Apply information from the Aquifer virtual case studies to answer the following questions:

You are working in the internal medicine clinic today with Dr. Irving. She asks you to evaluate Mr. Caldwell, a 75-year-old male, who is here today with his daughter because of concerns about his memory raised at his last visit.

Initial Approach to Evaluation of Memory Problems

1. Focused history

2. Cognitive assessment

3. Functional evaluation

You go to the exam room and introduce yourself to Mr. Caldwell. He responds, “Happy to meet you. This is my daughter Kathy.”

After you’ve greeted them both briefly, you begin asking Mr. Caldwell questions about his memory.

Focused History

“How long have you been having problems with your memory?”

“Oh, I have the same memory problems as any 75-year-old. Occasionally, I forget my keys or forget something at the grocery store. But I still remember my wedding day and I still remember my grandchildren’s names. I’m not doing any worse than any of my friends.”

“Have you had any trouble keeping up with your finances or medications?”

“Well, my wife used to manage the money until she died two years ago. I have trouble with the numbers in my checkbook and trouble figuring out my medications so Kathy takes care of these things for me now.”

After this initial questioning, you proceed with your cognitive evaluation.

The MoCA test is administered to Mr. Caldwell. He achieves a score of 17, suggesting moderate impairment.

Based on Mr. Caldwell’s score, how would you classify his memory loss? Choose the single best answer.

The best option is indicated below. Your selections are indicated by the shaded boxes.

· A. Delerium

· B. Depression

· C. Major neurocognitive disorder

· D. Mild neurocognitive disorder

· E. Normal aging

SUBMIT

Answer Comment

> The correct answer is C

Mr. Caldwell has a score of 17 and by his history has problems in at least one DSM-5 cognitive domain. In addition, some of his instrumental activities of daily living like managing his medications and finances are now not possible. He is classified as having Major Neurocognitive Disorder (C).

TEACHING POINT

Major Neurocognitive Disorder

The main subtypes of major neurocognitive impairment that classify as forms of dementia are as follows:

· Alzheimer disease

· Vascular disease / dementia

· Lewy body dementia

· Frontotemporal lobar degeneration

The additional subtypes are as follows:

· Parkinson disease

· Traumatic brain injury

· HIV

· Prion disease

· Huntington disease

· Substance/medication use

· Other medical condition

· Multiple etiologies

Prevalence

The DSM-5 estimates that the prevalence of major neurocognitive disorder (which they use congruently with the term dementia) vary across ages.

The prevalence of Major Neurocognitive Disorder is approximately 1-2% at age 65 and as high as 30% by age 85.

The prevalence of Mild Neurocognitive Disorder ranges from 2-10% at age 65 and from 5-25% by age 85.

Development and Course:

When due to neurodegenerative conditions like the common forms of dementia, the onset of symptoms is usually insidious and gradual. Later in life if may be difficult to distinguish normal aging from prodromal phases of Mild Neurocognitive Disorder. In addition, given the high prevalence of other medical conditions in older individuals, the symptoms of these conditions often go unnoticed or are overlooked due to the coexisting problems.

Risk Factors:

Age is the most common risk factor since increased age leads to greater neurodegenerative and cerebrovascular disease. Females are also more prone to developing these conditions, although this may be due to their overall increased lifespan.

After Mr. Caldwell grants you permission, you ask his daughter a couple of questions about his activities of daily living:

“Have you noticed that your father has any trouble with his memory?”

“I definitely think he’s having some trouble. He has a lot more trouble remembering new information. He’s right, he does remember things that happened a long time ago, like his wedding, and he knows all of his grandkids. However, last week he forgot what he needed at the store and he has missed some bills and occasionally forgets his medications.”

“Is he able to prepare his own meals?”

“Dad makes his own meals and eats well – he was always the cook in the family. He can do his laundry and take care of the house. He doesn’t drive or get out much because he doesn’t have a car and he has some trouble with his balance because of his knee pain, so my husband and I or our kids take him on most of his errands.”

TEACHING POINT

Functional Assessment: Activities of Daily Living

Activities of daily living (ADLs) are divided into two subcategories: basic and instrumental (IADLs)

The patient’s family members may be very helpful with this information.

Question

Which of the following basic or instrumental ADLs are likely to be affected early in the course of dementia? Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

· A. Bathing

· B. Doing laundry

· C. Dressing

· D. Managing finances

· E. Managing medications

Now that you have gained some information about Mr. Caldwell’s memory, you take a second to review his medical history with Mr. Caldwell and his daughter:

Active problems

Active problems:

1. Hypertension

2. Occasional insomnia

3. Hyperlipidemia

4. Osteoarthritis

Social history / habits

Social history / habits:

· retired high school librarian

· lives at home alone

· widowed for 2 years

· 2 close friends in his apartment complex

· never smoked

· occasional alcohol around holidays only, never excessive.

Medications

Current medications:

1. Hydrochlorothiazide 25 mg by mouth once a day.

2. Amlodipine 5 mg by mouth once a day.

3. Lorazepam 2 mg by mouth before bed as needed for insomnia (takes 2-3 times/week).

4. Acetaminophen 500 mg – two tablets by mouth three times per day.

5. Lovastatin 40 mg by mouth once a day.

TEACHING POINT

Avoid Polypharmacy, Especially in Older Adults

Review the medication list at every visit to ensure the most appropriate and least number of medications are being prescribed.

Polypharmacy is a common problem among older patients and can result in avoidable adverse drug events.

Don’t forget to include over-the-counter medications, supplements, and herbal remedies

You have completed your initial assessment of Mr. Caldwell’s memory problems, so you move on to other important and common issues to assess in the geriatric patient, such as fall risk assessment:

“Mr. Caldwell, have you fallen in the past year?”

He responds, “no,” and his daughter agrees. However he does say that he occasionally feels “unsteady”.

“Can you describe what you mean by ‘unsteady’?”

“Well, I’m not dizzy and I don’t feel lightheaded. It’s just this feeling that I could trip and fall. I think part of it is because my knees bother me from the arthritis. I have to be more careful where I step and pay more attention to my feet.”

“Can you tell me more about when you are most likely to feel unsteady?”

“It’s hard to say. It may be worse when I wake up in the morning, or if I have to get up in the middle of the night.”

“Have you had a hearing test lately?”

“Yes, I had my hearing tested last month, and it was fine.”

TEACHING POINT

Common Issues to Assess in the Geriatric Patient: Fall Risk, Frailty, & Urinary Incontinence

Fall Risk

Learn more about recommendations for prevention of falls in older patients.

Screening for Hearing and Vision Deficits

While hearing and vision impairment may contribute to fall risk in older patients, routine hearing and visual acuity screening in people over 50 years old is not currently recommended by the U.S. Preventive Services Task Force.

Hearing: In 2012 it was concluded that current evidence is insufficient to assess the balance of benefits and harms of screening for hearing loss in this population. (Grade I statement.)

Vision:  In 2016 it was concluded that current evidence is insufficient to assess the balance of benefits and harms of visual acuity screening in the improvement of outcomes in older adults. (Grade I statement.)

Which of the following items from Mr. Caldwell’s history increases his risk of falling in the next year? Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

· A. Cognitive impairment

· B. History of hyperlipidemia

· C. Knee osteoarthritis leading to difficulty ambulating

· D. Polypharmacy

· E. Use of acetaminophen

· F. Use of lorazepam

SUBMIT

Answer Comment

> The correct answers are A, C, D, F

​ Mr. Caldwell’s risk factors for fall include:

· Cognitive impairment (A)

· Self-reported gait disturbance from osteoarthritis (C)

· Use of more than four prescription medications (D)

· Use of lorazepam (F)

· Use of hydrochlorothiazide (a diuretic)

History of hyperlipidemia (B) is a risk factor for coronary artery disease, but not for falling. Use of acetaminophen (E) can cause hepatic failure in high doses but is not a risk factor for falling.

TEACHING POINT

Fall Risk Factors

The more risk factors a patient accumulates, the more likely he or she is to fall.

According to the CDC, risk factors for falls can be divided into​ Intrinsic and Extrinsic categories as outlined below:

You move on to ask Mr. Caldwell about urinary incontinence:

“Do you ever notice leaking urine?”

“Well, since you mention it, I do. It’s been going on for a year or two now and hasn’t changed much.”

“When do you notice it?”

“I can’t always predict when it’s going to happen. It’s not when I sneeze or cough — my wife used to have that problem. Usually it’s when I have a full bladder or sometimes right after I empty my bladder. I also have a hard time starting the stream sometimes, and sometimes more comes out after I think I’m done.”

“Do you need to get up to urinate at night?”

TEACHING POINT

Urinary Incontinence

Assessment

Make sure to assess for this during your interviews, because patients often will not volunteer this information. Incontinence is a common problem in older patients and is often multifactorial.

A symptom diary can be very helpful in assessing the severity of incontinence. This involves tracking when incontinence occurs and whether it seems to be triggered by specific times of day, beverages, medications, or other circumstances.

From the history provided, what type of incontinence do you suspect Mr. Caldwell exhibits? Choose the single best answer.

The best option is indicated below. Your selections are indicated by the shaded boxes.

· A. Functional incontinence

· B. Overflow incontinence

· C. Stress incontinence

· D. Urge incontinence

SUBMIT

Answer Comment

> The correct answer is B

Mr. Caldwell’s description of difficulty starting the stream suggests “hesitancy,” and his description of more coming out when he thinks he’s done suggests “dribbling”-both of which are consistent with overflow incontinence (B), possibly due to benign prostatic hypertrophy.

He specifically denies trouble when coughing or sneezing which rules out stress incontinence (C), makes no mention of either rushing to “make it in time” (D) or physically not being able to get to the toilet when he needs to go (A).

You are now ready to examine Mr. Caldwell. Kathy asks Mr. Caldwell if she should leave, and he requests for her to stay.

Prior to performing the physical exam, you consider specific elements that may be helpful in the assessment of the syndromes you have reviewed so far.

TEACHING POINT

Assessing Geriatric Syndromes on Physical Exam

You re-enter the room once Mr. Caldwell is ready and begin the exam.

Physical Exam:

Orthostatics: Lying BP 124/75, pulse 82; Standing BP 132/72, pulse 76.

HEENT: Sclerae anicteric. No conjunctival pallor. Mucous membranes moist.

Cardiovascular: Regular rate and rhythm, normal S1 and S2, no murmurs/rubs/gallops. No carotid bruits. Extremities warm, 2+ pulses, no edema.

Chest: Clear to auscultation bilaterally, no wheezes/rales/rhonchi.

Abdomen: Soft, non-tender, non-distended, no organomegaly.

Musculoskeletal: Mild crepitus in knees bilaterally. No knee effusions or warmth. No joint line tenderness. Get Up and Go test takes 18 seconds. Patient has an antalgic gait, favoring left leg. Does not need to use arms to rise from a seated position. Does not appear unsteady.

Neurologic: Cranial nerves II-XII grossly intact. Strength 4+/5 in bilateral upper and lower extremities. Grip strength 5/5 bilaterally. Reflexes 2+ throughout. Normal heel-knee-shin, rapid alternating movement, and finger-nose-finger. Normal Romberg. Sensation is intact in upper and lower extremities to light touch.

Mr. Caldwell’s physical exam is normal except for his Get Up and Go test. You realize that, in addition to his major neurocognitive disorder, Mr. Caldwell is at high risk for falling.

TEACHING POINT

“Get Up and Go” Test

Instructions for patient:

Get up (without armrests, if possible), stand still for a moment, walk forward 10 feet, turn around and walk back to chair, turn and be seated.

Assessment:

A normal time ranges from 8-12 seconds. Patients who take greater than 14 seconds to complete this are at higher risk for falls.

In addition, the assessor should make note of sitting balance, transfers from sitting to standing, pace and stability of walking, and ability to turn without staggering.

You tell Mr. Caldwell he can get dressed and you will come back with Dr. Irving.

When you leave the room, you feel like you have formulated a plan for what to do about Mr. Caldwell’s fall risk. However, you are still unsure about how to approach his major neurocognitive disorder.

TEACHING POINT

Major Neurocognitive Disorder (Dementia) Subtypes

Review the different subtypes of major neurocognitive disorder.

Alzheimer dementia (AD) accounts for 75% of cases of major neurocognitive disorder. It usually presents as gradual memory loss, with specific difficulties in short-term memory and in learning new facts. Patients may have a family history of AD. It is caused by amyloid plaques and neurofibrillary tangles in the brain, which can only be confirmed at autopsy. However, the clinical diagnosis is up to 90% accurate. AD should be considered a terminal illness; average life expectancy after diagnosis is about six years.

Lewy body dementia (LBD) is another common cause of major neurocognitive disorder. It is caused by the deposition of Lewy bodies in the nuclei of cerebral cortical neurons. LBD is characterized by fluctuations in memory and cognition, visual hallucinations, and parkinsonism. “Parkinsonism” refers to resting tremor, bradykinesia, rigidity and postural instability that are typically associated with Parkinson disease but can be caused by other disorders.

Vascular dementia classically manifests as step-wise deterioration in memory. It is thought to be due to damage from discrete vascular events, such as strokes or transient ischemic attacks (TIAs). Patients have other vascular risk factors and evidence of past stroke on exam or imaging. The presentation and course of vascular dementia is very heterogenous due to differences in extent, severity, number, and location of the vascular lesions.

Frontotemporal dementia (FTD) is characterized by dementia associated with behavior/personality changes and language impairment. FTD is typically used to describe a group of disorders that have different causes, but all types involve atrophy of the frontal and temporal lobes, which is thought to be the cause of symptoms. It is a common cause of major neurocognitive disorder in individuals younger than 65.

Recall from prior that other subtypes of major neurocognitive disorder include Parkinson disease, Huntington disease, traumatic brain injury, HIV, prion disease, substance/medication use, and cases of multiple etiologies.

Evaluating For Reversible Causes Of Major Neurocognitive Disorder

Depression Screening:

All patients with concern for cognitive impairment should be screened for depression. This condition is common in older adults and may be mistaken for cognitive impairment. There are several validated screening tools like the Patient Health Questionnaire 2 or 9 and the Geriatric Depression Scale.

Laboratory Testing:

The American Academy of Neurology (AAN) recommends screening for B12 deficiency with a B12 level and a complete blood count as well as screening for hypothyroidism with a TSH level. Other potential tests are detailed below.

TSH

Hypothyroid or hyperthyroid conditions can contribute to cognitive impairment.

Vitamin B12 and Complete Blood Count

While both folate and B12 deficiencies can cause macrocytic anemia, only B12 deficiency can cause posterior column disease and cognitive impairment. As part of the evaluation for vitamin B12 deficiency,​ the AAN also recommends a complete blood count.

Complete Metabolic Panel

While some metabolic abnormalities can lead to memory impairment there is no clear evidence that this test is useful or cost-effective so it should not be routinely sent. Examples of electrolyte issues that could cause cognitive symptoms include:

Hypercalcemia leading to confusion, psychiatric disturbances, and memory loss, particularly in older patients, and hyponatremia leading to mental status changes in older adults.

Rapid Plasma Reagin (RPR) and HIV

Screening for these conditions is not routinely recommended unless the patient is high risk due to sexual history or travel.

Thiamine (Vitamin B1)

In patients with a history of alcohol abuse or those who are not receiving adequate nutrition, it is also reasonable to consider thiamine deficiency. In the U.S., thiamine deficiency is most commonly seen in patients with alcohol use disorder and typically causes Wernicke-Korsakoff syndrome. Wernicke syndrome is characterized by nystagmus or other ocular abnormalities, gait abnormalities, and memory loss with other mental status changes. It develops over days. Korsakoff syndrome includes retrograde and antegrade amnesia. These syndromes are part of a spectrum of disorders.

Neuroimaging

The question of whether to obtain imaging, such as a head CT or MRI in the workup of dementia is also controversial. The AAN recommends a non-contrast head CT or MRI as part of the routine workup. In theory, this imaging would help exclude other contributing pathologies such as stroke, subdural hematoma, normal pressure hydrocephalus, and an intracranial mass.

You present your findings to Dr. Irving and explain that you would like to evaluate for reversible causes of major neurocognitive disorder by ordering a TSH, B12 level, and a complete blood count.

Dr. Irving tells you that she administered a PHQ-9 questionnaire to Mr. Caldwell at his last visit and that did not show any evidence of depression, which can lead to cognitive impairment.

She also reminds you it is very important to review a patient’s medications and consider the impact they may be having on the patients symptoms. Mr. Caldwell is taking hydrochlorothiazide, which can cause clinically significant hyponatremia, especially in older patients. Hyponatremia can cause mild memory deficits and could increase Mr. Caldwell’s risk for falls as well. For this reason she recommends checking a basic metabolic panel as well.

TEACHING POINT

Medication Side Effects in Older Adults

All medications can have unwanted side effects, but older patients are at higher risk for many reasons.

1. Older adult patients are often on multiple medications that interact.

2. With aging, there are physiologic changes affecting pharmacokinetics and pharmacodynamics.

3. Poor nutritional intake and renal or liver impairment can cause problems with metabolism of medications.

4. Drug clearance may be decreased by an age-associated decline in renal function.

5. As older patients lose muscle mass relative to fat, the volume of distribution of many drugs increases and patients may require lower doses of drugs.

· Poor nutritional intake and renal or liver impairment can cause problems with metabolism of medications.

· Drug clearance may be decreased by an age-associated decline in renal function.

· As older patients lose muscle mass relative to fat, the volume of distribution of many drugs increases and patients may require lower doses of drugs.

It’s important to consider all of these factors before prescribing a medication to an older patient. In particular, reviewing the appropriateness and indications for opioids, anxiolytics, and any medications with anticholinergic properties should be done at each visit.

You discuss the diagnosis of major neurocognitive disorder as follows:

“Mr. Caldwell, do you understand why we asked you to complete the memory and laboratory tests?”

“Well, I figure you are trying to find out if there is something wrong with me. I guess you might be concerned about my memory. I know I have some forgetfulness and need assistance with certain things, but I figured it was just me getting old.”

“I would like to share the results of the tests. Would like to know everything in detail or just the main outcome?”

“Just make it easy for me to understand. I’m a big picture kind of guy.”

You say “Okay. Unfortunately, the news may not be what you want to hear, I’m afraid. Based on your testing you have dementia, or what we call dementia.” You pause for a few moments to allow him time to process this news. Kathy appears tearful, and Mr. Caldwell just looks at you silently.

Then Mr. Caldwell asks: “Is this Alzheimer’s dementia?”

“Although we can’t be sure what causes most cases of dementia, which in medical terminology we call major neurocognitive disorder, we believe Alzheimer’s dementia is the most common cause. Mr. Caldwell, since you have no history of stroke, personality changes, or features of any of the other major causes, it is most likely that this is Alzheimer’s. This can be a very difficult diagnosis for some people; how are you feeling about it?”

“Well, it’s not what I wanted to hear, but I’m not totally surprised. Kathy and I have been worried about this. I guess it might just take a little time to sink in.”

Kathy asks:

“How do we know that this isn’t just normal aging?”

“It can sometimes be difficult to tell. Some people do find that memory declines as they age. However, that typically doesn’t interfere with their ability to perform their daily activities. Because your dad is having trouble with his finances and his grocery shopping, his memory loss is more severe and qualifies as dementia. In addition, the test that your father did last week, called the mini-mental state exam, helps to confirm our diagnosis.”

“What is Dad’s prognosis? How quickly will he lose his memory?”

You add, “This is a lot to take in; what other questions do you have?” Kathy asks for more information about Alzheimer’s dementia. Dr. Irving refers them to the Web site of the Alzheimer’s Association.

You plan that Mr. Caldwell will follow up in clinic in 2-4 weeks after he has had his home-safety evaluation and physical therapy. You plan to address the discussion of medications at that time.

You are in clinic with Dr. Irving two weeks later when Mr. Caldwell and Kathy return for a follow-up visit.

You review his chart and find all of the labs you checked returned normal.

Dr. Irving asks you to go into the room and see how things are going with Mr. Caldwell. She will come in later to discuss follow-up of Mr. Caldwell’s Alzheimer’s dementia.

You greet Mr. Caldwell and Kathy:

“Mr. Caldwell, it’s great to see you! How is it going with the physical therapist?”

“Good to see you again! It’s going pretty well. She has been out to the house twice. We’re working on leg exercises, and I do them every day for 20 minutes, even when she’s not there. I haven’t noticed a big difference in my balance yet, but I do feel a little stronger. And it’s nice to have the company.”

“Kathy how did the home-safety evaluation go?”

“They were great. They came and took away a few slippery rugs I’d been trying to get Dad to get rid of. They are going to come back out and help us get some bars in the bathroom, and they set up some night lights for Dad. I think it was really helpful.”

“How have you been sleeping without the lorazepam?”

“OK, I think. The first few nights it was hard to fall asleep, and it still takes me longer, but I feel less groggy in the morning. I’d rather have it back, but if you think it’s important to stay off it, then I will.”

Dr. Irving now joins you to discuss the possibility of initiating medication for Mr. Caldwell’s Alzheimer’s dementia.

“Using medications to treat patients with Alzheimer’s dementia is controversial. There are two types of medications that are typically used.” She continues to describe the indications and side effects of cholinesterase inhibitors and memantine concluding, “Your dad’s Alzheimer’s dementia is moderate, so we would consider prescribing medication for him at this point.”

“I’d like to get a little more information about these drugs and talk it over with Kathy a little more,” Mr. Caldwell says.

TEACHING POINT

Medications for Alzheimer’s Dementia

Although there are no medications to cure Alzheimer’s disease or other forms of dementia, there are several medications that may be used to help slow the progression of cognitive and functional decline.

Cholinesterase inhibitors (ex: donepezil, rivastigmine, and galantamine)

· Indications: Used for patients with dementia of any severity – mild, moderate, or severe

· Effectiveness: There may be small, beneficial effects in cognitive and functional performance, though the clinical significance of these effects is unclear

· Common side effects: Nausea, vomiting, and diarrhea, but these usually get better if people keep taking the medications

Memantine

· Indications: Moderate or severe Alzheimer’s dementia

· Effectiveness: Studies have shown small improvements in cognition but the clinical significance is unclear

· Common side effects: Dizziness, possibility of confusion and hallucinations

There is some research that demonstrates the potential for cognitive and functional performance may be better if memantine and a cholinesterase inhibitor are used together, but once again the clinical significance remains unclear.

These medications all cost more than $150 per month if paid for out of pocket. However, with insurance coverage the cost is much lower.

For each of these medications, treatment decisions should be individualized and consider drug tolerability and cost.

Other

· There are ongoing studies on various supplements including vitamins for treatment or prevention of dementia. So far, the available research has been disappointing and no supplement or vitamin can be recommended at this time based on the studies to date.

Family Medicine 18: 24-year-old female with headaches

Today, you are working with Dr. Lee, who tells you, “Sarah Payne is our first patient. She is a 24-year-old college student who is coming in today with a complaint of headaches.”

You and Dr. Lee enter the exam room together. After you both greet Sarah, you begin the interview.

“Can you tell me more about these headaches you’ve been having?”

“Well, I actually get two different kinds of headaches. The first kind of headache I don’t get as often, but they are really horrible and I don’t know how much more I can deal with them. Then on top of that, there’s this other headache that I get a lot, but they aren’t as nasty.”

“Let’s talk about the severe headaches first. Can you tell me more about what these are like?”

“I’ve had these headaches off and on ever since my period started when I was thirteen. Usually they begin suddenly in either my right or left temple — although the pain can be all over my head. When I say pain, I mean this horrible throbbing and pulsing that gets so bad that I have to leave my classes and go home. Sometimes it’s all I can do not to throw up.”

“How often do you get these severe headaches?”

“Lately, I’ve been getting these once or twice weekly and they last for a day or two.”

“Has there been any recent change in your headaches?”

“Well, I used to just get these headaches off and on. But over the past two months, I’ve been getting this headache more often — almost every week.”

“Have you noticed anything that seems to cause these headaches?”

“No, nothing specific seems to cause the headaches, but sometimes before the headaches come on, I have this general sense of uneasiness.”

“Have you found anything that helps to relieve these headaches?”

“The only thing that will help is getting into a dark, quiet room. Ibuprofen doesn’t touch these headaches.”

“Do these headaches seem related to your menstrual cycle?”

“They are particularly bad just before my period starts.”

Dr. Lee shows Sarah a pain scale and asks her to point to how her pain feels for each type of headache. She indicates the second headache is moderate pain (5 on the 10 points scale), while the first is severe (8 or 9 on a 10 points scale). This will be a useful tool to continue to gauge her pain and the success of treatment.

Pain scale

“Now could you tell me a bit more about the second kind of headaches you get?”

“These headaches aren’t as nasty. The throbbing isn’t so bad that I can’t tough it out, but they’re still really annoying. They start in the back of my head and then move into my forehead and above my eyes.”

“How often do you get these other, milder headaches?”

“Every day!”

“Have you noticed anything that seems to precipitate the headaches?”

“I get them mostly when I’ve been studying a lot or I’m really stressed.”

“Have you noticed any symptoms that go along with these headaches?”

“Light and sound don’t bother me with this headache the way they do with the first kind. But my neck gets stiff and the back of my head feels tender when I press on it.”

“How often do you take headache relievers or pain pills?”

“I take two ibuprofen tablets three to four times a day, approximately six times a month…” Sarah keeps her eyes averted towards the floor and then admits, “Actually, I take my dad’s hydrocodone every once in a while, when I just can’t stand it anymore. It doesn’t make the pain better, but it gives me a chance to sleep and the pain is usually gone after I wake up.” She estimates taking three to five hydrocodone per month.

On further questioning, Sarah denies the following:

· Vision changes, numbness or weakness in her arms or legs, confusion, and memory loss.

· Recent fever and chills, night sweats, or weight loss.

· Recent trauma or head injury.

Review of systems: Negative except as in HPI.

Past medical history:

· No medication allergies.

· Intrauterine device (IUD).

· Has never been pregnant.

Then Sarah stops you and tells Dr. Lee that she’s concerned she has a brain tumor and thinks she might need an MRI urgently.

You consider when an MRI would be warranted.

You proceed to ask Sarah further questions and discover the following:

Social History

· Oldest of three children.

· Mom – secretary; dad – truck driver.

· Attends college.

· Works part-time as a waitress to help pay for college and has student loans as well.

· Broke up with her boyfriend about three months ago and is not currently sexually active.

· Denies tobacco or alcohol use and drinks six to ten caffeinated sodas daily.

Family History

· Mother has a history of having “sick headaches” during her periods.

· Sister diagnosed with migraines last year.

· No family history of tumors, strokes, or other pathology of the central nervous system.

You notice throughout the course of the interview that Sarah seems tense, often fidgeting or tapping her fingers and occasionally wringing her hands. You tell Sarah,

“You appear a little anxious today. Can you please tell me what is making you feel that way?”

Sarah wipes a tear and agrees that she is anxious that there is something very wrong with her causing these headaches.

She also says she has been having a tough time since finding out her boyfriend was unfaithful to her. She has been drinking more caffeinated soda to stay awake in class and at work. She describes being occasionally irritable. She occasionally does not feel like going out with friends, but still goes.

She has been able to attend school and keep up with her studies. She denies being depressed or down or feeling hopeless.

You respond, “It sounds like you’ve got a lot on your plate. May I ask you a few questions to help me better understand why your headaches are getting worse?” Sarah agrees.

“Over the past two weeks, have you had difficulty relaxing or felt on edge?”

“No. I felt pretty stupid for letting him hurt me like that, but I don’t think it’s been like you are describing.”

“Have you not been able to stop worrying or feel like something awful is going to happen?”

“No. Getting out with my friends makes me feel better, and I’m still able to do what I like. I don’t think I am overly anxious.”

You determine that Sarah’s GAD score is 2, a negative screen for Generalized Anxiety Disorder.

Important Physical Exam Findings with Headache

Signs of increased intracranial pressure:

· Papilledema

· Altered mental status

Other important findings to look for:

· Signs of meningeal irritation such as Kernig’s sign or Brudzinski’s sign

· Focal neurologic deficits such as unilateral loss of sensation, unilateral weakness, or unilateral hyperreflexia.

TEACHING POINT

How to Perform a Neurological Exam

Test cranial nerves II through XII:

Complete the neurologic exam:

· Light touch: Sensation to light touch on all extremities.

· Motor: Assess power and symmetry in all extremities. Look for rigidity or clonus. Test flexor plantar response bilaterally.

· Reflexes: Deep tendon reflexes.

· Cerebellar exam: Look for finger-to-nose or heel-to-shin ataxia.

Finger-to-nose: You ask her to use the tip of her index finger to touch the tip of your index finger, then the tip of her nose, then your finger again several times looking for accuracy and “past pointing.”

Heel-to-shin: You have Sarah extend her left leg, place the right heel on the left knee, and then move the heel smoothly down the shin to the ankle. Repeat using the left heel on the right shin, observing for accuracy and tremor.

Assess gait by having the patient walk toward you while walking on her heels, then walk away from you on her tiptoes. Then you have her walk in tandem, placing one foot directly in front of the other as if walking on a tightrope.

Physical examination:

Vital signs:

· Heart rate: 88 beats/minute

· Blood pressure: 118/70 mmHg

· Weight: 124 lbs

· Height: 5’ 4”

· Body Mass Index: 21 kg/m2

General: Speech is of normal rate, tone, and volume. Affect is slightly anxious and occasionally tearful. Her thought process is logical and goal oriented.

Mental status: She is alert and oriented to person, place, and time. Her short- and long-term memory are intact. Her insight and judgment are appropriate.

Cardiovascular, respiratory, and ear, nose and throat: Exams are normal. Fundi are visualized with no papilledema. Tenderness to palpation is found over the occiput. Full range of neck motion in all directions and there is no adenopathy. Kernig and Brudzinski signs are absent.

Neurologic: Normal.

At this point you and Dr. Lee excuse yourselves and leave the exam room to discuss her case.

Dr. Lee asks you to consider your differential diagnosis for the cause of Sarah’s two different types of headaches, based on your findings from her history and physical exam. From the following, select the two leading diagnoses.

The best options are indicated below. Your selections are indicated by the shaded boxes.

· A. Migraine headache

· B. Tension-type headache

· C. Cluster headache

· D. Bacterial meningitis

· E. Intracranial hemorrhage

· F. Brain tumor

· G. Medication overuse headache

· H. Headache due to anxiety disorder or depression

SUBMIT

Answer Comment

The correct answers are A, B.

The description and pattern of Sarah’s headaches are typical for migraine (A) and tension-type (B) headaches.

In addition, she takes only six hydrocodone per month. Her increased amount of caffeine from sodas can exacerbate her headaches.

Findings suggestive of migraine headaches:

· Severe headaches one to two times weekly

· Unilateral and throbbing in nature

· Associated nausea, photophobia and hyperacusis

· Family history of migraines

· Increased caffeine consumption and poor sleep are possible triggers

· Normal neurologic exam

Findings suggestive of tension-type headaches:

· Mild to moderate bilateral headaches that last all day on most days

· Pain that radiates down neck with tender occiput

· Increased stressors and poor sleep in recent weeks are possible trigger

· Normal neurologic exam

Dr. Lee agrees with your assessment. You return to Sarah’s room together.

“I think you are having two different types of headaches,” Dr. Lee tells Sarah.

“The very bad headaches you are getting sound like migraines. The less severe ones are likely tension-type headaches. There are many things you can do to improve both types of headaches and some of the treatments overlap. I suggest you start with a headache diary and I’d also like you to think about making a few changes to your routine.”

Dr. Lee finishes by addressing Sarah’s concerns about an MRI directly.

“I’m happy to tell you that you don’t need imaging studies like an MRI. Based on what I know so far, I think it’s extremely unlikely that we would find anything worrisome on an MRI. However, if your headaches were to change or you were to develop new symptoms such as numbness or weakness you’d need to call so I could reassess your need for an MRI. Does that sound okay to you?” Sarah nods.

TEACHING POINT

Patient Management of Migraine and Tension-Type Headaches

1. Headache diary

· Make note each day of whether or not you have a headache.

· Keep track of the severity of the headaches and which treatments are effective.

· Identify and avoid headache triggers. Use a list of things that trigger headaches, and monitor which of these triggers worsen your headaches.

2. Caffeine

Caffeine can help headaches but an excess can make them worse, especially when coming off of it abruptly. Slowly decrease the use of diet sodas. The caffeine worsens both migraines and tension-type headaches, but coming off of caffeine too quickly may make things worse in the short term.

3. Sleep

Try to get more sleep. Aim for eight hours each night and establish a regular sleep routine, meaning try to go to sleep at the same time each night.

Which of the following are triggers that may increase the frequency and severity of Sarah’s headaches? Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

· A. Sleep disturbance

· B. Emotional stress

· C. Caffeine

· D. Aspartame and phenylalanine

· E. Intense exercise

SUBMIT

Answer Comment

The correct answers are A, B, C, D, E.

All of the above are potential triggers for both migraine and tension-type headaches.

TEACHING POINT

Triggers for Tension & Migraine Headaches

Physical or environmental triggers:

1. Intense or strenuous exercise

2. Sleep disturbance

3. Menses

4. Ovulation

5. Pregnancy (though for many women, headaches actually improve during pregnancy)

6. Acute illness

7. Fasting

8. Bright or flickering lights

9. Emotional stress

Medications or substances that act as triggers:

1. Estrogen (birth control/hormone replacement)

2. Tobacco, caffeine or alcohol

3. Aspartame and phenylalanine (from diet soda)

Dr. Lee continues, “You also need to reduce your stress level, because this is contributing to your headaches. I have some ideas to help you do this.”

TEACHING POINT

Examples of Effective Stress Relievers

· Meditation or a scheduled moment of stillness

· Listening to a relaxation audio program

· Setting limits on other people’s expectations

· Talking with trusted family and friends

· Getting moderate, regular exercise

· Getting at least eight hours of restful sleep each night

Based on her history, which of these can you use with Sarah? Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

· A. Ergot alkaloids

· B. Triptans

· C. Acetaminophen/butalbital/caffeine

· D. Aspirin/butalbital/caffeine

SUBMIT

Answer Comment

The correct answers are A, B.

You may use ergot alkaloids (A) or triptans (B).

While Sarah has an IUD and is very unlikely to become pregnant, you will need to warn her about their use if she should choose to remove the IUD or becomes pregnant.

Since you are concerned that Sarah’s recent overuse of caffeine may be contributing to her worsening symptoms, it would not be advisable to prescribe a caffeine-containing medication, such as in choice (C) acetaminophen/butalbital/caffeine, or (D) aspirin/butalbital/caffeine. You would also want to explore with Sarah her recent use of hydrocodone, an opioid narcotic medication, before prescribing a combination product containing butalbital (C) and (D), a barbiturate, as both may be habit-forming.

You should also ask Sarah about other over-the-counter or herbal medicines she may be taking prior to giving her anything that interacts with a monoamine oxidase inhibitor (MAOI) such as triptans (B) or acetaminophen/dichloralphenazone, as some herbal preparations, especially those for stress relief or improved mood, act as MAOIs.

Dr. Lee turns to Sarah and says, “The triptan class of medication is effective and usually well-tolerated, so this is what I recommend we try first. The other classes of medicines we discussed are usually not my first choice due to their higher risk of side effects. Your medicine will be called sumatriptan and it will come as a 25 milligram tablet. You should take one tablet at the first sign of headache and repeat in two hours if the first dose was not effective. If that doesn’t work or only partially worked for that headache, the next time you get a headache you can try two tablets, repeating two tablets in 2 hours if not effective.”

Dr. Lee reminds you, “There are some factors that would prevent a patient from taking this medication. Patients with a history of heart disease, stroke or uncontrolled hypertension can’t take this medication. You also need to be careful with patients on an SSRI medication because the combination of sumatriptan and an SSRI can cause serotonin syndrome. Another reason that may prevent a patient from taking this medication is cost. Without insurance, a triptan medication can cost between $16 and $792 per month.”