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23 Cards in this Set
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- 3rd side (hint)
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Why are elderly at higher risk of developing chronic subdural hematoma (SDH)?
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Brain atrophy causes increased tension on the bridging veins. The stretched veins become weak and more susceptible to breakage. Pts are also MC on anticoagulants.
What is the clinical presentation? |
Slow progression: HA, N/V, apathy, altered consciousness, personality changes, then dementia (reason for you order a CT with new onset dementia. **Larger hematomas are able to develop with fewer symptoms versus the younger population.
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How are chronic subdural hematomas diagnosed?
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CT scan: mass effect with shift of the ventricles. CT is more sensitive in acute SDH.
When would an MRI be needed in dx of SDH? |
MRI needed if the lesion is isodense or hypodense.
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Tx of chronic SDH?
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Surgical treatment with closed drainage via burr holes. Fair prognosis (mortality 15%; recurrence 20%)
What is the prevention of SDH? |
Assist w/ fall prevention; Assure anti-coags are needed and they are an appropriate candidate; discuss warning signs w/ at risk pts; maintain a HIGH INDEX OF SUSPICIOUS - ie pretend you are as smart as Kathy is. Kathy would never miss diagnose a SDH.
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Etiology of secondary Parkinson's dz?
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Anti dopamnergic drygs (reglan, most antipsychotics); Wilson's dz; vascular dz (strokes).
Cellular characteristics of the dz? |
Loss of substantia nigra neurons of the basal ganglia.
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Clinical manifestations of parkinson's?
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Resting tremor ("pill rolling" - decreased w/ mvt); bradykinesia & rigidity (MAJOR factors for mortality!): propulsive gait; drooling; freezing; micrographia (handwriting gets smaller - an early sign); impaired blinking; cogweel rigidity; impaired postural & righting reflexes (can't stop a fall - tend to be retropulse and fall backwards); +/- dementia (very late dz - if early think lewy body)
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Diagnostic evaluation in parkinson's?
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H&P; neuro exam; therapeutic trial. There is not 1 test that definitively diagnoses the dz.
What are the complications? |
dementia/depression; insomnia/ chronic pain; corneal ulcers (from impaired blinking); consequences of immbility (pressure wounds, UTI DVT, etc.); aspiration pneumonia; FALLS = #1 CAUSE OF DEATH**
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what is the target of the pharmacologic management of parkinson's?
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Restoring dopamine/acetylcholine balance.
How do the medications do this? |
increase dopamine and decrease ACH.
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What is the dopamine precursor that is the DOC in parkinsons?
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Sinemet (levadopa/carbadopa)
what is carbidopa? |
dopa decarboxylase inhibitor that slows the conversion and prevents N/V.
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What are the side effects of sinemet?
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On/off phenomenon (pt improving then presents w/ chorea mvt); N/D; confusion*, agitation, tremor may increase.
What type of diet should a pt on sinemet be advised to follow? |
eat card during the day and proteins at night since sinemet's absorption is decreased with high protein intake.
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Of the dopamine agonists, which one is used according to Queen Kathy?
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Bromocriptine.
Which dopamine agonist is injected if the patient is in a frozen state? |
apomorphine
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S/E of dopamine agonist Pergolide?
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Risk of valvular disease; NOT used.
S/E of other dopamine agonists like Ropinirole and Pramipexole? |
Both have many drug interactions and pramipexole has anticholinergic properties (Kath's fav drug class to hate)
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How is depression treated in parkinson's?
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Amitriptyline; imipramine
SSRI's only; can NOT use MAO inhibitors. What other class can be used? |
MAO - B: Selegilene
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anticholinergics used in parkinson's tx?
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Trihexylphenidyl, procyclidine, benztropine, biperiden.
When should these definately NOT be used? |
Pt > 70. all the anticholinergic S/E are common and must be monitored if used.
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What are the antihistamines used for in the treatment of parkinson's?
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Helps the resting tremor.
Which one should be used due to less S/E than the others? |
Gabapentin.
others with more s/e: diphenhydramine, orphenadrine. |
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What are the catechol-o-methyl transferase inhibitors used for in the treatment of parkinsons?
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Encapone and Tolcapone: enhance the effects of sinemet by inhibiting the peripheral metabolism of L-dopa which enhances L-dopa's benefits.
Monitoring needed when used as an add on to sinemet? |
LIVER function monitoring is a MUST! also should avoid MAO-I.
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Use of amantadine in parkinsons?
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Amantadine is used in younger Pts. Actions not known - probably a dopamine agonist.
S/E? |
Hallucination and seizure potentiation.
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Treatment of a parkinson's pt who is now experiencing hallucinations?
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Seroquel is the antipsychotic reccomended if one is needed.
What should you do BEFORE prescribing seroquel? |
Hallucination are MC a S/E of senemet - so decrease their sinemet dose first!
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Other non-pharmacologic therapies used in parkinsons?
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Exercise, postural training (to decreased stooped position), fetal tissue transplant +/-; surgical ablation for tremor (best in a younger pt with a severe tremor).
What is the prevention for Parkinsons? |
Avoid precipitant drugs (REGLAN - even 1 dose can cause it in a susceptible Pt: older female with a heart issue). Estrogen may have protective effect in younger pts.
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What stages of sleep are decreased in the elderly?
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ALL stages of sleep are decreased EXCEPT for 1. stage 2 is variable.
Other characteristics of sleep? |
Sleep latency increased, daytime naps increased; decreased sleep efficacy, & frequent awakenings.
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What external factors that interupt sleep should be excluded in evaluation sleep problems?
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Caffeine, drugs (sedative hypnotics), stress, sleep hygiene (use bed ONLY for sleep and sex) and the presence of other disease states (CHF & PND w/ sob at night).
List the sleep characteristics that you should determine? |
Time to onset, time of retiring/ awakening, total sleep time, # awakenings, daytime sleepiness/ naps, previous hx of problem and SNORING.
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What monitoring studies can be done to observe a pt during sleep?
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polysomnography, holter, and oxietry for Obstructive Sleep Apnea.
Why is it vital to address sleep deprivation in the elders? |
association with higher mortality.
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what are the common causes of sleep disorders?
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Depression, sleep apnea, periodic limb mvts, inadequate hygiene, environment, drug dependency, and medical problems.
What should be the first step in the management of an elderly pt with insomnia? |
Discontinue offending drugs, establish sleep hygiene, tx primary disorders, tx medical/psych disorder and then monitor their response.
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Treatment for nocturnal myoclonus?
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Sinemet (1st DOC), muscle relaxants, bromocriptine.
Tx of sleep apnea? |
Wt loss, avoid ETOH, nasal CPAP, tracheostomy, plastic surgery, O2.
*ALWAYS avoid sleep meds (ambien) in elderly pts with issues sleeping. Kathy hates sleep meds. |
