Transcript Age - CAPA
Neurology What not to miss in Family Medicine Danielle Pirrie CCPA Toronto East General Hospital – Department of Neurology [email protected] Objectives Review quick assessment tools to use for recognizing mild cognitive impairment Review need for urgent workup after a TIA or minor stroke Review red flags of headache and management of chronic headaches Case #1 78yo female c/o 2 month hx of memory loss, information collaborated by husband but also with hx of forgetting daughter’s phone number once, once forgetting a hair appointment, and 4 times confusing salt and sugar when cooking She volunteers at the local hospital 5 hours one day per week in the gift shop She babysits her 7yo grandson 2 afternoons per week She swims at the local community center 3 days/wk Case #1 P/E VS: afebrile, HR 84, BP 136/82, RR 20, SpO2 99% RA Neuro exam normal (CN, motor, sensation, coordination, speech) Cardiac exam normal Mild Cognitive Impairment Can involve problems with memory, language, thinking and judgment Does not interfere with daily functioning May have an increased risk of developing dementia Memory deficits may remain stable for years Mild Cognitive Impairment Forget things more often Forget appointments or social engagements Lose train of thought Feel overwhelmed by making decisions, planning, interpreting instructions Get lost around familiar environments Poor judgment Mild Cognitive Impairment Criteria Subjective report of cognitive decline Gradual onset Present for at least 6 months Excludes significant depression, delirium, or other disorders likely responsible Normal daily functioning Does not meet criteria for dementia Petersen RC, et al. JAMA 1995;273:1274-8 Mild Cognitive Impairment In office assessment Mini mental status exam: typically will do very well on this testing Montreal cognitive assessment: should score above 21/30 or else more likely dementia Likely to lose points on cube drawing, memory, and abstraction Clock drawing likely to be OK Follow up: keep copies of previous testing and compare year to year Ensure that mental status changes are not sudden Mild cognitive Impairment R/O reversible causes of memory changes: B12 deficiency or hypothyroidism Neuroimaging: r/o brain tumour, stroke or hemorrhage Review medications that may affect memory: Benzodiazepines Antihistamines Psychiatric meds Mild Cognitive Impairment Treatment Physical exercise – reduced vascular risk factors Psychosocial intervention Cognitive intervention Avoid conditions that can exacerbate memory loss Medications DON’T WORK Cholinesterase inhibitors (i.e. donepezil (Aricept), rivastigmine (Exelon), galantamine) NSAID (rofecoxib) Estrogen replacement therapy Ginkgo biloba Dementia Loss of global cognitive ability in a previously unimpaired person, beyond what might be seen from normal aging. Cognition affected Memory Attention Language Problem solving Cognition changes at least 6 months Dementia Types % Alzheimer’s 55.5 Vascular 14.5 Multiple causes 12.2 Parkinson’s 7.7 Brain injury 4.4 ETOH-induced 4.0 Dementia Treatment Ensure no reversible causes of mental status changes Drugs: cholinesterase inhibitors (Exelon, Aricept, Reminyl) Contraindications of cholinesterase inhibitors Bradycardia or AV block Severe hepatic or renal disease COPD/asthma Obstructive urinary disease Active peptic ulcer disease Seizures disorder Cognitive impairment summary Mild cognitive impairment Does not affect daily function Conservative management Warn that may progress to dementia Dementia Affects daily function Memory, language, insight, planning Meds can be tried for memory function if not contraindicated Case #2 72yo female, hx of well controlled HTN, 2 hour episode of right arm and leg weakness upon waking yesterday morning Resolved with no residual weakness, felt back to normal No visual disturbances, no speech problems, no HA No previous episodes like this or any other neurologic issues PMH: HTN Meds: HCTZ 25mg OD Case #2 P/E VS: temp 35.7oC, HR 83, BP 132/76, RR 18, SpO2 98% CN: II-XII normal Motor: no focal deficits Sensory: normal Coordination: normal Gait: normal Diagnosis??? Transient Ischemic Attacks Not seen as benign process anymore Estimated the risk of stroke after a TIA or minor stroke to be 8-12% at 7 days and 11-15% at 1 month Approximately 15% of ischemic strokes are preceded by a TIA Important to ask about previous episodes as it may have a cresendo effect Should be followed up in a stroke clinic or by family physician with stroke workup Coull AJ, Lovett JK, Rothwell PM BMJ 2004; 328:326 Stroke/TIA Workup CT scan Carotid doppler Echocardiogram Holter monitor Hypercoagulable screen in young people with stroke Stroke/TIA ABCD2 score 1. Age 60 years (1); 2. Blood Pressure 140/90 mm Hg on first evaluation (1); 3. Clinical symptoms: Unilateral weakness with or without speech difficulties(2) Speech impairment without weakness (1); 4. Duration 60 minutes (2); or 10 to 59 minutes (1); 5. Diabetes (1). Johnson SC, et al. "Validation and refinement of scores to predict very early stroke risk after transient ischemic attack" Lancet, 369:283-292, 2007 Stroke/TIA treatment ASA Cholesterol lowering agent (LDL < 2.0) Treat diabetes Treat HTN (<140/90) Encourage healthy lifestyle STOP SMOKING!!! Stroke/TIA summary TIAs are not benign processes but should be discussed as “warning strokes” Full stroke workup important Reduce future risk of stroke Case #3 37 y.o. male c/o worsening general headache, increasing over the last week, throbbing, 5/10 No N/V, no visual disturbances Previous HA history similar but usually not as intense or lasting as long Regular acetaminophen decreases HA so he is able to sleep His physical exam is completely normal Case #3 Does this patient need neuroimaging? Does he present with any red flags that would make you concerned? Treatment? Headaches Primary HA – more common Migraine with or w/o aura Tension HA Cluster HA Secondary HA – less common Post-traumatic HA Vascular disorders, i.e. stroke, SAH, AVM, arteritis, venous thrombosis, arterial HTN Nonvascular disorders, i.e. pseudotumour cerebri, infection, low CSF pressure Other: substance use or withdrawal, infection, metabolic disorders Referred pain from neck, eyes, teeth, nose, sinuses, etc Headaches History is most important since most people with HA have normal neuro exam. Headache questions How often do you get HA? Similar to previous? Severity? RED FLAGS HA beginning after age 50 – temporal arteritis, space occupying lesion Sudden onset of HA – SAH, AVM, think vascular Increasing frequency and severity – mass lesion, SDH, medication overuse New-onset in pt with risk factors for CA or HIV – meningitis, abcess, metastisis HA with systemic illness – meningitis, encephalitis, systemic illness Papilledema – mass lesion, pseudotumour cerebri, meningitis Newman LC, Lipton RB. Emergency department evaluation of headache. Neurol Clin 1998;16:285–303. Headache How to treat? HA diary Migraine <2/month: analgesics and triptans are main tx >2/month: preventive therapy; beta-blockers, antidepressants, anti-seizure drugs, botox When to refer? Headache summary History is most important part of the HA exam Most HA are primary, but secondary HA are more life threatening Refer and arrange for neuroimaging for any red flags Questions?