Neurology

1. Neurology What not to miss in Family Medicine Danielle Pirrie CCPA Toronto East General Hospital – Department of Neurology dpirr@tegh.on.ca

2. 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

3. 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

4. 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

5. 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

6. 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

7. Mild Cognitive Impairment Petersen RC, et al. JAMA 1995;273:1274-8 • 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

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

9. 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

10. Mild Cognitive Impairment DON’T WORK • Treatment • Physical exercise – reduced vascular risk factors • Psychosocial intervention • Cognitive intervention • Avoid conditions that can exacerbate memory loss • Medications • Cholinesterase inhibitors (i.e. donepezil (Aricept), rivastigmine (Exelon), galantamine) • NSAID (rofecoxib) • Estrogen replacement therapy • Ginkgo biloba

11. 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

12. Dementia

13. 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

14. 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

15. 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

16. 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???

17. Transient Ischemic Attacks Coull AJ, Lovett JK, Rothwell PM BMJ 2004; 328:326 • 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

18. Stroke/TIA Workup CT scan Carotid doppler Echocardiogram Holtermonitor Hypercoagulable screen in young people with stroke

19. Stroke/TIA Johnson SC, et al. "Validation and refinement of scores to predict very early stroke risk after transient ischemic attack" Lancet, 369:283-292, 2007 • 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).

20. Stroke/TIA treatment ASA Cholesterol lowering agent (LDL < 2.0) Treat diabetes Treat HTN (<140/90) Encourage healthy lifestyle STOP SMOKING!!!

21. Stroke/TIA summary TIAs are not benign processes but should be discussed as “warning strokes” Full stroke workup important Reduce future risk of stroke

22. 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

23. Case #3 Does this patient need neuroimaging? Does he present with any red flags that would make you concerned? Treatment?

24. 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. pseudotumourcerebri, infection, low CSF pressure • Other: substance use or withdrawal, infection, metabolic disorders • Referred pain from neck, eyes, teeth, nose, sinuses, etc

25. Headaches History is most important since most people with HA have normal neuro exam.

26. 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, pseudotumourcerebri, meningitis Newman LC, Lipton RB. Emergency department evaluation of headache. NeurolClin 1998;16:285–303.

27. 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?

28. 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

29. Questions?