Practical Pearls

Studies, including a recent one by Joseph Shega, MD and colleagues, suggest that many patients with dementia are able to accurately self-report present pain experience when questioned. While patients may not mention ongoing pain to the physician without prompting, those with mild to moderate dementia will typically provide reliable reports if asked directly. "The biggest barrier to assessing patients' pain is that you actually ask the question and not expect them to bring up the complaint," Dr. Shega says. Read More…

The notion of therapeutic adherence has emerged to more accurately reflect the patient's role in treatment. Rather than "comply" with instructions from the physician telling the patient what he or she has to do, the patient should be recruited to play an active role in developing a treatment strategy he or she will "adhere" to. Read More…

With the 2009 edition of the CPT manual, the Epley maneuver for patients with Benign Positional Vertigo (BPV) is now associated with code 95992. According to CPT, the code can be used once per day per patient in addition to providing the E/M service, explains Marc Nuwer, MD. "However, Medicare has decided instead to bundle it into the E/M service for that day…For some carriers, the new code 95992 would be used along with the E/M service code. For Medicare, neurologists should consider using the Prolonged Service codes, whenever that applies, instead of using the new code 95992." Read More…

GBM patients presenting with seizures should be placed on an AED at the time of presentation. AEDs are used prophylactically during surgery but should be stopped after surgery in patients who have not had a seizure, as there is no evidence that use of AEDs prevents seizures. Non-hepatic enzyme inducing AEDs are typically utilized when a patient requires chronic seizure prophylaxis. A number of chemotherapeutic medications (such as Irinotecan) and newer targeted therapies (particularly tyrosine kinase inhibitors) undergo hepatic metabolism and thus may be rendered ineffective in the setting of hepatic enzyme induction. Read More…

Patients with early logopenic variant of PPA, which mimics conduction aphasia, are likely to have Alzheimer's disease pathology. This form can be at times confused with the language disturbance in the non-influent aphasia type of FTD and also semantic dementia. Careful evaluation of comprehension, speech output and repetition will help sort these different forms of speech and language impairment. Read More…

While incontinence is frequently attributed to dementia, neurologists must first rule out potentially reversible causes remembered by such mnemonics as DRIPP, according to Thomas E. Lackner, PharmD, Professor in the College of Pharmacy and Institute for the Study of Geriatric Pharmacotherapy at the University of Minnesota. DRIPP stand for: Delirium; Restricted mobility; Infection/Inflammation; Polyuria; and Pharmaceuticals. Read More…

The STOP Act for Stroke will likely be introduced in Congress yet again-after dying in four previous Congresses. Neurologists can write to their national representatives to encourage passage. Read More…

Methysergide was not tested in controlled trials for prevention of cluster headaches, and data are largely anecdotal. "We consider using Sansert primarily for refractory episodic cluster headache patients," Stephen Landy, MD says, "because their cycles are usually less than four months and thus less likely to be associated with fibrotic complications. Patient can obtain it from Canada." Read More…

The patient's medical history remains crucial in diagnosis of epilepsy, Mark Spitz, MD maintains. But it may be overlooked. A patient's self-report of seizures is notoriously unreliable due to his or her altered awareness during the seizure event. Reports of the event from family, friends, or caregivers present at the time of the seizure tend to emphasize what's "dramatic, and not necessarily what's helpful to the physician," Dr. Spitz observes. Upon direct questioning, however, witnesses usually can recall details that may prove useful to the evaluating physician: staring, subtle twitches a few seconds prior to the seizure, how the patient fell or jerked. Read More…