NEUROLOGIC DISORDERS

FRITZ IAN ESTRELLA FLORESCA, BSN, RN

NEUROLOGIC PROBLEMS
FRITZ IAN ESTRELLA FLORESCA, BSN, RN

NEUROLOGIC PROBLEMS
FRITZ IAN ESTRELLA FLORESCA, BSN, RN

BASIC CONCEPTS IN NORMAL NEUROLOGIC FUNCTION

Oxygen Supply the brain requires 20% of oxygen in the body Glucose supply the brain requires 65 to 70% of the glucose in the body Blood Supply The brain requires 1/3 of the cardiac output Blood Brain Barrier protects the brain from certain drugs, chemicals and microorganisms, it is a layer of semi permeable capillaries CSF Volume Cushions, nourishes the brain and determines the ICP ( 100 to 150 ml. ) 75 180mmH2O or 0 15 mmHg

NEUROLOGIC ASSESSMENT
1. MENTAL STATUS assess for orientation and memory ( immediate recall, recent and remote ) 2. LEVEL OF CONSCIOUSNESS the most sensitive indicator of changes in neurologic status . ARAS ( Ascending Reticular Activating System ) and Reticular Formation is the center for Wakefulness. LEVEL I - Conscious, cognitive and coherent

 LEVEL II Confused, drowsy, lethargic, obtunded, somnolent LEVEL III Stuporous, responds only to noxious stimuli or strong and intense LEVEL IV Light Coma = primitive and disorganized response to painful stimuli. - Deep Coma = no response even to most painful stimuli

GLASGOW COMA SCALE

Is an objective measure to describe level of consciousness based on three areas; eye opening, motor response and verbal response. Highest possible score is 15 and the lowest possible is 3

3. SENSORY FUNCTION center for perception is the parietal lobe. STEREOGNOSIS the ability to perceive sensory stimuli. AGNOSIA-is inability to perceive stimuli. 4. MOTOR FUNCTION the regulating mechanism for motor function is as follows; Frontal Lobe is the motor center for voluntary purposeful and coordinated movements APRAXIA Inability to perform fine motor movements AGRAPHIA Inability to write

 CEREBELLUM is responsible for equilibrium and sense of posture. ROMBERG TEST done to assess sense of equilibrium (stand straight with eyes shut) ATAXIA Uncoordinated movement characterized by wide base stance and swaying manner of walking BRADYKINESIA slow movement not associated with muscle weakness. AKINESIA absence of muscle movement

5. REFLEX TESTING assess for superficial and deep tendon reflexes as they may indicate spinal cord injuries. Also assess for signs of meningeal irritation; KERNIGS SIGN pain is experienced when the knees are flexed in a supine position. BRUDZINKIS SIGN spontaneous flexion of the hips when the neck is flexed in a supine position

PARALYSIS AGITANS (Parkinsons Disease)

Is a degenerative disorder characterized by disturbance in the extrapyramidal system commonly attributed to defficiency or problem in dopamine. Incidence: commonly affects both sexes on later adulthood Etiology : Mostly Idiophatic but may be attributed to viral infections (Encephalitis), Drugs (psychotropics), CO poisoning (Carbon Monoxide), Arteriosclerosis, Recent studies shows that patients with low LDL is at risk of developing the disease.

The structure involved and typical appearance of Patient with the disorder

PATHOPHYSIOLOGY
Depigmentation of the Substantia Nigra

Loss of Neurons

Decrease production of Dopamine resulting to Disequilibrium with Acetylcholine

CLINICAL MANIFESTATIONS
Pillrolling tremors of the fingers Resting Non Intentional tremors Rigidity with muscle weakness Mask like appearance of the face Drooling Dysphagia Shuffling , Festinating gait Moist oily skin Defects in Judgement, Emotional instability Microphonia,micrographia No true paralysis/ No loss of sensation

 The increased muscular rigidity in Parkinsons results from defective inhibition by some of the basal nuclei, in this disease, Dopamine is defficient. Because dopamine cannot cross the blood brain barrier, it is treated with a precursor of Dopamine ( L Dopa ) which can cross the blood brain barrier. The drawback is that L Dopa have long term negative side effects.

DIAGNOSTIC TESTS
Electroencephalography (EEG) records brain waves, but it doesn't read minds or measure IQs. Instead, it's used to detect the level of electrical activity in the brain An EEG measures primarily grey matter or higher brain function. CT Scan may also be done to rule out other neurologic disorders No test is diagnostic of the Disorder

MANAGEMENT
DIET high residue and high calorie/ soft - increase fluid to prevent constipation - avoid foods that may cause drug interactions - aspiration precaution When on Levodopa therapy avoid -B6 rich foods blocks the effect of levodopa ( tuna,pork,salmon,beef liver)

 Prevent from contractures - firm bed and no pillows - best in prone position when lying in bed - hold hands folded at the back when walking Patient teaching must include - gradual change of position and wearing of elastic stockings to prevent postural hypotension - Reddish brown urine is harmless, may be attributed to drug therapy

DRUG THERAPY

ANTI-PARKINSONIAN (DOPAMINERGICS)
LEVODOPA (full form of L Dopa) CARBIDOPA /LEVODOPA ( Sinemet) - improves muscle flexibility by inhibiting the action of acetylcholine - Carbidopa reduces destruction of Levodopa at the periphery AVOID THE FOLLOWING DRUGS WHEN ON LEVODOPA THERAPY Phenothiazines (use for treatment of schizoprenia), Reserpine (an alkaloid drug used for the treatment of high blood pressure and as tranquilizer), Pyridoxine they block the effects of Levodopa

RECENT ADVANCES
ROPINIROLE PRAMIPEXOLE Drugs which have fewer side effects than L Dopa which are recently used to treat symptoms Transplantation of Fetal Cells Capable of Producing Dopamine Removal of a portion of the Corpus Striatum or implantation of an electrical pulse generator to stimulate specific basal nuclei are very effective

ANTICHOLINERGICS
COGENTIN (Benztropine Mesylate) ARTANE (Trihexyphenidyl) AKINETON (Biperiden HCl) - reduces tremors by preventing excessive acetylcholine action. - side effects includes blurring of vision, dryness of mouth and throat, constipation, urinary retention, dysarthria,mental disturbance

MAOI (Parnate, Marplan, Nardil )

- enhances norepinephrine activity - hypertensive crisis may occur Avoid foods rich in Tyramine METHYLDOPA potentiates the effect of levodopa - is a drug usually use for the treatment of hypertension

ANTIVIRAL/DOPAMINE AGONIST
AMANTADINE HCl (Symmetrel) BROMOCRIPTINE (Parlodel)

ANTISPASMODICS
PROCYCLIDINE HCL (Kemadrin)

ANTIHISTAMINE
DIPENHYDRAMINE (Benadryl) to decrease tremor and anxiety

MYASTHENIA GRAVIS
Definition Myasthenia gravis is a neuromuscular disorder characterized by variable weakness of voluntary muscles, which often improves with rest and worsens with activity. The condition is caused by an abnormal immune response.

Causes, incidence, and risk factors

In myasthenia gravis, weakness occurs when the nerve impulse to initiate or sustain movement does not adequately reach the muscle cells. This is caused when immune cells target and attack the body's own cells (an autoimmune response). This immune response produces antibodies that attach to affected areas, preventing muscle cells from receiving chemical messages (neurotransmitters) from the nerve cell.

 The cause of autoimmune disorders such as myasthenia gravis is unknown. In some cases, myasthenia gravis may be associated with tumors of the thymus (an organ of the immune system). Patients with myasthenia gravis have a higher risk of having other autoimmune disorders like thyrotoxicosis, rheumatoid arthritis, and systemic lupus erythematosus.

 Myasthenia gravis affects about 3 of every 10,000 people and can affect people at any age. It is most common in young women and older men.

Symptoms
Vision changes:
Double vision Difficulty maintaining steady gaze Eyelid drooping

Patients with generalized disease may also have:

Swallowing difficulty, frequent gagging or choking Weakness or paralysis (may worsen with exertion later in the day) Muscles that function best after rest Drooping head Difficulty climbing stairs Difficulty lifting objects Need to use hands to rise from sitting positions Difficulty talking Difficulty chewing

CONTINUATION
Additional symptoms that may be associated with this disease: Hoarseness or changing voice Fatigue Facial paralysis Drooling Breathing difficulty

Signs and tests

Examination may be normal or may show muscle weakness that progressively worsens as the muscle is used. In many patients the eye muscles are affected first. Reflexes and sensation are normal. Weakness may affect the arms, legs, breathing or swallowing muscles and any other muscle group. Standard EMG results are usually normal.

CONTINUATION
Repetitive stimulation (type of nerve conduction study) is more sensitive. Single-fiber EMG is even more sensitive. Acetylcholine receptor antibodies may be present in the blood. A Tensilon test is positive in some cases but must be interpreted carefully by an experienced doctor. Baseline muscle strength is evaluated. After Tensilon (edrophonium, a medication that blocks the action of the enzyme that breaks down the transmitter acetylcholine) is given, muscle function may improve.

Treatment
There is no known cure for myasthenia gravis. However, treatment may result in prolonged periods of remission. Lifestyle adjustments may enable continuation of many activities. Activity should be planned to allow scheduled rest periods. An eye patch may be recommended if double vision is bothersome. Stress and excessive heat exposure should be avoided because they can worsen symptoms.

CONTINUATION
Some medications, such as neostigmine or pyridostigmine, improve the communication between the nerve and the muscle. Prednisone and other medications that suppress the immune response (such as azathioprine, cyclosporine, or mycophenolate mofetil) may be used if symptoms are severe and there is inadequate response to other medications. Plasmapheresis, a technique in which blood plasma containing antibodies against the body is removed from the body and replaced with fluids (donated antibody-free plasma or other intravenous fluids), may reduce symptoms temporarily and is often used to optimize conditions before surgery.

CONTINUATION
Surgical removal of the thymus (thymectomy) may result in permanent remission or less need for medicines. There are several medications that may make symptoms worse and should be avoided. Therefore, it is always important to check with your doctor about the safety of a medication before taking it. Crisis situations, where muscle weakness involves the breathing muscles, may occur. These attacks seldom last longer than a few weeks. Hospitalization and assistance with breathing may be required during these attacks. Often plasmapheresis is used to help end the crisis.

Support Groups
The stress of illness can often be helped by joining support groups where members share common experiences and problems. See myasthenia gravis - support group.

Expectations (prognosis)
There is no cure, but long-term remission is possible. There may be minimal restriction on activity in many cases. Patients that only have eye symptoms (ocular myasthenia gravis), may progress to have generalized myasthenia over time. Pregnancy is possible for a woman with myasthenia gravis but should be closely supervised. The baby may be temporarily weak and require medications for a few weeks after birth but usually does not develop the disorder.

Complications
Restrictions on lifestyle (possible) Side effects of medications (see the specific medication) Complications of surgery Myasthenic crisis (breathing difficulty), may be life threatening

Amyotrophic Lateral Sclerosis (ALS)

Amyotrophic lateral sclerosis (ALS) is a terminal neurological disorder characterized by progressive degeneration of nerve cells in the spinal cord and brain. Often referred to as "Lou Gehrig's disease" (a famous baseball player who died from the disease), it is one of the most devastating of the disorders that affects the function of nerves and muscles. ALS does not affect mental functioning or the senses (such as seeing or hearing), and it is not contagious. Currently, there is no cure for amyotrophic lateral sclerosis.

Statistics of ALS:
Consider the following statistics regarding ALS: Most people who develop ALS are between the ages of 40 and 70, although the disease can occur at a younger age. ALS occurs throughout the world with no racial, ethnic, or socioeconomic boundaries. ALS affects as many as 30,000 Americans, with 5,600 new cases diagnosed in the US each year.

What are the different types of ALS?

There are three known classifications of ALS, including the following: sporadic - the most common form of ALS in the US, involving 90 percent to 95 percent of all cases. These cases occur randomly, without any known cause, and there is no association with persons in the family with the disease. familial - suggests that the disease is inherited and accounts for a very small number of cases in the United States, about 5 percent to 10 percent. Guamanian - an extremely high incidence of ALS was observed in Guam and the Trust Territories of the Pacific in the 1950s.

SYMPTOMS of ALS
The following are the most common symptoms of ALS. However, each individual may experience symptoms differently. Symptoms may include: twitching and cramping of muscles, especially those in the hands and feet loss of motor control in the hands and arms impairment in the use of the arms and legs

Symptoms continuation
tripping and falling dropping things persistent fatigue uncontrollable periods of laughing or crying slurred or thick speech and difficulty in projecting the voice

As the disease progresses, symptoms may include:

difficulty breathing difficulty swallowing paralysis The symptoms of ALS may resemble other conditions or medical problems. Always consult your physician for a diagnosis.

DIAGNOSIS OF ALS
In addition to a complete medical history and physical examination, diagnostic procedures for ALS may include the following: laboratory tests (including blood and urine studies and thyroid functioning tests) muscle and/or nerve biopsy - a procedure performed to remove tissue or cells from the body for examination under a microscope.

continuation
spinal tap (Also called a lumbar puncture.) - a special needle is placed into the lower back, into the spinal canal. This is the area around the spinal cord. The pressure in the spinal canal and brain can then be measured. A small amount of cerebral spinal fluid (CSF) can be removed and sent for testing to determine if there is an infection or other problems. CSF is the fluid that bathes the brain and spinal cord.

 x-ray - a diagnostic test which uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film. magnetic resonance imaging (MRI) - a diagnostic procedure that uses a combination of large magnets, radiofrequencies, and a computer to produce detailed images of organs and structures within the body.

 electrodiagnostic tests (i.e., electromyography (EMG) and nerve conduction velocity, or NCV) - studies that evaluate and diagnose disorders of the muscles and motor neurons. Electrodes are inserted into the muscle, or placed on the skin overlying a muscle or muscle group, and electrical activity and muscle response are recorded.

MANAGEMENT
Specific treatment for ALS will be determined by your physician based on: your age, overall health, and medical history extent of the disease your tolerance for specific medications, procedures, or therapies expectations for the course of the disease your opinion or preference

 For most people with ALS, primary treatment may involve the management of symptoms, and may include physical, occupational, speech, respiratory, and nutritional therapies. Some medications and/or heat or whirlpool therapy may help to relieve muscle cramping. Exercise, although recommended in moderation, may help to maintain muscle strength and function.

 There is no proven treatment for ALS. However, the US Food and Drug Administration (FDA) approved Rilutek, the first drug that has prolonged the survival of persons with ALS.

 Managing the symptoms of ALS is a process that may be challenging for people with the condition, their caregivers, and the medical team. However, it is important to know that there are many community resources available for support and assistance. Researchers are conducting studies to increase their understanding of genes that may cause the disease, mechanisms that can trigger motor neurons to degenerate in ALS, and approaches to stop the progress leading to cell death.