Management of Patients with Oncologic or Degenerative Neurologic Disorders

Primary Brain Tumors

• Definition: Localized intracranial lesions that originate within the brain and occupy space inside the skull.

• Nature: These tumors can be categorized as either malignant or benign.

• Metastasis: Primary brain tumors rarely spread (metastasize) to other parts of the body outside of the central nervous system.

Types of Brain Tumors

• Gliomas:

  • A specific type of intracerebral brain neoplasm.

  • Glioblastoma multiforme (GBM): The most common and highly aggressive malignant brain tumor. It is associated with a poor prognosis for the patient.

• Meningiomas:

  • Recognized as the most common overall brain tumor.

  • These are typically slow-growing and benign in nature.

• Acoustic Neuroma:

  • A benign tumor specifically affecting the eighth cranial nerve (Vestibulocochlear nerve).

  • This nerve is primarily responsible for the functions of hearing and balance.

• Pituitary Tumors:

  • Nonfunctioning tumors: These do not produce or secrete hormones.

  • Functioning tumors: These tumors can produce one or more hormones, typically secreted by the anterior pituitary gland.

• Brain Angiomas:

  • Masses composed largely of abnormal blood vessels.

  • These are found either within the brain tissue or on its surface.

Assessment and Diagnostic Findings for Brain Tumors

• Magnetic Resonance Imaging (MRI): Considered the gold standard for identifying and characterizing brain tumors.

• Computed Tomography (CT): Used to visualize brain structures and identify lesions.

• Positron Emission Tomography (PET): Utilized to assess metabolic activity and tumor grade.

• Cytologic Studies of Cerebrospinal Fluid (CSF): Examination of the fluid to check for malignant cells.

Management of Brain Tumors

• Primary Tumor Treatment:

  • Surgery is associated with the best clinical outcomes.

  • Multimodal benefits can be derived from radiation therapy, chemotherapy, and specific drug regimens.

• Metastatic Brain Cancer Treatment:

  • Treatment is primarily palliative.

  • The focus is on eliminating or reducing serious symptoms to improve quality of life.

• Nursing Priorities:

  • Frequent neurologic checks and monitoring of vital signs.

  • Maintaining a detailed neurologic flow chart.

  • Implementing measures to prevent increased intracranial pressure (ICP).

  • Reorienting the patient as needed.

  • Assisting with self-care and activities of daily living.

  • Implementing safety measures to prevent injury.

Cerebral Metastases

• Prevalence: Metastatic brain tumors are four times more common than primary brain tumors.

• Etiology: The underlying causes and mechanisms are poorly understood.

• Clinical Manifestations: Can produce focal (localized) or generalized neurologic symptoms, including:

  • Increased intracranial pressure (ICP).

  • Headache.

  • Personality changes.

  • Fatigue.

  • Vomiting.

  • Seizures.

Spinal Cord Tumors

• Classification: May be primary (originating in the spine) or metastatic.

• Spinal Cord Compression (SCC):

  • Considered a medical emergency.

  • Occurs due to the extension of a tumor into the epidural space.

  • Assessment Findings: Pain, loss of reflexes above the level of the tumor, loss of sensation, loss of motor function, weakness, and paralysis.

• Treatment: Surgical removal of the tumor is the preferred intervention.

Nursing Management: The Patient Undergoing Spinal Surgery

• Physical Assessment: Nurses may observe weakness, muscle wasting, spasticity, sensory changes, bowel and bladder dysfunction, and potential respiratory issues.

• Monitoring: Patients must be monitored closely for any deterioration in neurologic status.

• Discharge Planning: Patients often require extensive predischarge teaching and long-term rehabilitation.

Parkinson Disease (PD)

• Definition: A slowly progressing neurologic movement disorder that eventually leads to significant disability.

• Pathophysiology: Associated with decreased levels of dopamine. This deficit results from the destruction of pigmented neuronal cells in the basal ganglia region of the brain.

• Clinical Features (TRAP):

  • Tremor: Often occurring at rest.

  • Rigidity: Stiffness of the limbs and trunk.

  • Akinesia/Bradykinesia: Absence or slowing of physical body movement.

  • Postural Disturbances: Loss of postural reflexes, leading to balance issues.

• Complications: Typically related to movement disorders and functional limitations.

• Management Goals: Controlling symptoms and maintaining the patient's functional independence.

• Treatments: Antiparkinsonian medications and Deep Brain Stimulation (DBS) have proven therapeutic benefits.

• Nursing Priorities:

  • Enhancing mobility and self-care.

  • Improving nutrition and enhancing swallowing safety.

  • Maintaining bowel function.

  • Improving communication and supporting the patient's coping ability.

Pharmacotherapy for Parkinson Disease: Dopaminergic Agents

• Action: Increases the amount of dopamine available in the brain via various mechanisms.

• Indications for Use:

  • Idiopathic parkinsonism.

  • Secondary parkinsonism (also known as extrapyramidal reactions).

  • Certain conditions other than parkinsonism.

• Contraindications:

  • Hypersensitivity to the medication.

  • Narrow-angle glaucoma.

  • Active depression.

  • May activate malignant melanoma.

  • Hypertensive crisis.

  • Peptic ulcer disease.

  • Severe cardiovascular, pulmonary, renal, hepatic, or endocrine disorders.

Pharmacotherapy for Parkinson Disease: COMT Inhibitors and Anticholinergics

• Catechol-O-Methyltransferase (COMT) Inhibitors:

  • Management includes assessment for therapeutic and adverse effects.

  • Requires specific patient teaching regarding pharmacokinetics and contraindications.

• Anticholinergics (Mechanism and Use):

  • Action: Inhibit the actions of acetylcholine in the brain and affect the parasympathetic nervous system.

  • Indications: Idiopathic parkinsonism; specifically used to decrease salivation, spasticity, and tremors.

  • Efficiency: Used for patients with minimal symptoms or those intolerant of levodopa. Often used in combination therapy to relieve symptoms of extrapyramidal reactions.

  • Limitation: Not effective for treating bradykinesia.

• Anticholinergic Contraindications:

  • Glaucoma and myasthenia gravis.

  • Gastrointestinal (GI) obstruction and prostatic hypertrophy.

  • Urinary bladder neck obstruction.

  • Cardiovascular disorders.

  • Hepatic or renal disease.

  • Elderly patients with cognitive impairments.

Principles of Anticholinergic Therapy

• Goals: Control symptoms, maintain functional ability, minimize adverse drug effects, and slow disease progression.

• Drug Selection Factors: Type of parkinsonism and severity of symptoms.

• Dosing:

  • The optimal dose is the lowest dose that allows for adequate patient function.

  • Dosage must be individualized and increased only as necessary as the disease progresses.

  • Often allows for a reduction in levodopa dosage if that therapy is causing difficulties.

Anticholinergic Effects and Toxicity

• Organ-Specific Effects:

  • CNS: Stimulation followed by depression.

  • Cardiac: Increased cardiac rate.

  • Respiratory: Bronchodilation and decreased respiratory tract secretions.

  • Gastrointestinal: Decreased GI spasms and decreased salivary/sweat gland secretions.

  • Genitourinary: Ureter and urinary bladder relaxation.

  • Other: Smooth muscle relaxation in the gallbladder and bile ducts.

• Anticholinergic Toxicity Symptoms (Overdose):

  • Hyperthermia and mydriasis (dilated pupils).

  • Paralytic ileus.

  • Delirium and tachycardia.

  • Urinary retention.

  • Seizures, coma, and respiratory arrest.

Huntington Disease, ALS, and Degenerative Disk Disease

• Huntington Disease:

  • An autosomal dominant genetic disorder.

  • Triad of Symptoms: Chorea (involuntary movements), cognitive impairment, and behavioral features.

• Amyotrophic Lateral Sclerosis (ALS):

  • A degenerative disease characterized by the loss of both upper and lower motor neurons.

  • Symptoms: Fatigue and limb weakness with a gradual onset of asymmetric, progressive weakness.

  • Management: There is no cure; focus is on maintaining function, well-being, and quality of life.

• Degenerative Disk Disease:

  • Manifestations: Pain, motor and sensory deficits, and alterations of reflexes.

  • Treatment: Usually conservative; surgery is indicated if the disk causes spinal cord compression.

  • Herniation Locations: Cervical or lumbar.

Questions & Discussion

• Question #15: A functioning pituitary tumor that affects the anterior portion of the gland may result in:

  • Answer: A. Cushing disease.

• Question #16: Is the following statement true or false? The headaches associated with metastatic brain tumors are typically worst in the middle of the day and respond favorably to NSAIDs.

  • Discussion: (Fact Check: Morning headaches are more characteristic of increased ICP relative to brain tumors).

• Question #17: A patient with lung cancer is currently undergoing diagnostic testing for spinal metastases. What assessment finding is suggestive of a metastatic spinal tumor?

  • Answer: B. New onset of severe back pain.

• Question #18: Which of the following interventions is most likely to preserve and promote the mobility of a patient with Parkinson disease?

  • Answer: A. Implementation of a progressive exercise program.