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Junior - Neuro 2 > 2 - Altered Mental Status > Flashcards

2 - Altered Mental Status Flashcards

1
Q

HPI questions?

A

Time (course of change)
Changes in personality
Changes in mood
Changes in memory

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2
Q

Mental status exam categories?

A 
General behavior and appearance
Stream of talk
Mood and affective response
Content of thought
Sensorium
Folstein mini mental status exam
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3
Q

Folstein mini mental status exam score of <24/30 gets what?

A

Additional testing

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4
Q

Topics covered by a formal mental status exam?

A 
Consciousness
Orientation
Speech/language
Fund of information
Insight/judgment
Abstract thought
Calculations
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5
Q

LOC assessment?

A

Normal: you know
Impaired: sleepiness -> obtunded

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6
Q

Attention/calculation assessment?

A

Serial 7’s

Identify a letter in a series w/o error

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7
Q

Language and speech assessment?

A

Elements (fluency, naming etc)
Dysarthria (arriculation)
Aphasia (produce and comprehend)

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8
Q

Examples of aphasia?

A 
Broca’s 
Wernicke’s 
Global 
Conduction 
Transcortal motor
Transcortal sensory
Subcortal
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9
Q

Global aphasia?

A 
Impairment: 
- Fluency
- repetition 
- comprehension 
may have associated severe right hemiparesis cause by large lesion in the L hemisphere
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10
Q

Conduction aphasia?

A

Preserved:

  • Fluency
  • Comprehension

Impaired:

  • repetition
  • naming
  • writing
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11
Q

Transcortical motor aphasia?

A

Fluency impaired

Preserved:

  • comprehension
  • repetition

May have an associated R hemiparesis caused by lesion in broca’s area

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12
Q

Transcortal sensory aphasia?

A

Preserved:

  • fluency
  • repetition

Impaired:
- comprehension

Lesion in the wernicke’s area

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13
Q

Subcortical aphasia?

A

Variable:

  • Fluency
  • comprehension

Preserved:
- repetition

May have hypophonia caused by a lesion in the L basal ganglia or thalamus

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14
Q

Types of amnesia?

A

Psychogenic - forget emotional shit

Organic - forget objective facts

Retrograde - events prior to injury

Anterograde - inability to store, retain and recall new knowledge

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15
Q

How is Memory tested?

A

Immediate: 3 easy to ID objects

Short term: repeat 3 obj 5-15 min later

Remote: mothers maiden name, school attended, past presidents etc

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16
Q

Evaluate integrative sensory function?

A

Asterogenosis

Agraphesia

2 point discrimination

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17
Q

How is spacial thought evaluated?

A

“Construction”

Can they draw clock or intersecting shapes?

Evaluates parietal lobe function

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18
Q

Red flags in the HX?

A 
Progressive declining LOC
PUPILLARY ASYMMETRY
Seizures
Repeated vomiting
Double vision
Worsening HA
Cant recognize (faces, places)
Confused/irritable
Slurred speech
Unsteady on feet
Weakness/numbness in extremeties
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19
Q

Causes of delirium and dementia?

“I watch death”

A

I - infection

W - withdrawl (ETOH/drugs)
A - acute metabolic 
T - trauma
C - CNS pathology
H - hypoxia
D - deficiencies (b12, folate, etc)
E - endocrinopathies 
A - acute vascular 
T - toxins
H - heavy metals
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20
Q

3 types of memory?

A
  1. Working memory
  2. Episodic memory
  3. Lasting memory
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21
Q

Working memory?

A

<30 sec
Rule of 7

RAS, prefrontal cortex and parietal lobe

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22
Q

Episodic memory?

A

Minutes - years
What, where and when
“Lay down” memories and tag to experiences

Hippocampus, dorsomedial nucleus of thalamus

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23
Q

Lasting memory?

A

Lifelong - protein synthesis and creation of new synapse

Anterior temporal lobe
Frontal lobe

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24
Q

How to test working and episodic memory?

A

Working: “repeat after me”

Episodic: trivial events of the day “what did you eat for breakfast?”

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25
Q

Causes of amnestic syndromes?

A

Acute:

  • head trauma
  • hypoxia/ischemia
  • bilat cerebral artery occlusion
  • alcoholic blackouts
  • wernicke encephalopathy
  • dissociative (psychogenic) amnesia

Chronic:

  • alcoholic korsakoff
  • postencephalitic amnesia
  • brain tumor
  • paraneoplastic encephalitis
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26
Q

What is the difference between acute and dementia related amnesia?

A

Acute: impaired attention and cant learn new material

Demented: normal attention span, recent memory loss

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27
Q

What is executive function?

A

Central organizing function of the brain

  • Planning
  • Initiating and regulating behavior
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28
Q

Delirium vs dementia

A

Delirium: acute onset bad LOC
- reversible

Dementia: chronic, normal LOC but confused
- irreversible

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29
Q

Hallmark of delirium?

A

Described as waxing and waning levels of consciousness

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30
Q

Key features of delirium?

A
  • Attention impairment
  • memory impairment
  • agitation
  • apathy/withdrawal
  • sleep disturbance
  • emotional lability
  • perceptual disturbances (hallucination)
  • neurologic signs
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31
Q

Causes of delirium?

A
  • Stroke
  • ETOH/drugs
  • endocrine disturbances
  • electrolyte disturbances
  • nutritional disorders
  • organ system failure
  • psychiatric diagnosis
  • infectious disorders
  • hypertensive encephalopathy
  • concussion
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32
Q

Does the alcohol level predict the level of impairment?

A

Nope

33
Q

Stages of alcohol withdrawal?

A

5-10 hrs “dry”
- Tremulousness, tachycardia, HTN

2 days
- seizures

3-5 days
- agitation, tremulousness, hallucinations, CV collapse

34
Q

Meds to help with alcohol withdrawl?

A

Benzo’s
Fluid, electrolyte, glucose balance
B-blocker (adrenergic response)

35
Q

What is the key to understanding alcohol withdrawal?

A

Socks apparently

36
Q

What is a common nutritional disorders that acutely confused pts may have?

A

B-12 (pernicious anemia)

Wernicke’s encephalopathy (thiamine)

37
Q

Classical triad of wernicke’s encephalopathy?

A

Ophthalmoplegia/nystagmus

Gait ataxia

Global confusion

38
Q

What do all patients with undiagnosed altered mental status, oculomotor disorders or ataxia get?

A

Parenteral thiamine (wernicke’s encephalopathy)

39
Q

What is korsakoff’s psychosis?

A

Deficits in learning and memory following wernicke’s encephalopathy

Gaps in memory
Confabulation
Disordered temporal sequencing

40
Q

What is dementia?

A

Disorder involving impairment of learning and memory and impairment one or more of the following:

  • complex tasks
  • reasoning ability
  • spatial orientation
  • language
41
Q

Prevalence of dementia in the west?

A
  1. Alzheimers (50%)
  2. Vascular (10-20%)
  3. Parkinson’s
  4. Chronic intoxication
42
Q

3 most common reversible causes of dementia?

A

Depression
Hydrocephalus
Alcohol dependence

43
Q

Reversible vs irreversible causes of dementia?

A

19% reversible

81% irreversible

44
Q

Biggest risk factor for dementia?

A

Increasing age (over 50)

45
Q

Levels of cognitive impairment?

A

Normal: No affect on daily life (age causes)

Mild cognitive impairment (MCI): affects daily life

46
Q

Mild cognitive impairment (MCI) often turns into’?

A

Frank dementia

  • Usually Alzheimer’s
47
Q

Risk factors for Alzheimers?

A

Memory deficit >1.5 SD from normal

Presence of apolipoprotein e4 allele (epsilon?)

Small hippocampal volume

48
Q

Types of dementia?

A
  1. Alzheimers: AB42 protein
  2. Frontal temporal dementia: tau protein
  3. Lewd body dementia (DLB): a-synuclein protein
  4. Prion disorders: creutzfeldt-jakob disease
49
Q

MC cause of dementia in US?

A

Alzheimers

50
Q

Alzheimer’s disease macro and microscopic changes?

A

Macroscopically: diffuse cortical atrophy

Microscopically:

  • neurotic plaques of AB42 amyloid
  • silver-staining neurofibrillary tangles in neural cytoplasm
  • accumulation of AB42 amyloid in arterial wall of cerebral blood vessels
51
Q

What is alzheimer’s disease?

A

Progressive neurological disorder that results in:

  • memory loss
  • language deficit
  • visual spatial deficit
  • anosognosia
52
Q

What is anosognosia?

A

Lack of awareness of cognitive deficits

Sometimes seen in alzheimer’s disease

53
Q

Etiology of alzheimer’s disease?

A

Female:male 2:1
Family hx common
Lower eduction
Head trauma/concussions

54
Q

Where are neuritic plaques and neurofibrillary tangles usually found with alzheimer’s disease?

A

Hippocampus
Lateral temporal cortex
Lateral septum (nucleus basalis of mynert)

55
Q

What does an MRI show for Alzheimers?

A

Nothing until they become severe then it MAY show cortical atrophy leading to compensatory dilation of the ventricles

So, nothing…

56
Q

Early signs of alzheimer’s?

A

Non-focal neurologic exam

  • short term memory abnormal
  • speech hesitant
  • 24-27 score on MMSE
57
Q

Later signs of alzheimer’s?

A
  • Paranoia, hallucinations, delusions
  • primitive reflexes emerge
  • mute, bedbound, incontinent
58
Q

Diagnostic studies for alzheimers?

A

No labs
MRI, CT (only effective later)

Neurophychiatric testing (memory, verbal, executive function)
Apo episilon genetic testing
59
Q

Meds for alzheimers?

A

Meds to target CNS levels of ACh

Cholinesterase inhibitors

  • donepezil
  • rivastigmine
  • galantamine

N-Methyl-D-asparte (NMDA) receptor antagonist
- memantine

60
Q

Do meds cure alzheimers?

A

No they are aimed at slowing the progression of cognitive decline

61
Q

Types of vascular dementia?

A

Multi-infarct dementia

Diffuse white matter disease

62
Q

What is vascular dementia?

A

Vascular insult/CVD leading to dementia

No uniform set of criteria

63
Q

Findings that suggest vascular dementia?

A

Cognitive deficit onset post stroke

Abrupt onset w stepwise deterioration

Focal findings on neuro exam c/w CVA

Infarcts on imaging

64
Q

Vascular dementia’s effect on alzheimer’s?

A

CVD may affect severity of alzheimer’s symptoms

65
Q

What is frontotemporal dementia FTD?

A

50-70 yrs old

Associated with atrophy of temporal and frontal lobes

66
Q

Microscopic findings with FTD?

A

Tau protein accumulation with neurons

67
Q

What is associated with dementia with lewy bodies?

A 
Hallucinations
Parkinsonism
Fluctuating alertness
Falling
REM sleep disorder
68
Q

Reversible causes of dementia?

A
  • Depression
  • Normal pressure hydrocephalus
  • Metabolic disorders
  • Medication induced
  • ETOH
  • Malignancy
69
Q

What condition is MC mistaken for dementia?

A

Depression

  • mental slowness, apathy, self-neglect, irritability, difficulty with memory
70
Q

What is Pseudodementia: psychological disease

A

Depression that mimics dementia

71
Q

Differentiating dementia and depression?

A

Dementia:

  • unaware of deficits
  • not vegetative
  • worse at night
  • abnl neuro exam
  • abnl labs

Depression:
The opposite

72
Q

Tx for pseudodementia: depression?

A

Treat the depression SSRI, SNRI, CPT, etc

73
Q

Normal pressure hydrocephalus triad?

A

Cognitive decline (dementia)

Urinary incontinence/urgency

Gait difficulty

74
Q

Treatment for normal pressure hydrocphalus?

A

Shunt

75
Q

Dementia puglistica?

A

Recurrent head trauma

76
Q

altered mental status without obvious cause?

A

Full workup:

  • LP
  • Blood Cx
  • Imaging
  • Broad diagnostic blood work
77
Q

Management of delirium?

A

Treat the underlying medical cause

78
Q

Hallmark of delirium?

A

Waxing and waning mental status

Junior - Neuro 2 (4 decks)

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