Prepared By,Hemali M Patel

Govt Clg of nursing,Ahmedabad

MOVEMENT DISORDERS

ANATOMY AND PHYSIOLOGY

MOVEMENT DISORDERS

SEIZURE??

EPILEPSY??

????

Seizure is an ACUTE Manifestation

Epilepsy is a Chronic DISEASE

SEIZURE AND EPILEPSY• SEIZURE – Episode of paroxysmal

and transient brain dysfunction.

• EPILEPSY - Recurrent chronic seizures. Seizures are the indispensable characteristic of epilepsy

SEIZURE• It is episodes of

abnormal motor , sensory , autonomic or psychic activity ( or combination of this ) that result from sudden excessive discharge from cerebral neuron.

Classification for causes of seizuresNon-recurrent (Acute)

With FeverExtra-crania

l Infecti

onsFebrile Convulsion

s

Intracranial Infecti

ons

Meningitis

EncephalitisBrain Absce

ssSubdu

ral absces

sExtra dural

abscess

Septic venou

s thrombosis

Without Fever

Traumatic

Toxic

Hypoxic

Metabolic

Vascular

Recurrent (Chronic)

Epilepsy Diagnosis requires the occurrence of at least ≥2 unprovoked seizures in a time

frame of >24 hrs

Causes

Acquiredcause

Cerebro

vascular

disease

Brain tumor

Brain infecti

on Allergi

es Hypoxemia

Fever Hyperte

nsionDrug & alcohol withdra

wl

Idiopathiccause

Genetic Devlopmental defect

CAUSE ACCORDING TO AGE0-1

MONTHBirth injury

AsphyxiaHypoxiaInfection

Congenital

malformation

1-6 MONTH

CNS infectionTraumaticCongenita

l malforma

tion

3-6 yearFebrile

convulsion Idiopathic cause

PATHOPHYSIOLOGY OF SEIZURES

+VE-VE

+VE

-VE

PATHOPHYSIOLOGY Due to any cause

↓ Prolonged depolarization and other

chemical changes↓

Discharge the neurons in an uncontrolled manner

↓ Spreads to adjacent areas of brain

or distant areas of the CNS↓

SEIZURE

What is a seizure-_low.mp4

CLASSIFICATION

PARTIAL

GENERALIZED

CLASSIFICATION

UNCLAS-SIFIED

CLASSIFICATIONA.GENERALIZED SEIZURES

• Tonic-clonic seizures (Grandmal)

• Absence seizures (petit mal)

• Atonic and akinetic seizures

• Myoclonic seizures

B .PARTIALSEIZURES

. Simple partial seizures .

. Complex partial seizures.

. Partial seizure with secondary generalization

MAIN DIFFERENCE Generalized Partial

Both Cerebral Hemispheres

Only a part of a hemisphere

Loss of Consciousness No loss of consciousness

Treated by Valproate Treated by Carbamazipine

PARTIAL SEIZURES

SIMPLE-PARTIAL

SEIZURES

COMPLEX PARTIAL SEIZURES

PARTIAL SEIZURES WITH

SECONDARY GENERALIZATIO

N

PARTIAL SEIZURES• focal origine,Consciousness

is fully preserved• Activity is restricted to

discrete areas of cerebral cortex.

• Typically associated with structural abnormalities of the brain.

PARTIAL SEIZURES• 1.Simple partial seizures with motor signs• Characterized by• Localized motor symptoms.• Abnormal discharges remain unilateral.• Manifestations• Aversive seizure • Eyes and head turn away from the side of the focus.• Awareness of movement .

CONTI,….• Sylvan (Rolandic) seizure• Tonic-clonic movements involving the face

salivation• Arrested speech• Most common during sleep.• Jacksonian march

Orderly, sequential progression of clonic movements beginning in a foot, hand, or face and moving or “marching” to adjacent body parts.

2.Simple partial seizures with sensory signs

• Characterized by numbness, tingling, prickling, paresthesia or pain originating in one area.(eg. face or extremities) and spreading to other parts of the body.

• Visual sensations.• Equillibrium.• Alteration in hearing,alfaction• Autonomic symptoms• Odd internal feelings• Uncommon in children younger than 8 years

3.Complex partial seizures (psychomotor seizures)

If counsciousness is imapired, symptomatically more complex then simple seizure is termed as”Complex seizure”

• Unable to respond appropriately to visual or verbal commands during seizure.

• Impaired recollection of awareness of Ictal phase.

• Aura Ictal phase Post ictal phase

Partial Seizures with Secondary Generalization

• Partial seizures can spread to involve both cerebral hemispheres and produce a generalized seizure, usually of the tonic-clonic variety.

• Is often difficult to distinguish from a primarilly generalized tonic-clonic seizure.

• Careful history identifies a preceding aura

GENERALIZED SEIZURES• Tonic-clonic seizures (Grandmal)• Absence seizures (petit mal)• Atonic and akinetic seizures• Myoclonic seizures

1.Tonic-clonic seizures (Grandmal)• Tonic phase• Eyes roll upward• Immediate loss of consciousness• Stiffens in generalized, symmetric, tonic

contraction of entire body musculature• Arms usually flexed• Legs, head & neck extended• Ictal cry• Apenic, may become cyanotic• Increased salivation and loss of swallowing

reflex

Clonic Phase• Violent jerking movement and

relaxation of muscles• May foam at the mouth• May be incontinent of urine &

faeces.• Last no more than 1 minute.

TONIC CLONIC PHASE

POSTICTAL STATE

• Appear to relax• May remain semiconscious and difficult to

arouse• May awaken in a few minutes to hours• Remains confused for several hours.• Poor coordination• Mild impairment of fine motor movement• May have visual and speech difficulties• May vomit or complain of severe head ache.• On awakening is fully conscious• Usually feels tired• No recollection of entire event.

2. ABSENCE SEIZURES • Sudden,Brief loss of consciousness• Counsciousness return as suddenly as it was

lost and no post ictal confusion.• Onset usually between 4 and 12 years of age.

• More common in girls than in boys • Usually cease at puberty• Minimal or no alteration in muscle tone• Abrupt onset suddenly develops 20 or more

attacks daily• Events can be precipitated by

hyperventilation ,hypoglycemia, fatigue.

3. ATONIC AND AKINETIC SEIZURES

• Characterized by• Onset usually between 2 and 5 years of age• Sudden, momentary loss of muscle tone and postural

control• Events recur frequently during the day, particularly in

the morning hours and shortly after awakening.• Manifestations• Loss of tone causes child to fall to the floor violently• Unable to break fall by putting out hand• Loss of consciousness only momentary

4. MYOCLONIC SEIZURES

• Sudden and brief muscle contraction.• No postictal state• May or may not be symmetric • May or may not include loss of consciousness

EPILEPSY• It is a group of

syndromes characterised by unprovoked , recurring seizures

• A chronic neurologic disorder manifesting by repeated epileptic seizures (attacks or fits) which result from paroxysmal uncontrolled discharges of neurons within the central nervous system (grey matter disease).

CAUSES• 1.Idiopathic cause• 2.Acquired cause Birth trauma , Asphyxia, Head injuries Infection like bacterial , viral & parasitic Toxicity like carbon monoxide & lead poisoning Circulatory problem Fever Metabolic & nutritional disorder Drug or alcohol intoxication Brain disease like brain tumor , brain abscess & congenital

malformations.

CLINICAL MANIFESTATION

Aura phase

Convulsion phase

Post ictal phase

PATHOGENESIS• The 19th century neurologist Jackson

suggested “a sudden excessive disorderly discharge of cerebral neurons“ as the causation of epileptic seizures.

• Recent studies in animal models of focal epilepsy suggest a central role for the excitatory neurotransmiter glutamate (increased in epi) and inhibitory gamma amino butyric acid (GABA) (decreased)

Epilepsy - ClassificationThe modern classification of the

epilepsies is based upon the nature of the seizures rather than the presence or absence of an underlying cause.

Epilepsy - Classification• Focal seizures – account for 80% of adult

epilepsies- Simple partial seizures- Complex partial seizures- Partial seizures secondarilly generalised

• Generalised seizures

• Unclassified seizures

STATUS EPILEPTICUS• It is a series of generalized seizures that

occours without fully recovery of consciousness between attacks.

• Lasting atleast 30 minutes.

• Withdrawl of antiseizure medication,Fever and concurrent infection.

Epilepsy Differential Diagnosis

The following should be considered in the diff. dg. of epilepsy:

• Syncope attacks • Cardiac arrythmias • Migraine • Hypoglycemia • Narcolepsy – inappropriate sudden sleep

episodes• Panic attacks

INVESTIGATION• History collection • Physical and neurological examination• Complete blood count• Blood & CSF glucose level• Serum electrolytes, BUN, calcium• LP for cerebrospinal infection• X-ray, CT scan • EEG

MEDICAL TREATMENT

Partial Tonic-clonic

Absence Myoclonic Atonic

CarbamazepinePhenitoiinValproic acidLamotrigine

Valproic acidLamotrigine

EthosuximideValproic Acid

Valproic Acid

SURGICAL MANAGEMENT

• Temporal resection• Cortical resection• Hemispherectomy

NURSING INTERVENTIONS• During a seizure

• Indications of difficulties with airway or breathing.• Significant pressurize events • Behaviour before the seizure, aura• Type of movements observed• Time seizure began and ended• Site where twitching or contraction began• Areas of the body involved.• Movements of the eyes and changes in pupil size .• Apparent degree of consciousness during the seizure• Incontinence• Colour change• Mouth

• After a seizure

• After Seizure(Postictal)• Vitals & Neuro checks• Keep patient on side• Allow to rest• Document seizure• Record:• Seizure-Date, time, duration Where

seizure began-body part first involved• Any aura prior to seizure?• Any Progression movement • Type of seizure-generalized or local

• Type of movement-tonic, clonic, automatism, blinking, staring

• Changes in pupil size & any eye deviation

• LOCs & alertness• Bladder &Bowel continence• Presence of apnea, cyanosis, &

salivation• Pt Postictal status-weak or

drowsy, confusion-keep in calm,quiet atmosphere, re-orient

NURSING DIAGNOSIS• Risk for injury related to seizure activity• Ineffective breathing pattern related to

spasms of respiratory musculature• Social isolation related to the feelings about

seizures or public fears and misconceptions.• Chronic low self-esteem related to lack of

control over seizures.

NURSING INTERVENTIONS• Use preventive measures• Make sure the patient can be readily observed.• During a seizure, monitor vital signs and assess

neurological status frequently.• After a seizure, check the patient frequently and

report the following.• Behavior changes• Irritability• Restlessness• Listlessness

PREVENTING RESPIRATORY ARREST

• Clear the area around • Do not restrain • Loosen the clothing around the neck• Turn the pt on side so saliva can flow out of the

mouth.• Place a small, folded blanket under the head to

relevant trauma if the seizure occurs when the pt is on the floor.

• Suction the pt. and administer o2 as necessary• Do not give anything by mouth or attempt to lace

anything in the mouth.• After the seizure, place the pt in a side lying

position

Chorea• CHOREA is an inherited,

degenerative brain disorder which results in loss of both mental and physical control.

• CHOREA also known as Huntington Chorea (chorea mean to dance-like movement that is uncontrollable)

ChoreaThe dancing lady_low.mp4

PATHOPHYSIOLOGY Chorea is a chromosome disorder that occurs

on 4p16.3

At 4p16.3 juncture, the Huntington gene (HTT) contain a sequence of DNA bases (cytosine-adenine-guanine, CAG)

This sequence repeat many times (CAG-CAG-CAG-CAG-CAG-CAG-CAG-CAG)

Repeating of the CAG bases create a protein called huntingtin (Htt)

< 36 repeat is Htt but > 36 is mHtt

NUMBER OF CAG REPEATING DETERMINE ONSET

Repeated count Classification Disease Status

< 27 Normal unaffected

27-35 intermediate unaffected

36-39 Reduce penetrance

+/- affected

>39 Full penetrance

affected

Huntington’s choreaNote loss of caudate and putamen

SYMPTOMS• Motor

• Cognitive

• psychosocial

• Chorea, muscle rigidity, unbalanced gait, tremor, dysphasia and choking

Difficulty processing information and concentration, loss of memory, poor judgment

• Aggressive antisocial behavior, aggression toward others, depression

GENETIC ASSOCIATION• Single gene & chromosome

related disorder

• Is autosomal dominant disorder

• HD is inheritance/ sporadic mutation due to (radiation, chemical, and viral infection)

Drugs Treatment1. Antipsychotics: hallucinations,

delusions, violent outbursts

2. Antidepressants: depression

3. Tranquilizers: anxiety, chorea

haloperidol, chlorpromazine, olanzapine

fluoxetine, sertraline hydrochloride

benzodiazepines, paroxetine, beta-blockers

Tetrabenazine: chorea

Nursing Diagnosis• Risk for injury• Risk for self-mutilation (suicide)• Risk for imbalance nutrition less the body requirement• Mobility impair• Risk for ineffective airway• Chronic confusion• Powerlessness• Hopelessness• Memory impairment • Impaired communication

Intervention• Monitor pt for self-harm (sleeping, home safety)• Keep pt away from sharp objects• Feed pt slowly• Use communication strategies• Encourage pt to be socially active• Group homes or nursing home• Outpatient therapy (physical/speech)• Educate family• palliative care