Transcript NEURO-FOR-THE-NOT-SO-NEURO

NEURO-FOR-THE-NOTSO-NEURO-MINDED
Barb Bancroft, RN, MSN, PNP
CPP Associates,
Chicago, IL
[email protected]
www.barbbancroft.com
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 17-22 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…
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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…
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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…
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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
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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 2nd 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
Caudate nucleus
Globus pallidus
Substantia nigra
Subthalamic 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 GABAminergic 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 3rd area of the
motor “triad”
The cerebellum…
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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…
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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.
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Barb Bancroft, RN, MSN, PNP
CPP Associates, Inc.
Chicago, IL.
[email protected]
www.barbbancroft.com