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Transcript of NEURO-FOR-THE-NOT- SO-NEURO-MINDED Barb Bancroft, RN, MSN, PNP CPP Associates, Chicago, IL...
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NEURO-FOR-THE-NOT-SO-NEURO-MINDED
Barb Bancroft, RN, MSN, PNPCPP Associates,
Chicago, [email protected]
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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
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“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
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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
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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
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Alzheimer’s…
• The Alzheimer’s brain
• Cortical atrophy
• Sulcal widening
• Atrophy of gyri
• Brain weight
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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
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Clock drawing…global function
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Frontal lobes…
• Voluntary speech center• Dr. Pierre Paul Broca• Broca’s aphasia• Non-fluent aphasia—telegraphic, staccato speech
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Frontal lobes…
• Pre-central gyrus (motor cortex—upper motor neurons)
• Voluntary movement center
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Upper Motor Neurons/CS tract
• Contralateral hemiparesis• Pronator drift• Hemiparalysis (spastic paralysis)
• Head injury, stroke,tumors
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• “And that’s why we always stand to the side when we check reflexes…”
• Hyperreflexia
• Babinski—extensor plantar reflex
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TEMPORAL LOBES…
• 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
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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?
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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)
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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)
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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)
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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
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TEMPORAL LOBES…
• Self-preservation and preservation of the species—the autonomic nervous system
• The 4 F’s…fight, flight
• Feeding activities • And….
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And…
• Sexual Function
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Sexual function in the brain and dopamine…
• SSRIs increase serotonin and you’re happy, but…
• When serotonin goes up, dopamine goes down
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TEMPORAL LOBES…
• Self-preservation and preservation of the species—The other 2 F’s
• Flight—Fright (epi, NE)• Episodic dyscontrol syndrome—TBI
patients
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TEMPORAL LOBES…
• 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
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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?
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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
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PARIETAL LOBES…
• Integration of tactile sensations—touch, pressure, vibration, and proprioception (do you know where your left buttocks is, right now?)
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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
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PARIETAL LOBES..testing
• Ability to localize stimuli• Sharp vs. dull• Tests for proprioception• Graphesthesia
• Apraxia—example: a dressing apraxia ideomotor apraxia constructional apraxia
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Abstraction…
• What does “Don’t cry over spilled milk” mean?
• HUH?
• How are a car, plane and boat alike?
• Cow, horse, and pig?
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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
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QUIZ…
• What were those 3 items I asked you to remember?
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The BASAL GANGLIA…
• The 2nd area of the motor “triad”
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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
Substantia nigra
Subthalamic nucleus
Globus pallidus
Caudate nucleus
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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
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The BASAL GANGLIA
The functions of the basal ganglia depend on a balance between various neurotransmitters
GABA-- ↓ dopamine:acetylcholine 50:50When this balance is disturbed, movement
disorders occur
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The BASAL GANGLIA…
• Control of movement, initiation and cessation of movement
• Postural reflexes—the righting reflex
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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
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Huntington’s chorea…chromosome #4
• Excess dopamine due to the loss of GABA-minergic input from the degeneration of the caudate nucleus
• Chorea—rapid, jerky movements of muscle groups
• Dementia• Neuroleptic drugs to block dopamine
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Other movement disorders
• Tourette’s syndrome
• Athetoid Cerebral Palsy
• Tardive dyskinesia
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The cerebellum—the 3rd area of the motor “triad”
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The cerebellum…
• Coordination• Synergy• Balance• Equilibrium
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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
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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
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The cerebellum…
• THINK BOOZE and the CEREBELLUM
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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)
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Small cell carcinoma of the lung with mets to the cerebellum
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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)
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The BRAINSTEM…(the “bulb”)
• II (Optic) and III (Oculomotor)—light reflex, accommodation, and the optic disk (papilla)
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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)
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The BRAINSTEM…
• CN III, IV, VI—follow my finger (extraocular movements)
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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
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The BRAINSTEM…
• IX (Glossopharyngeal) and X (Vagus)
• The gag reflex
• The uvula
• Closing off nasopharynx—say “K, K, K”
• Cleft palate
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The BRAINSTEM…
• CN XII (Hypoglossal)—tongue movement and strength
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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)
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Know your dermatome chart…
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OR draw your own…
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Neuromuscular junction
• Disease of the neuromuscular junction—myasthenia gravis
• Muscle weakness—consider thyroid disease, drug-induced myopathy, polymyositis, inherited muscular dystrophies
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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
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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
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Thanks.
• Barb Bancroft, RN, MSN, PNP• CPP Associates, Inc.• Chicago, IL.• [email protected]• www.barbbancroft.com