10. Neurocognitive Disorders Flashcards
1
Q
Name DSM-5 diagnostic criteria: Delirium (6)
A
- attention and awareness: disturbance in attention (i.e. reduced ability to direct, focus, sustain, and shift attention) and awareness (reduced orientation to the environment)
- acute and fluctuating: disturbance develops over short period of time (usually hours to days), represents a change from baseline attention and awareness, and tends to fluctuate in severity during the course of a day
- cognitive changes: an additional disturbance in cognition (i.e. memory deficit, disorientation, language, visuospatial ability, or perception)
- not better explained: disturbances in criteria A and C are not better explained by another neurocognitive disorder (pre-existing, established, or evolving) and do not occur in the context of a severely reduced level of arousal (i.e. coma)
- direct physiological cause: evidence that disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal (i.e. due to a drug of abuse or medication), toxin, or is due to multiple etiologies
- Note: delirium can be described as HYPERactive, HYPOactive, or MIXED presentation. While patients with hyperactive delirium may demonstrate features of restlessness and agitation, as well as experience hallucinations and delusions, those with hypoactive delirium present with lethargy, sedation and respond slowly to questioning
2
Q
Describe: Confusion Assessment Method (CAM) for Diagnosis of Delirium
A
Highly sensitive and specific method to diagnose delirium
- Part 1: an assessment instrument that screens for overall cognitive impairment
- Part 2: includes four features found best able to distinguish delirium from other cognitive impairments
Need (1) + (2) + (3 or 4)
- Acute onset and fluctuating course
- Inattention
- Disorganized thinking
- Altered level of consciousness - hyperactive or hypoactive
3
Q
Name common symptoms: Delirium (6)
A
- distractibility, disorientation (time, place, rarely person)
- misinterpretations, illusions, hallucinations (visual hallucinations are organic until proven otherwise)
- speech/language disturbances (dysarthria, dysnomia)
- affective symptoms (anxiety, fear, depression, irritability, anger, euphoria, apathy)
- shifts in psychomotor activity (groping/picking at clothes, attempts to get out of bed when unsafe, sudden movements, sluggishness, lethargy)
- impairment in sleep duration and/or architecture (i.e. sleep-wake reversal)
4
Q
Name risk factors: Delirium (13)
A
- most common precipitating factors include:
- polypharmacy (particularly involving psychoactive drugs such as anticholinergics)
- infection
- dehydration
- immobility
- malnutrition
- and use of bladder catheters
- other factors include:
- hospitalization (incidence 10-56%); frail and surgical patients are at the greatest risk
- previous delirium
- nursing home residents (incidence 60%)
- old age (especially males)
- severe illness (i.e. cancer, AIDS)
- recent anesthesia or surgery
- brain vulnerability: pre-existing neurologic or neurocognitive disorder, substance abuse, past psychiatric illness
5
Q
Name investigations: Delirium (4)
A
- standard: CBC and differential, electrolytes (including Ca2+, Mg22+, and PO43-), glucose, BUN, Cr, TSH/ T4, LFTs, vitamin B12, folate, albumin; urinalysis, urine C&S
- as indicated: ECG (to assess QT interval when considering treatment with an antipsychotic agent), CXR, head CT or MRI, toxicology/heavy metal screen, VDRL, HIV, LP, blood cultures, EEG (typical finding in delirium is generalized slowing, can also be used to rule out underlying seizures or post-ictal states as etiology)
- indications for CT head: focal neurological deficit, acute change in status, anticoagulant use, acute incontinence, gait abnormality, history of cancer
- MRI may be more useful: it can detect or exclude acute or subacute stroke and multifocal inflammatory lesions in patients with negative head CT
6
Q
Name etiologies: Delirium (11)
A
I WATCH DEATH
- Infectious (encephalitis, meningitis, UTI, pneumonia)
- Withdrawal (alcohol, barbiturates, benzodiazepines)
- Acute metabolic disorder (electrolyte imbalance, hepatic or renal failure)
- Trauma (head injury, post-operative)
- CNS pathology (stroke, hemorrhage, tumour, seizure disorder, Parkinson’s)
- Hypoxia (anemia, cardiac failure, pulmonary embolus)
- Deficiencies (vitamin B12, folic acid, thiamine)
- Endocrinopathies (thyroid, glucose, parathyroid, adrenal)
- Acute vascular (shock, vasculitis, hypertensive encephalopathy)
- Toxins: substance use, sedatives, opioids (especially morphine), anesthetics, anticholinergics, anticonvulsants, dopaminergic agents, steroids, insulin, glyburide, antibiotics (especially quinolones), NSAIDs
- Heavy metals (arsenic, lead, mercury)
7
Q
Describe management: Delirium (12)
A
- identify and manage underlying cause
- identify and treat underlying cause immediately
- stop all non-essential medications
- maintain nutrition, hydration, electrolyte balance, and monitor vitals
- optimize the environment
- environment: quiet, well-lit, near window for cues regarding time of day
- optimize hearing and vision
- room near nursing station for closer observation; constant care if patient jumping out of bed, pulling out lines
- family member present for reassurance and re-orientation
- frequent orientation: calendar, clock, reminders
- avoid frequent changes of assigned nursing staff
- pharmacotherapy
- low dose, high potency antipsychotics: haloperidol has the most evidence and can be given IV or IM; alternatives include risperidone (less sedating), olanzapine (more sedating, can be anticholinergic itself), quetiapine (if EPS sensitive), aripiprazole (does not prolong QTc)
- benzodiazepines only used in alcohol/substance withdrawal delirium; otherwise, can worsen delirium (antipsychotics are not useful in EtOH or benzodiazepine withdrawal delirium)
- try to minimize drugs with anticholinergic effects
- physical restraints to maintain safety only if necessary
8
Q
Describe prognosis: Delirium (1)
A
up to 50% 1yr mortality rate after episode of delirium
9
Q
Name DSM-5 diagnostic criteria: Major Neurocognitive Disorer (5)
A
- A) evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition) based on both:
- concern of the individual, a knowledgeable informant, or the clinician that there has been a significant decline in cognitive function
- substantial impairment in cognitive performance, preferably documented by standardized neuropsychological testing or, in its absence, another quantified clinical assessment
- B) cognitive deficits interfere with independence in everyday activities (i.e. at a minimum, requiring assistance with complex instrumental activities of daily living such as paying bills or managing medications)
- Note: if deficits do not interfere (as in B) and cognitive impairments are mild-moderate (as in A.2), this is considered “mild neurocognitive disorder”; see Neurology, N21
- C) cognitive deficits do not occur exclusively in the context of a delirium
- D) cognitive deficits are not better explained by another mental disorder (i.e. major depressive disorder, schizophrenia)
- E) in the case of neurodegenerative dementias such as Alzheimer’s Disease, disturbances should be of insidious onset and progressive
- Specify whether due to: see image below
10
Q
Name: The 4 As of Dementia (4)
A
- Amnesia
- Aphasia
- Apraxia
- Agnosia
11
Q
Describe: The “Mini Cog” Rapid Assessment (3)
A
- 3 word immediate recall
- Clock drawn to “10 past 11”
- 3 word delayed recall
12
Q
Describe epidemiology: Major Neurocognitive disorder (5)
A
- prevalence increases with age: 5% in patients >65 yr of age; 35-50% in patients >85 yr of age
- probability of dementia in an older person with reported memory loss is estimated to be 60%
- prevalence is increased in people with Down’s syndrome and head trauma
- Alzheimer’s disease comprises >50% of cases; vascular causes comprise approximately 15% of cases (other causes of dementia neurocognitive disorder – see Neurology, N21)
- average duration of illness from onset of symptoms to death is 8-10 yr
13
Q
Name subtypes: Major Neurocognitive disorder (3)
A
14
Q
Describe investigations: Major Neurocognitive disorder (3)
A
Investigations (rule out reversible causes)
- standard “neurocognitive work-up”: see Delirium, PS22
- as indicated: VDRL, HIV, LP, CXR, EEG, SPECT, head CT, or MRI
- indications for head imaging: same as for delirium, plus: age <60, rapid onset (unexplained decline in cognition or function over 1-2 mo), dementia of relatively short duration (<2 yr), recent significant head trauma, unexplained neurological symptoms (new onset of severe headache/seizures)
15
Q
Describe management: Major Neurocognitive disorder (6)
A
- treat underlying medical problems and prevent new ones
- provide orientation cues for patient (i.e. clock, calendar)
- provide education and support for patient and family (i.e. day programs, respite care, support groups, home care)
- consider power of attorney/living will and long-term care plan (nursing home)
- inform Ministry of Transportation about patient’s inability to drive safely
- consider pharmacological therapy
- cholinesterase inhibitors (donepezil [Aricept®], rivastigmine, galantamine) for mild to severe disease
- NMDA receptor antagonist (memantine) for moderate to severe disease
- low-dose antipsychotics (i.e. risperidone, aripripazole), escitalopram, or trazodone if behavioural or emotional symptoms prominent – start low and go slow
- reassess pharmacological therapy every 3 mo
