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Nervous System Flashcards

1
Q

What are the 4 most common types of dementia and how do they differ in symptoms?

A

Alzheimers; memory, repeated questions
Parkinsons
Lewy body; more sleep disturbance and repeated falls/faints
Vascular: CVD and movement problems

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2
Q

What (with what symptoms) calls for pharmacological treatment in dementia?

A

Cognitive symptoms (memory, concentration, problem solving), severe disease.

Non cognitive only when severely distressed or a danger

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3
Q

What is the drug of choice in mild to moderate dementia due to alzheimer’s with cognitive symptoms?

A

Anticholinesterase inhibitor

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4
Q

What is the drug of choice in Parkinsons dementia and what is the issue with this treatment?

A

Rivastigmine. May worsen tremor.

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5
Q

What is the drug of choice in alzheimer’s with severe non cognitive symptoms?

A

Antipsychotic or benzodiazapines

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6
Q

What is the drug of choice in severe alzheimer’s wihh cognitive symptoms?

A

Memantine

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7
Q

What is the issue with antipsychotic use in dementia patients

A

Increased risk of stroke and death in elderly dementia. Balance risk factors.

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8
Q

In what conditions would acetylcholinesterase inhibitors be cautioned or avoided?

A

Caution in asthma and COPD as may exacerbate, peptic ulcers, use with NSAIDs/steroids/rate limiting drugs. Avoid in heart block and sick sinus syndrome

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9
Q

When should the efficacy of treatment be assessed in dementia?

A

At 3 months.

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10
Q

What are the most common side effects of acetylcholinesterase inhibitors?

A

Nausea, vomiting and diarrhoea

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11
Q

What dose considerations should be given for anti epileptic in children?

A

Interval may need to be reduced as metabolised quicker

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12
Q

What are the category 1 anti epileptics for maintaining brand?

A

Phenytoin, carbemazepine, phenobarbital and primidone

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13
Q

Which antiepileptics have the highest risk of antiepileptic hypersensitivity syndrome?

A

Carbemazepine, lacosamide, lamotrigine, oxcarbazepine, phenobarbital, phenytoin, primidone, and rufinamide

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14
Q

What are the main symptoms of antiepileptic hypersensitivity syndrome?

A

Fever rash lymphadenopathy

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15
Q

Upon withdrawal of an antiepileptic, how long before someone can normally drive?

A

6 months after last dose

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16
Q

Besides valproate, what other antiepileptic drugs have risk of teratogenicity?

A

Phenytoin, primidone, phenobarbital, lamotrigine, carbemazepine, topiramate

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17
Q

Which antiepileptics may need their doses changing during pregnancy?

A

Phenytoin, carbemazepine, lamotrigine

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18
Q

Which antiepileptics should be cautioned for use during breastfeeding and why

A

Primidone, phenobarbital, benzodiazepines. Established risk of drowsiness

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19
Q

Besides hypersensitivity, what other symptoms should patients look out for with carbemazepine?

A

Bruising, bleeding, mouth ulcers (blood disorders)

Reduced appetite, abdominal pain (liver toxicity)

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20
Q

Which antiepileptics are best tolerated?

A

Levetiracetam, Pregablin and gabapentin

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21
Q

Which antiepileptic is used in children but can cause serious rashes?

A

Lamotrigine

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22
Q

What should be monitored during dos phenytoin infusion?

A

Heart rate, blood pressure and respiratory function

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23
Q

What is the normal plasma concentration for phenytoin and when might it change?

A

10-20mg/L. Protein binding my be reduced in pregnancy, elderly, diseased and in first 3 months of life

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24
Q

At what age do symotoms normally appear for ADHD?

A

3 - 7

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25
Q

What is the first line drug treatment for ADHD and how long is it trialed for before trying others?

A

Methylphenidate for at least 6 weeks. Or atomoxetine if risk of abuse.

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26
Q

What effects should patients look out for with treatment for atomoxetine?

A

Agitation, suicidal thoughts, potential for liver damage (unexplained nausea, malaise, darkened urine, jaundice)

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27
Q

What should be recorded 6 monthly during ADHD treatment?

A

Pulse, BP, psychiatric symptoms, appetite, weight and height

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28
Q

How long should treatment persist for mania?

A

At least 2 years from last manic episode or 5 years if risk of relapse

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29
Q

What adjunctive drugs may be given in mania and when should they be avoided

A

Antidepressants - avoid with rapid fluctuation or hypomania

Benzodiazepine but only short term

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30
Q

What drug therapy is recommended in acute hypomania and mania?

A

Atypical antipsychotic. Add lithium or valproate if uncontrolled

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31
Q

What drug is useful in rapid cycling mania?

A

Carbemazepine

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32
Q

What is the target lithium levels?

A

0.4-1mmol/l
0.8-1 if manic episode
Samples should be taken 12h after dose.

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33
Q

What should be monitored in lithium patients and how often?

A

Body weight, electrolytes, EGFR, thyroid function. 6 monthly.

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34
Q

What are the symptoms of liver toxicity and what else should patients look out for with lithium treatment?

A

Vomiting, diarrhoea, muscle weakness, confusion, drowsiness, hypernatreamia.

Hypothyroidism, headache, visual disturbance

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35
Q

Patients with non cognitive symptoms in dementia should be prescribed antipsychotic drugs. True or false

A

Only if Severe due to increased risk of stroke and death

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36
Q

What side effects can anticholinesterases have?

A

Blurred vision, urinary incontinence

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37
Q

Which antiepileptics can be given once daily?

A

Lamotrigine, parampenel, phenobarbital and phenytoin

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38
Q

What monitoring should occur with fosphenytoin?

A

HR, BP, respiratory function during infusion and observe at least 3o minutes after

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39
Q

Vitamin D supplements should be considered with which antiepileptics?

A

Phenytoin, phenobarbital, sodium valproate, primidone

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40
Q

What are the symptoms of phenytoin toxicity?

A

Nystagmus, diplopia, slurred speech, ataxia, confusion, hyperglycemia

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41
Q

What symptoms to look our for and monitoring should be done with valproate?

A

Raised liver enzymes
Abdominal pain, anorexia, jaundice, oedema, malaise, drowsiness
Pancreatitis
Pregnancy prevention programme

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42
Q

How long should valproate be reduced over?

A

4 weeks

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43
Q

What issues have topiramate been associated with?

A

Acute myopia with secondary angle closure glaucoma within 1 month of starting. Raised intra ocular pressure
Congeniral abnormalities

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44
Q

What issues has vigabatrin been associated with?

A

Visual field defects from 1 month to several years after starting. Test 6 monthly and report visual disturbance

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45
Q

Whta should infants be monitored for during breastfeeding in benzodiazepine use?

A

Sedation, feeding difficulties adequate weight gain and development milestones

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46
Q

For what medicines is the risk of impaired skilled tasks period extended and for how long?

A

24 hours with short general anaesthetics and IV benzodiazepines

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47
Q

What benzodiazepines are safer in hepatic impairment?

A

Those with shorter half lives. Temazepam, oxazepam

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48
Q

Can taking benzodiazepines effect your behaviour?

A

Yes paradoxical effects in hostility and aggression may be reported. Talkative Ness and excitement to aggression and antisocial behaviour. Anxiety. Perceptual disorder.

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49
Q

An overweight patient is prescribed a benzodiazepine, which may be effected by his weight?

A

Midazolam accumulates in adipose tissue

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50
Q

Are benzodiazepines safe in pregnancy?

A

Risk of neonatal withdrawal symptoms. Avoid regular use and only when clear indication. High doses in late pregnancy may cause neonatal hypothermia, hypotonia and respiratory depression

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51
Q

What should be monitored for with lis/dexamfetamine?

A

Growth in children. Discontinue if tics occur. (just dex)

Pulse, BP, appetite, weight and height every 6 months. Aggressive behaviour and hostility in initial treatment in both

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52
Q

Can amfetamines be mixed with food?

A

Lis dexamfetamine can be mixed with soft food or in water/orange juice.

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53
Q

What should be monitored with guanfacine?

A

Baseline evaluation of somnolence, sedation hypotension bradycardia, qt prolongation and arrhythmia. Monitor for side effects and bmi (3m in first year then 6m)

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54
Q

How should antipsychotics be discontinued?

A

Over at least 4 weeks if continuing with other antimanic drugs or up to 3 months if not

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55
Q

How long does the prophylactic effect of lithium take to occur?

A

6-12 months

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56
Q

What signs should be monitored in valproate treatment?

A

Raised liver enzymes and prothrombin time may be transient but could be linked to liver dysfunction

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57
Q

A patient prescribed lithium will be on it lifelong. True or false.

A

False. Continued therapy should be assessed regularly due to risk of Thyroid disorder (monitor 6m) and memory impairment. Patients maintained on lithium past 3 - 5 y only if benefit persists.

58
Q

What are the signs of lithium toxicity?

A

Diarrhoea, vomiting visual disturbance, polyuria, muscle weakness, fine tremor to coarse tremor, cns disturbance (confusion, drowsiness), Myoclonus, incontinence, hypernatremia. Arrhythmia, seizures, renal failure if Severe.

59
Q

Which class of antidepressants are first line?

A

SSRIs. Less antimuscarinic and cardio toxic effects than tricyclics and maois have food interactions

60
Q

What time frames are given to antidepressant therapy for reviews, remission and effect?

A

Review every 1 to 2 weeks at start. Continue for at least 4 weeks. 6 in elderly before considering a switch. Continue following remission for further 6 months (12m in elderly or Gad). Maintenance for at least 2 years if recurrent.
Maois may take longer to work (3 weeks or more and additional 1-2 for maximal).

61
Q

Which antidepressants cause Hyponatreamia?

A

All. But more with SSRIs

62
Q

Why does there need to be a break between certain antidepressants during a switch? Which?

A

Longer half lives may I crease risk of serotonin syndrome

Other antidepressants (incl MAOI) should not be stated for 2 weeks after MAOI stopped (3 weeks if starting imipramine or clomipramine).
Maois should not be started until 7-14 days after tricyclic (3 weeks after above 2) has stopped, or until a week after ssri (5 weeks if fluoxetine) stopped
63
Q

Which tricyclics are more sedative?

A

Amitriptyline, clomipramine, dosulepin, doxepin, Mianserin, trazadone and trimipramine

64
Q

Lofepramine has less cardio toxic side effects but what else can it cause?

A

Hepatic toxicity

65
Q

Which depressed patients respond best to Maois?

A

Phobic or with atypical, hypochondriac or hysterical features.

66
Q

When can vortioxetine or tryptophan be used?

A

Vortioxetine if non responsive to 2 antidepressants within current episode
Tryptophan by hospital specialists

67
Q

What should patients on MAOIs avoid?

A

Food suspected of stale or going off especially meat fish poultry or offal. Avoid game. Persists 2 weeks after stopping. Avoid alcoholic or dealcoholised drinks. Tyramine rich food (mature cheese, yeast, fermented soya bean)

68
Q

What advice is given by the royal college of psychiatrists on doses of antipsychotic drugs?

A

Before increasing above bnf upper limit consider alternative approaches such as adjuvant or newer drugs such as clozapine,
Bear in mind risk factors including obesity and particular caution in elderly over 70
Consider drug interactions
Carry out ECG to exclude prolonged qt
Increase dose slowly and no more often than weekly
Carry out regular pulse, blood pressure, and temperature checks and ensure adequate fluid intake
Consider high dose for limited period and review regularly. Abandon if 3 months with no improvement

69
Q

What are positive and negative symptoms of schizophrenia?

A

Positive is thought disorder, hallucinations delusions

Negative is apathy social withdrawal

70
Q

How are first generation antipsychotic drugs grouped for side effects?

A

Group 1 (chlorpromazine, levomepromazine and promazine) prounounced sedative and moderate antimuscarinic/extrapyrimidal

Group 2 (pericyazine) moderate sedative, fewer extrapyrimidal

Group 3 (fluphenazine, perphenazine, prochlorperazine, trifluoperazine) fewer sedative and antimuscarinic but more pronounced extrapyrimidal. Same with butyrophenones (haloperidol benperidol)

Thioxanthenes (flupentixol, zuclopenthixol) moderate of all

Pimozide and sulpride reduced of all

EPS also common with depot

71
Q

What are the extrapyrimidal side effects?

A

Parkinsonism (tremor) , dystonia (abnormal face and body movements), akathisia (restlessness), tardive dyskinesia (rhythmic involuntary, most serious as may be irreversible)

72
Q

What effect do antipsychotics have on prolactin? Which?

A

Increase (as dopamine inhibits). Except aripiprazole which reduces as partial agonist. Rispeidone, amisulpride and first gen more likely. Sexual dysfunction, reduced bone mineral density, menstrual disturbances, breast enlargement and galactorrhoea.

73
Q

Which antipsychotics most commonly cause sexual dysfunction and why?

A

Reduced dopamine transmission and hyperprolactinaemia decrease libido. Rispeidone and haloperidol

74
Q

Which antipsychotics are at most rijs of diabetes?

A

Clozapine, olanzaoine, quetiapine and rispeidone

75
Q

A patient taking an antipsychotic is experiencing hyperthermia, muscle rigidity, tachycardia and urinary incontinence. What may they be experiencing and what should be done.?

A

Neuroleptic malignant syndrome. Discontinue antipsychotic

76
Q

Which type of antipsychotics works best on negative symptoms?

A

Second gen

77
Q

What monitoring is done with antipsychotic?

A

FBC, U&Es, LFTs at start and annual.
Lipids and weight at baseline, 3m then yearly
Fasting blood glucose at baseline 4-6m, then yearly.

78
Q

Why are FBCs particularly important with clozapine?

A

Neutropenia and potentially fatal agranulocytosis reported. Must be normal before starting. Monitor every week for 18 weeks then at least every 2 weeks. 4 weeks after stable for a year. 4 weeks after discontinuation.

79
Q

Does constipation with clozapine warrant discontinuation?

A

It should be recognised and actively treated due to impairment of intestinal peristalsis leading to intestinal obstructions.

80
Q

What can be used for muscular symptoms in movement disorder eg motor neurone disease?

A

Quinine first line. Then baclofen. Tizanidine, gabapentin and dantrolene considered.

81
Q

What is used to treat saliva problems in motor neurone disease or Parkinsons?

A

Antimuscarinics. Glycopyrronium if cognitive impairment. Botulinum with referral (second line in Parkinsons) Humidification, nebulisers, carbocisteine

82
Q

Why might opioids or benzodiazepines be used in motor neurone disease?

A

For breathlessness exacerbated by anxiety

83
Q

What area of the brain is effected in Parkinsons?

A

Substantia nigria

84
Q

What must be done once a patients Parkinsons diagnosis is confirmed?

A

Inform dvla and car insurer

85
Q

Which drug is most suitable if Parkinsons patients have their quality of life effected by motor symptoms?

A

Levodopa but motor complications more likely

86
Q

What are the main adverse effects associated with antiparkinsons

A

Psychotic symotoms
Excessive sleepiness and sudden onset of sleep (dopamine receptor agonists)
Impulse control disorders (especially dopamine receptor agonists) particularly if previous impulse behaviour alcohol consumption or smoking

87
Q

Which drug is immediately not considered for Adjunct therapy with levodopa if motor fluctuations occur?

A

Ergot derived dopamine receptor agonists (only if not adequately controlled with non ergot)

88
Q

What can be given for daytime sleepiness in Parkinsons?

A

Modafinil if pharmacological causes excluded.

89
Q

What can be used for postural hypotension in Parkinsons?

A

Midodrine first line. Fludrocortisone as alternative

90
Q

Are antipsychotics used in Parkinsons?

A

Quetiapine or clozapine can be to treat hallucinations and delusions. Phenothiazines and butyrophenones can worsen motor features.

91
Q

What can be given for rapid eye movement in Parkinsons?

A

Clonazepam or melatonin

92
Q

What is given in advanced Parkinsons disease?

A

Apomorphine. Domperidone for nausea and vomiting associated (admin 2 days before) but assess cardiac risk factors.
Levodopa/carbidopa intestinal gel if Severe motor fluctuations and hyperkinesia or dyskinesia.
deep brain stimulation

93
Q

Which antiparkinsons medication needs extra counselling to prevent worry to patients?

A

Entacapone colours urine reddish brown

94
Q

What is a major caution of tolcapone?

A

Hepatitoxicity. Usually in women during first 6 months. Test before and every 2 weeks in first year, then every 4 weeks for 6m then every 8 weeks. Tell patients to seek attention with anorexia nausea, vomiting fatigue, abdominal pain, dark urine or Pruritis.

95
Q

Why should antiparkinsons medication never be abruptly withdrawn?

A

Small risk of neuroleptic malignant syndrome

96
Q

What monitoring is required with apomorphine?

A

Hepatic, haemopoeitic renal and cardio function

Test initial and 6m anaemia and thrombocytopenia if used with levodopa

97
Q

Can dopamine receptor agonists be used in pregnancy?

A

Most avoid.
Bromocriptine should not be used postpartum or in puerperium if high BP, CAD, mental disorder. Provide contraceptive advice if appropriate.
Cabegoline exclude pregnancy and discontinue 1 month before intended and if pregnancy occurs.

98
Q

What different types of drugs can be used in nausea/vomiting and when are they preferred?

A

Antihistamines - pregnancy vomiting
Phenothiazines - neoplastic disease, radiation, drug induced (chlorpromazine most sedative). Can be rectal or buccal if vomiting severe.
Other antipsychotics in terminal illness (haloperidol, levomepromazine)
Metoclopramide - gastro, hepatic, biliary
Domperidone - less likely for BBB side effects
Serotonin receptor antagonists - chemotherapy
Dexamethasone - chemotherapy
NK1 receptor antagonists - chemotherapy
Nabilone (cannabinoid) - chemotherapy

99
Q

What options of antiemtics are there in pregnancy?

A

Antihistamine eg promethazine
Prochlorperazine or metoclopramide

Hyperemesis gravidarum - regular therapy, fluid and electrolytes. Maybe nutrition or thiamine if risk of wernicks

100
Q

What risk factors are there for post op nausea and vomiting?

A

Female, non smokers, history and opioid use.

101
Q

What is the most effective drug for motion sickness prevention?

A

Hyoscine hydro bromide. Sedating antihistamines are better tolerated (cyclizine/cinnarizine preffered over more sedating promethazine)

102
Q

What antiemetic can reduce effectiveness of hormonal contraception?

A

NK receptor antagonists

103
Q

What pain are paracetamol, NSAIDs and opioids each suitable for?

A

Paracetamol and NSAIDs for musculoskeletal

Opioid for moderate to severe, particularly visceral

104
Q

What drugs should be given in dental pain?

A

NSAIDs most suitable as anti infnflammatory. Opioids relatively ineffective. Benzydamine if acute pain of oral mucosa

105
Q

Which analgesics are less suitable post operatively?

A

Tramadol not as effective as others for severe pain. Buprenorohine may antagonise previously administered opioids. Pethidine has toxic metabolite.

106
Q

Why are fentanyl patches unsuitable for a patients first opioid?

A

Not suitable for acute pain or changing analgesic requirements as time to steady state is long and cannot be titrated. Only in opioid tolerant.

107
Q

What is the maximum daily dose of codeine in under 18 year olds?

A

Not to be used under 12. Max 240mg if older.

108
Q

What is the issue of ultra rapid metabolisers of codeine?

A

Morphine toxicity may occur.

109
Q

What are the serious side effects of opioids?

A

Respiratory depression, including in neonates if used during delivery. Dependance, tolerance, withdrawal. Overdose (coma, respiratory depression and pinpoint pupils)

110
Q

What drugs are associated with medication overuse headache?

A

Opioid and non opioid analgesics, 5ht1 receptor agonists, ergotamine

111
Q

Why are dispersible preparations more suitable for migraine?

A

Peristalsis reduced during attacks so quick absorption needed

112
Q

Which antiemetics promote peristalsis?

A

Metoclopramide, Domperidone

113
Q

What classes of drug may be used to prevent migraine?

A

Beta blockers, tricyclic antidepressants, antiepileptics.

114
Q

Cluster headaches should only be treated with standard analgesics. True or false.

A

False, they are rarely responsive. Sumatriptan by SC injection, oxygen.
Verapamil or lithium for prophylaxis

115
Q

What are the treatment issues with paramax and migramax?

A

Contain metoclopramide. Can cause severe extrapyrimidal side effects especially in children and young people so don’t exceed 3 months

116
Q

What symptoms warrant discontinuation of triptans?

A

Heat, heaviness, pressure or tightness (throat or chest)

117
Q

How should triptans be administered?

A

One dose as soon as possible after onset, then another dose after 2 hours if recurs (not if no response at all)

118
Q

Rizatriptan 10mg
Propranolol 40mg
What is the issue?

A

Max 5mg with propranolol

119
Q

What opioid analgesics can be used in neuropathic pain?

A

Efficacy evidence for tramadol, morphine and oxycodone

120
Q

What may decrease adherence to capsaicin cream?

A

Intense burning in initial treatment

121
Q

What are the treatment options for Trigeminal neuralgia?

A

Surgery. Carbemazepine. Phenytoin sometimes.

122
Q

Which drugs are and aren’t recommended as anxiolytics and hypnotics?

A

Benzodiazepines are most common.

Meprobamate and barbiturates are not recommended due to side effects, interactions and danger in overdose.

123
Q

How should benzodiazepines be withdrawn?

A

Transfer stepwise to equivalent diazepam dose
Reduce this dose by 1-2mg every 2 - 4 weeks or by one tenth if high doses. Maintain if uncomfortable until symptoms lessen.
Steps of 500mcg may be necessary towards end.

124
Q

What are withdrawal symptoms of benzodiazepines and how long may it take to experience and resolve?

A

3 weeks after stopping (with long acting) or within a day (with short acting). Confusion, toxic psychosis, convulsions, delerium tremens if abrupt. Insomnia, anxiety loss of appetite/weight, tremor, tinnitus.
Usually resolves within 6 - 18 months after last dose but may be longer/shorter depends on person.

125
Q

Which benzodiazepines are long and short acting?

A

Nitrazepam, flurazepam, diazepam, alprazolam, chlordiazepoxide, clobazam (prolonged)
Loprazolam, lormetazepam, temazepam, lorazepam, oxazepam (shorter)

126
Q

Which hypnotic is most useful in elderly?

A

Chlormethiazole

127
Q

Is alcohol considered a hypnotic?

A

No. It has diuretic action interfering with sleep and disturbs sleep patterns.

128
Q

Can buspirone and benzodiazepines be used together?

A

Advisable to withdraw benzodiazepines before starting buspirone

129
Q

Varenicline or bipropion may be used with NRT. True or false.

A

No, not recommended together

130
Q

Why does smoking effect the dose of some drugs? Which?

A

It stimulates CYP1A2. Particularly theophylline, cinacalcet, ropinorole, antipsychotics.

131
Q

When are each of the NRT formulations preferred?

A

Patches - 24h for cravings on morning

132
Q

What side effects can occur with NRT?

A

Local irritation. Oral irritation. Increased salivation. Coughing, nasal irritation, sneezing, watery eyes. Blurred vision. Gastro intestinal disturbance if swallowed eg nausea, vomiting, dyspepsia, Hiccup. Dry mouth.
Palpitations, arrhythmia, chest pain. Atrial fibrillation
Abnormal dreams (remove patcg before bed) , paraesthesia.
Rash, hot flushes

133
Q

What are the advantages and disadvantages of buprenorohine over methadone?

A

Less sedating, fewer interactions, milder withdrawal, lower overdose risk.

Increased risk of precipitated withdrawal when other opioid agonists in circulation. Give 6-12 hours after other short acting opioid or 24-48 hours after methadone.

134
Q

Opioid substitution is better in pregnancy rather than withdrawing cold turkey from illicit drugs. True or false.

A

True. Don’t withdraw at all in first trimester (miscarriage) . Withdrawal regime can start during second. Also not recommended in third (stillbirth, distress) and drug metabolism may increase so may need BD.

135
Q

What are the signs of neonatal withdrawal from opioids?

A

High pitched cry, rapid breathing, hungry but ineffective suckling, excessive wakefulness usually within 24-72h but may be delayed up to 14 days.

136
Q

How does naltrexone prevent relapse?

A

Precipitates withdrawal symptoms and blocks effects of opioid receptor agonists

137
Q

What is given if alcohol withdrawal seizures occur and why?

A

Lorazepam. Fast acting benzodiazepine

138
Q

What vitamins may be needed for alcohol dependant patients?

A

Thiamine due to risk of wernicks

139
Q

When are corticosteroids given in alcohol dependance?

A

Hepatitis with discriminant function of 32 or more. Short term 1 month.

140
Q

What advice should be given with disulfiram ?

A

Reactions may occur following exposure to alcohol including in perfume, sprays and non alcohol beers/wines. Nausea, flushing, palpitations.

Seek medical attention if unwell with symptoms such as fever or jaundice (Hepatitoxicity)

A - bnf COPY (15 decks)

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