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NEURO-FOR-THE-NOT-SO-NEURO-MINDED. Barb Bancroft, RN, MSN, PNP CPP Associates, Chicago, IL [email protected] www.barbbancroft.com. 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..

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NEURO-FOR-THE-NOT-SO-NEURO-MINDED

Barb Bancroft, RN, MSN, PNP

CPP Associates,

Chicago, IL

[email protected]

www.barbbancroft.com


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

THE FRONTAL LOBES…


“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…

  • 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…

  • 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….


Sexual Function

And…


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…

  • 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

  • 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 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

The basal ganglia…

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 GABA-minergic 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”


Coordination

Synergy

Balance

Equilibrium

The cerebellum…


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


THINK BOOZE and the CEREBELLUM

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)


CN III, IV, VI—follow my finger (extraocular movements)

The BRAINSTEM…


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…

  • IX (Glossopharyngeal) and X (Vagus)

  • The gag reflex

  • The uvula

  • Closing off nasopharynx—say “K, K, K”

  • Cleft palate


CN XII (Hypoglossal)—tongue movement and strength

The BRAINSTEM…


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


Barb Bancroft, RN, MSN, PNP

CPP Associates, Inc.

Chicago, IL.

[email protected]

www.barbbancroft.com

Thanks.


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