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Neurology Update for 2013
Vanja Douglas, MDUCSF Department of Neurology
Neurohospitalist Division
Disclosures
2012: Received an honorarium for speaking about neurohospitalists for Grifols, Inc. (manufacturers of IVIG)
Learning Objectives• Describe how to work up and treat dementia• Understand effective delirium prevention and
treatment measures• List the new oral treatments for multiple
sclerosis• Initiate treatment of Parkinson disease• Know several new options for prevention of
migraine headache
Case 1• A 74 y/o man is brought to you by his son
because of concerns about his memory. He occasionally forgets the names of his grandchildren and will often forget to buy all the items he intended to at the grocery store. He still performs all his ADLs and balances his own checkbook.
• His mini mental status exam score is 27/30, with 2 points off for recall and one off for orientation.
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Question 1: What is the most likely diagnosis?
F r on t o
t e mp o r
a l . . . A l z
h e i me r d
e m e. . .
V a sc u l a
r d em e n
. . . M i
l d co g n
i t i ve . . .
D em e n
t i a wi t h
. . .
0%4%
9%
78%
9%
1. Frontotemporal dementia2. Alzheimer dementia3. Vascular dementia4. Mild cognitive impairment5. Dementia with Lewy Bodies
Mild Cognitive Impairment• Concern regarding a change in cognition• Impairment in one or more cognitive domains
– Objective impairment on bedside testing• Preservation of independence in functional
abilities• Not demented
– No significant impairment in social or occupational functioning
Dementia: Differential DiagnosisAlzheimer’s Disease
Hippocampusand posterior parietal
Amyloid plaques, tau tangles
Memory loss
FrontotemporalDementia (FTD)
Frontal and temporal lobes
Tau inclusionsTDP-43
Apathy, behavior, anxiety
Dementia with Lewy Bodies (DLB)
Brainstem Alpha-synuclein Hallucinations, parkinsonism
Vascular Dementia
Diffuse or focal Gliosis Executive slowing
Name Anatomy Pathology First SymptomsAlzheimer Disease Staging
Braak and Braak, Acta Neuropathol 1991
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Dementia: Reversible Causes• Depression• B12 deficiency• Hypothyroidism• Structural disorders (subdural hematoma,
hydrocephalus, slowly growing brain tumor)
• Syphilis• HIV• Delirium masquerading as dementia (liver disease, uremia,
hypoparathyroidism)
Alzheimer Disease Treatment
Rogers et al., Neurology 1998
Alzheimer Disease Treatment• Cholinesterase inhibitors (donepezil, rivas�gmine, galantamine) → Mild to moderate dementia (MMSE score 10 – 26)– Diarrhea, nausea and vomiting, bradycardia, syncope,
and heart block• Memantine → Moderate to advanced
dementia (MMSE score 3-14)– Some studies show benefit with combination therapy
Tariot et al., JAMA 2004
Delirium• You are called to the hospital because your 74
year-old patient with MCI has been admitted with pneumonia.
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Question 2: Which of the following is NOT an evidence-based method to prevent his developing delirium in the
hospital?
E a rl y a
m bu l a t
i . . . O r a
l r eh y d
r a t i. . .
F r eq u e
n t re - o
r . . . L o w
- d os e h
a l o p. . .
A vo i d
i n g n a p
s . . . P o
r t a bl e a
m pl i . . .
3% 6% 3%0%
84%
3%
1. Early ambulation and bed exercises2. Oral rehydration3. Frequent re-orientation 4. Low-dose haloperidol at bedtime5. Avoiding naps and schedule
adjustments to allow sleep at night6. Portable amplifying devices and visual
adaptive equipment
Model of Delirium
Risk Factors
Specific Insults
Delirium
Risk Factors• Age• Pre-existing cognitive dysfunction• Functional impairment
– Mobility, vision, hearing• Malnutrition/dehydration• Severe illness• Depression• Alcohol abuse
Images from Wikimedia Commons
Iatrogenic Precipitants• Medications (3 or more)• Sleep deprivation• Restraints• Urinary catheters• Frequent procedures• Surgery (thoracic, vascular, and hip)• Untreated pain
Images from Wikimedia Commons
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Prevention: Non-pharmacologicRisk factor for delirium Targeted interventionCognitive Impairment Board with names of care team members and
day’s scheduleFrequent reorientation
Sleep Deprivation Bedtime routine, avoid napsUnit-wide noise-reduction strategiesSchedule adjustments to allow sleep
Immobility Early ambulation, bed exercisesMinimal use of catheters and restraints
Vision impairment < 20/70 Use of visual aidsAdaptive equipment
Hearing impairment Portable amplifying devicesEarwax disimpaction
Dehydration (BUN/Cr ratio >18) Oral rehydration
Inouye et al, NEJM 1999
Prevention: Non-pharmacologicRisk factor for delirium Targeted interventionCognitive Impairment Board with names of care team members and
day’s scheduleFrequent reorientation
Sleep Deprivation Bedtime routine, avoid napsUnit-wide noise-reduction strategiesSchedule adjustments to allow sleep
Immobility Early ambulation, bed exercisesMinimal use of catheters and restraints
Vision impairment < 20/70 Use of visual aidsAdaptive equipment
Hearing impairment Portable amplifying devicesEarwax disimpaction
Dehydration (BUN/Cr ratio >18) Oral rehydration
Inouye et al, NEJM 1999
• Reduced delirium incidence from 15% to 9.9% (p = 0.02)
• NNT = 20
• Total delirium days 105 vs. 161 (p = 0.02)
Treatment• Treat the underlying cause• Remove unnecessary medications• Remove bladder catheters• Early mobilization• Normalize sleep-wake cycles• Sitters instead of restraints• Sedation should be used only when the
patient poses a danger to him/herself or staff
Pharmacologic TreatmentMedication Initial Dosage CommentsHaloperidol 0.5 mg to 1 mg BID One placebo-controlled
RCTRisperidone 0.5 mg BID Equivalent to haloperidol
in one RCTOlanzapine 1.25 mg to 2.5 mg
dailyBetter than placebo and equivalent to haloperidol in one RCT
Quetiapine 25 mg BID Better than placebo in the ICU in one RCT
Lonergan et al, Cochrane Database Syst Rev 2007
• Off label• Black box warning: increased risk of sudden death in dementia patients
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Case 2• A 33 year-old woman comes to see you because
of two weeks of left arm and leg numbness and tingling. The symptoms came on gradually over 2 days and have been stable since. She kept putting off coming to the doctor thinking she just slept on her left side awkwardly.
• Her exam shows decreased sensation in the left arm and leg and slow finger and foot taps on that side.
Question 3: What is the most appropriate next diagnostic step?
B i l at e r a
l c ar o . .
. M R
I o f t h e
b r a. . .
N on - c o
n t r as t C
. . . M R
I o f t h e
b r a. . .
M RI o f
t h e c e r
. . . L u m
b a r p u n
c t u r. . .
0%
19%
4%4%
56%
19%
1. Bilateral carotid ultrasound2. MRI of the brain3. Non-contrast CT of the brain4. MRI of the brain and cervical spine5. MRI of the cervical spine6. Lumbar puncture
Multiple Sclerosis: Workup• MRI is the cornerstone of diagnosis• Lumbar puncture is helpful but not always
necessary if MRI is typical• Labs: RPR/FTA-abs, ANA, SSA/SSB, B12• Consider: HIV, Lyme, antiphospholipid
antibodies, RF, aquaporin-4 antibodies, chest X-ray
Multiple Sclerosis MRI
Axial T2: Cerebellar lesions Saggital T2: Spinal cord lesion
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Multiple Sclerosis MRI
Saggital FLAIR: Dawson’s fingers Axial T1 post-gad: optic neuritis
Multiple Sclerosis: Diagnostic CriteriaClinical Presentation Additional Data Needed for MS
Diagnosis*2 or more clinical attacks2 or more objective lesions
none
2 or more clinical attacks1 objective lesion
Dissemination in space by MRIAdditional clinical attack
1 clinical attack1 objective lesion
Dissemination in time by MRINew lesions on later MRISecond clinical attack
Insidious progression from onset 1 year of progressionDissemination in space by MRI
Polman et al, Ann Neurol 2011
*No alternative diagnosis more likely
A Comparison of MS DrugsDrug Route of
AdministrationEffect on Relapses
Adverse Events
Interferon beta IM or Sub-Q Reduce by 1/3 DepressionFlu-like symptoms
Glatiramer acetate Sub-Q Reduce by 1/3 Injection site reactionsNatalizumab Monthly IV Reduce by 2/3 PMLFingolimod Oral Reduce by 1/2 Symptomatic bradycardia
Macular edemaDisseminated VZV
Teriflunomide Oral Reduce by 1/3 Alopecia, NauseaNeutropeniaTransaminitis
Dimethyl Fumarate Oral Reduce by 1/2 FlushingAbdominal discomfortDiarrheaLymphopenia, transaminitis
Case 3• A 65 year-old man comes to your clinic
complaining of a tremor. It bothers him the most when he is sitting in business meetings. He also notes that he can’t keep up with his grandkids like he used to. His exam shows a rest tremor on the right, with cogwheelingrigidity in the right arm, and a slightly shuffling gait.
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Question 5: Which of the following exposures is LEAST important to ask about in this patient?
M et o c
l o pr a m
i d e P r o
c h lo r p
e r az i . . .
P r om e
t h az i n e
( . . . M a
n g an e s
e H e
a d t r a u
m a R i s
p e ri d o
n e o r . .
.
0% 0%
16%
42%42%
0%
1. Metoclopramide2. Prochlorperazine (compazine)3. Promethazine (phenergan)4. Manganese5. Head trauma6. Risperidone or other second
generation antipsychotics
Parkinson Disease• Four cardinal signs
– Bradykinesia, rigidity, resting tremor, postural instability• Differential diagnosis
– Secondary parkinsonism (e.g., medications, trauma)– Other neurodegenerative diseases– Structural lesions uncommon
• Brain imaging not necessary for diagnosis
Question 6: With what medication would you initiate treatment?
L e vo d o
p a /c a r b
i . . . P r o
p r an o l
o l P r a
m i pe x o
l e G a
b a pe n t
i n R a s
a g i li n e
E n ta c a
p o ne
72%
8%4%4%
0%
12%
1. Levodopa/carbidopa2. Propranolol3. Pramipexole4. Gabapentin5. Rasagiline6. Entacapone
PD: Treatment• L-dopa vs. dopamine agonists:
– Well known that the longer one is exposed to L-dopa, the higher the risk of motor complications (dyskinesias, wearing off, on-off fluctuations, freezing)
– Often dopamine agonists are used first in order to delay the use of L-dopa
Image from Wikipedia Commons
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Levodopa vs. Dopamine agonistsYears of follow-up
Pramipexole Levodopa p
UPDRS (mean changefrom baseline)
2 -4.5 -9.2 <0.0014 3.2 -2.0 0.0036 2.4 0.5 0.11
First dopaminergicmotor complication
2 28% 51% <0.0014 52% 74% <0.0016 50% 78% 0.002
Quality of Life scores (mean change from baseline)
2 1 -1 0.0064 ~4 ~4 NS6 7.1 8.6 0.90
Parkinson Study Group, JAMA 2000, Arch Neurol 2004 and 2009
MAO-B Inhibitors: Neuroprotective?• Early vs. Delayed start rasagiline:
ADAGIO, NEJM 2009
Treatment Options in PD
Image from Wikipedia Commons
Dopamine agonistsLevo-DOPA 3-MT
COMT Inhibitors(e.g. entacapone)
MAO-B Inhibitors(e.g. rasagiline)
Other mechanisms:*Amantadine*Anticholinergics
PD: Treatment• Starting levodopa:
– Combine with carbidopa to prevent conversion to dopamine outside of the CNS
– Need at least 75 mg of carbidopa per day (e.g. Sinemet 25/100 TID)
– Can prescribe extra carbidopa• Titrate up to 3 tablets TID before calling a
patient unresponsive• Taken on empty stomach
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PD: Treatment• Carbidopa/Levodopa
– Avoid use of CR formulation except at bedtime• Dopamine agonists
– Use with caution in the elderly (>70 years old):• Daytime somnolence• Hallucinations• Obsessive behaviors (pathologic gambling)
– Use ropinerole or pramipexole; older ergot derived agonists such as pergolide can lead to cardiac valve fibrosis
PD: When to Refer• To confirm or reconsider diagnosis:
– Patient not responding to L-DOPA or agonist– Rapid progression
• Significant off periods requiring more than TID dosing of L-DOPA
• Significant dyskinesias or other dose-limiting side effects of L-DOPA
Bonus Case• A 34 year-old woman has a 5-year history of
headache. The headaches occur 4 times per month and are severe. They are throbbing, usually bitemporal, often associated with vomiting, and force her to lie in a dark room for 2-3 days. They are triggered by business travel.
Question 7: Which of the following medications has the LEAST evidence supporting its use for
migraine prevention?
P r op r a
n o lo l
A t en o l
o l V e
r a pa m
i l T o p
i r a ma t e
G ab a p
e n ti n
P e ta s i t
e s (b u t
. . .
0% 0% 0%0%0%0%
1. Propranolol2. Atenolol3. Verapamil4. Topiramate5. Gabapentin6. Petasites (butterbur)
Countdown
10
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Migraine Therapy: Prophylaxis• Consider when >3 headaches/month• Anti-epileptics
– Valproic acid, topiramate• Beta blockers
– Propranolol, metoprolol, timolol, atenolol, nadolol• Antidepressants
– Amitriptyline, venlafaxine
Silberstein et al, Neurology 2012
Migraine Therapy: Alternatives • Level A evidence:
– Petasites (butterbur): 50-75 mg BID• Level B evidence:
– Magnesium– MIG-99 (feverfew)– Riboflavin
Holland et al, Neurology 2012
Migraine Therapy: Abortive• Acetaminophen, NSAIDs, ASA, or Excedrin• Triptans• Antiemetics: metoclopramide, prochlorperazine,
chlorpromazine• Ergots: cafergot, dihydroergotamine• Acetaminophen/butalbital/caffeine (Fioricet)• Acetaminophen/dichloralphenazone/ isometheptene (Midrin)
Silberstein et al, Neurology 2000
Chronic Migraine and Medication Overuse Headache
• At least 15 headache days per month• Medication overuse: regular overuse (>2
days/week) of a migraine abortive for >3 months• Therapy:
– Chronic migraine: botulinum toxin– Medication overuse: stop all analgesics
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Botulinum Toxin
Episodic migraine
Chronic migraine
Probability of >50% reduction in headache days
Jackson et al, JAMA 2012
Summary• Dementia• Delirium• Multiple Sclerosis• Parkinson Disease• Migraine Headache