer’s Disease
Second: Vascular Dementia (ie: CVA)
Dementia is diagnosed using what?
Mini-Mental Status Exam
< 9 on the MMSE would be considered _______ (Mild/Moderate/Severe) dementia.
Severe
21 - 26 on the MMSE would be considered _______ (Mild/Moderate/Severe) dementia.
Mild
10-20 on the MMSE would be considered _______ (Mild/Moderate/Severe) dementia.
Moderate
What is the preferred imaging modality when evaluating for dementia?
MRI
What labs are important to order when working up a patient for possible dementia?
- CBC
- CMP
- B12
- Thyroid Function
Mild Cognitive Impairment is often, but NOT always, a ________ for AD.
Prodrome
A ____ scan if often useful in predicting the progressive of MCI.
You can often see atrophy in which lobe?
What pattern would be consistent with AD?
PET
Medial Temporal Lobe Atrophy
Hypometabolic Pattern
Carriers of what gene are more likely to progress to AD?
APOE4 Gene
What is the greatest risk factor to developing AD?
1st Degree FHx (10-30% increased Risk)
Other than a FHx of AD, what are additional risk factors to developing AD?
- Mutations that impact amyloid in the brain
- Trauma
- Environmental / Lifestyle
- T2DM
- HTN
Early onset AD, typically has an autosomal _____________ inheritance pattern that alter amyloid beta protein production
Dominant
Late onset AD often involves more complex genetics, the most firmly established is the _______ gene
APOE
T/F: Olfactory changes can be seen in patients with AD?
True
What are clinical features of AD?
- Memory Impairment
- Executive Dysfunction
- Neuropsychiatric Sx
- Sleep Disturbance
What may the MRI of a patient with AD show?
Reduced hippocampal volume
Medial Temporal lobe atrophy
What is the second most common form of dementia?
Dementia with Lewy Bodies
Dementia with Lewy Bodies needs to be differentiated from what movement disorder?
Parkinson’s Disease
Dementia with Lewy Bodies has a _______ (faster/shorter) decline in cognitive function and a _______ (worse/better) prognosis
Faster
Worse
_______ ________ is a neurodegenerative disease of the substantia nigra that primarily results motor symptoms
Parkinson’s Dementia
What is the most common type of frontotemporal dementia?
Behavioral Variant
____ _______ ________ is defined as the insidious onset and gradual progression of a language impairment (ie, aphasia) manifested by deficits in word finding, word usage, word comprehension, or sentence construction
Primary Progressive Aphasia
What is the most common human form of prion disease?
Creutsfeldt-Jakob Disease
Creutsfeldt-Jakob Disease is often described as __________ encephalopathy
Spongiform
What may be seen on MRI in a Creutsfeldt-Jakob Disease patient?
T2 hyperintensities in the putamen and head of the caudate
Cortical ribbon
What risk factors are associated with vascular dementia?
- Uncontrolled HTN
- HLD
- T2DM
- Heart Disease
Vascular dementia is often described as a “_________” decline in cognitive function due to multiple “hits” on the brain.
Stepwise
_______ _______ __________ is described as impaired CSF absorption that rests in large ventricles with a NORMAL opening pressure on LP
Normal Pressure Hydrocephalus (NPH)
What are the THREE clinical features of NPH?
- Wet (Urinary Urgency/Frequency/Incontinence)
- Wacky (Cognitive changes)
- Wobbly (Gait Disturbance)
How is NPH treated?
Ventriculoperitoneal (VP) shunt placement
AMS patients with a GCS < 8 require what?
Intubation
Huntington’s Disease is an autosomal _______ disorder.
It is an expansion of what trinucleotide?
On what gene?
Dominant
CAG Trinucleotide
HTT Gene
What is the TRIAD of Huntington’s Disease?
Chorea
Progressive Dementia
Inheritance Pattern
Would you expect a patient with Huntington’s Disease to have hyporeflexia or hyperreflexia?
Hyperreflexia
What psychiatric symptoms may a Huntington’s Disease patient have?
Irritability
Depression
Mutism
What may a MRI show on a Huntington’s Disease Patient?
Caudate Atrophy
Although there is no known cure for Huntington’s Disease, what medication can be used to treat a patient’s Chorea?
Tetrabenazine
Other than medications. what may a patient with Huntington’s Disease benefit from?
- PT/OT
- Speech Therapy
- Social Services
- Psychiatry
What are the FOUR most common clinical features of Parkinson’s Disease?
- RESTING TREMOR
- Bradykinesia
- Rigidity ]4. Shuffling Gait
T/F: All resting tremors are Parkinson’s until proven otherwise
True
Would a Parkinson’s patient be more likely to be hypotensive or hypertensive?
Why would this be a problem?
Hypotension
At higher risk for orthostatic hypotenison and ultimately at a higher fall risk
What is Myerson Sign?
Sustained eye blinking in response to repetitive taping just above the nasal bridge
Hypomimia is often seen in patients with Parkinson’s Disease…..
What is this?
Decreased facial expressions
Parkinson’s Disease is a result of ___________ neurons in the ________ ______ located in the basal ganglia
Dopaminergic
Substantia Nigra
What is the ‘Gold Standard’ for diagnosing Parkinson’s Disease?
Neuropatholgic Examination
Could an MRI show no structural abnormalities in a Parkinson’s Patient?
Yes, this is why it is non-diagnostic in these cases
Parkinson’s patients often have ______ _____ bodies present in their surviving substantia nigra neurons
Lewy Bodies
What medication combination is the ‘mainstay’ for Parkinson’s Disease treatment?
Levodopa + Carbidopa
What surgical procedure can be done to treat the tremors associated with Parkinson’s Disease?
Deep Brain Stimulation
What are the major causes of mortality in Parkinson’s patients?
Fall with injury/Fracture
Aspiration PNA
T/F: Essential Tremor is the most common movement disorder in the USA
True
Are essential tremors more commonly unilateral or bilateral?
Bilateral
Are essential tremors more like low frequency of high frequency?
High
What are the TWO most common manifestations of an essential tremor?
Postural: Occurring with maintenance against gravity
Kinetic: Occurring with voluntary movement (ie: flexion/Extension)
Are essential tremors sometimes improved with alcohol?
Yes
If there was a suspected familial inheritance of essential tremors in a patient…..
would this more likely be autosomal dominant or recessive?
Dominant
Although most essential tremors do not require treatment……
What medications can be used?
Beta-Blockers: Propanolol
or
Primidone
A patient complaining of urges to move his legs followed by an unpleasant sensation that typically onsets at rest, worsens at night, and is relieved by movement may have what movement disorder?
Restless Leg Syndrome (RLS)
Is primary RLS autosomal dominant or recessive inheritance pattern?
Dominant
What conditions may secondary RLS be associated with?
Pregnancy
Anemia
Ferritin Deficiency
Renal Failure
Neuropathy
RLS involves peripheral or central _________ dysfunction and abnormality in _____ metabolism
dopamine
Iron
If RLS symptoms remain intrusive, what medications can be used for treatment?
Dopamine Agonists
Pramipexole
Ropinirole
_________ is a movement disorder characterized by involuntary sustained or intermittent muscle contractions resulting in an abnormal posture or repetitive movements
Dystonia
What is a common ‘feature’ of dystonia?
Sensory Tick
Does early onset dystonia more commonly begin in the upper or lower extremities?
What may initially trigger this?
Lower Extremities
Initially, this can be triggered by vigorous physical activity
Early onset dystonia can be hereditary……
This involves a mutation on what gene?
What chromosome?
Gene: TOR1A
Chromosome: 9q34
Is hereditary dystonia autosomal dominant or recessive?
Dominant
Does adult onset focal dystonia typically begin in the upper or lower extremities?
Upper extremities
Cervical dystonia involves the muscles of what TWO areas?
Neck
Shoulders
Blepharospasms involve muscles of what area?
Periocular Muscles
Oromandibular, lingual, and facial dystonia involve muscles of what FOUR areas?
Jaw
Oral Muscles
Tongue
Facial Muscles
Spasmodic dysphonia involves muscles of what area?
Laryngeal
Are arms of legs more likely to be involved in limb dystonia?
Arms > Legs
What is the most common form of isolated focal dystonia?
Spasmodic Torticollis
In cervical dystonia, would you expect to see atrophic or hypertrophic SCMs?
Hypertrophic
What is first line for dystonia treatment?
BoTox Injections
What medication is used to treat dystonia most effectively in children?
Anticholingeric: Trihexyphenidyl
Tetrabenazine (Dopamine Antagonist) can be used to relieve hyperkinetic movements in dystonia…..
However what disease MAY the cause?
Parkinson’s
What is LAST LINE for dystonia treatment?
Deep Brain Stimulation