7: Dementia Flashcards
What is the most common type of dementia?
Alzheimer’s
In the DSM 5, there is a difference between major and mild neurocognitive disorders. What are the pros and cons of this?
PRO 1) public concern 2) early detection 3) early intervention CON 1) misdiagnosis
What are the 4 criteria for mild neurocognitive disorder (MCI)?
1) evidence of modest cognitive decline from previous level of performance in 1+ domain (based on individuals concern, family/friend, or clinician)
2) measurable memory impairment on standardized testing
3) cognitive deficits are insufficient to interfere with independence but greater efforts/compensatory strategies/accommodation may be required
4) not secondary to delirium/other mental disorder
What is MCI?
a transitional zone between normal cognition and dementia, but MCI may not lead to major cognitive impairment
What are 4 characteristics of delirium?
1) disturbance in attention and orientation to the environment, confusion
2) disturbance develops over a short period of time (hours to days)
3) fluctuates in severity throughout the day
4) change in additional cognitive domain such as memory, disorientation, language disturbance, etc. that isn’t accounted for by other neurocognitive disorder
What are 7 causes of delirium in the elderly population?
1) medications (esp. anti-depressants, anti-psychotics)
2) infections
3) metabolic disorders
4) surgery, anesthesia
5) substance withdrawal
6) kidney or liver disease
7) toxins
What are the 4 diagnostic requirements for Major neurocognitive disorders?
1) evidence of substantial cognitive decline from previous level of performance in 1+ cognitive domain (based on individuals concerns, family/friends, or clinician)
2) test performance is in the range of 2+ SD below appropriate norms
3) cognitive deficits are sufficient to interfere with independence
4) not secondary to delirium/other mental disorder
Major neurocognitive impairment must meet the following 6 requirements:
1) insidious onset of symptoms
2) not accounted for by delirium, schizophrenia, or major depression
3) must be acquired
4) must be persistent
5) must cross several areas of cognitive function
6) must be severe enough to interfere with life (work, social activities, relationships)
What are 5 risk factors of MCI to AD?
1) age
2) APOE carrier status (can be inherited from mother or father, risk factor but not a cause)
3) DM
4) HTN
5) increased cholesterol
What are protective factors for MCI/AD?
1) absence of APOE 4 variant
2) lifetime of exercise
3) youth
4) social stimulation
5) controlled cardiovascular risk
6) non-smoking
What are 3 examples of normal aging changes in memory?
1) forgetting appointments
2) forgetting a neighbors name
3) forgetting a birthday/anniversary
What are 3 examples of dementia/major CI memory changes?
1) forgetting making an appointment
2) not recognizing a neighbor or family member
3) not recognizing a spouse’s birthdate
What are 2 examples of normal aging disorientation?
1) forgetting what day of the week it is
2) occasionally getting lost in an unfamiliar place
What are 3 examples of dementia/major CI changes in disorientation?
1) routinely don’t know what day it is
2) not recognizing what time of day it is (morning, noon, night)
3) getting lost in their own neighborhood/house
What are 2 examples of normal aging lapses in judgement?
1) dressing inappropriately for the weather
2) unintentionally violating social conventions
What are 2 examples of dementia/major CI lapses in judgement?
1) wearing a wool coat on a hot day
2) addressing a stranger as close friends
What are 2 examples of normal aging difficulties performing mentally challenging tasks?
1) making a mistake balancing the checkbook
2) difficultly programming a new smart phone
What are 2 examples of dementia/major CI difficulties performing mentally challenging tasks?
1) inability to perform simple calculations
2) difficulty remembering what a tool is for (e.g. microwave)
What is a normal aging change with misplacing things?
occasionally misplacing regularly used items (e.g. keys, purse, phone)
What is a dementia/major CI change with misplacing things?
1) putting regularly used items in an odd place (e.g. purse in the refrigerator)
What are normal aging changes in mood?
experiencing a wide range of emotions in response to life events
What are dementia/major CI changes in mood?
exhibiting rapid changes in mood that occur for no apparent reason or for trivial reasons
What are 5 types of dementia?
1) Alzheimer’s (early and late onset)
2) vascular dementia
3) dementia with Lewy Bodies (DLB)
4) frontotemporal lobar degeneration (FTLD)
5) subcortial dementia
What is the most common type of dementia?
Alzheimer’s
When does early-onset dementia/AD occur?
age 30-60
What is the cause of early-onset dementia/AD?
genetics
When does late-onset dementia/AD occur?
ages 60+
What is the cause of late-onset dementia/AD?
unknown (combo genetic, lifestyle, environmental factors)
Late onset AD typically causes selective changes in ___________ and __________ __________ in the early stages. Why?
episodic and working memory
it starts in the hippocampus (medial temporal lobe) and enthorhinal cortex
What is the neuropathy of AD? 1/3
3 microscopic changes:
1) neurofibrillary tangles
2) neuritic plaques
3) granulovascular degeneration
What are neurofibrillary tangles?
threadlike structures normally found in the cell bodies, dendrites, axons and sometimes in the synaptic endings of neurons in the brain
What happens with neurofibrillary tangles in AD?
neurofibrils become twisted, tangled, and clumped together
also found in parkinsons and progressive supranuclear palsy
What are neuritic plaques?
minute areas of tissue degeneration consisting of granular deposits, concentrated in the cortical and subcortical regions
What do neuritic plaques cause?
significant reduction in neuronal synapses which impact transmission
Neuropathology changes are not _______.
They most frequently affect the ______________-___________ junctions and the ____________ ______________ lobes.
diffuse
temporoparietal-occipital junctions
inferior temporal lobes
In AD, the _____________ lobes, ________ and __________ cortex, and the ____________ lobes are usually spared in the beginning.
frontal lobes
motor and sensory cortex
occipital
What is typically the earliest/most prominent manifestation of AD?
episodic memory issues
What 4 things are typically well reserved in early stages of AD?
1) phonology
2) syntax
3) articulation
4) voice quality
What type of word retrieval problems occur in early stage AD?
mild, can recognize and try to correctt
Pts with early stage AD have occasional mild __________ _____________ and subtle _______________ impairments
verbal paraphasias
comprehension
In functional reading comprehension tasks, early stage AD pts typically have difficulty with what?
longer length or more complex information
Early stage AD pts have preserved _________________
automatics
Early stage AD pts have decreased _____________ _______________ and ___________ ______________
sustained attention
mental flexibility
Early stage AD pts are adequate ________________________ but may have issues with: (4)
conversationalists
1) humor
2) sarcasm
3) verbosity
4) topic maintenance
What are the neuropathologic hallmarks of early stage AD?
neurofibrillary changes limited to entorhinal and transentorhinal regions
Middle stage AD pts have ______-_____________ problems that become obvious in ____________________ and increased difficulty with _________-______________ of mistakes
word-finding
conversation
self-correction
Middle stage AD pts have increased sentence ______________ and ________________ sentences
sentence fragments
ungrammatical sentences
In middle stage AD pts, reading ______ declines and becomes _____________ for everything by the most ______________ material, so __________ reading is abandoned
rate
nonfunctional
familiar
recreational
Middle stage AD pts have increased ___________ and withdraw from ____________. They are ____________ conversational partners and offer _________/__________ comments instead of ______________ contributions.
apathy conversation passive trivialities/irrelevant substantive
In middle stage AD pts, comprehension of _____________ material is grossly impaired
nonliteral
What are 3 neuropathologic hallmarks of middle stage AD?
1) severe involvement of transentorhinal regions
2) moderate changes in hippocampus
3) mild changes in some cortical association areas
In late stage AD pts, _____________ is severely compromised. Reading is _____________, but they may recognize _________ __________ _______. Writing is _____________ but may be able to do _____ ________ ________.
communication nonfunctional highly familiar words nonfunctional over learned items
In late stage AD, comprehension is limited to:
short words and phrases
In late stage AD, what is speech like? What is syntax like? Error correction?
single words that are often bizarre and devoid of meaning
syntax breaks down, neologisms increase
unaware of errors and make no attempts to self correct
What are 4 key features of late stage AD pts communication?
1) nonfunctional conversationalists
2) failure to observe social conventions
3) insensitive to conversational rules
4) dwell on past experiences
What are 3 features of very late AD pts?
1) mute or echolalic
2) pallilalic
3) loss of all orientation to self and surroundings
What is being palilalic mean?
endless repeating of self generated works or phrases
What are the 2 neuropathologic hallmarks of late stage AD?
1) cortical association areas are severely involved
2) only primary sensory and motor areas are spared
What is vascular dementia caused by?
caused by ischemic cerebrovascular disease or circulatory disturbances
What percent of dementia is vascular?
15-20%
What are 5 risk factors for vascular dementia?
1) multiple strokes
2) HTN
3) DM II
4) smoking
5) hypercholesterolemia
What are the 2 onset types of vascular dementia?
1) acute
2) chronic
What type of deterioration occurs with vascular dementia?
stepwise
What are 3 key features of vascular dementia compared to AD?
perform better with memory tasks
and worse with attention and executive function
What is the cause of Lewy Body Dementia (DLB)?
results from abnormal clumps of neuronal protein in the cortex (related to PD)
DLB has symptoms overlapping with AD, but also has these 4 early symptoms:
1) visual or other sensory hallucinations
2) visual spatial impairment
3) sleep disturbance
4) fluctuating attention
What are some key features of DLB?
1) gait imbalances
2) reduced speech rate, fluency
3) preserved memory
What percent of dementia is frontotemporal lobar degeneration (FTLD)?
10%
When is FTLD most diagnosed?
before age 60yo (45-60)
What does FTLD result in?
significant impairment in:
1) behavior
2) personality
3) language impairment
4) motor skills
What are the 3 language variants of FTLD?
1) semantic variant (fluent speech with loss of semantic knowledge)
2) nonfluent variant
3) logopenic variant
What is a prominent feature in the early stages of subcortical dementias?
motor impairments
What 3 impairments appear months to years after the motor impairments in subcortical dementias?
1) memory
2) intellect
3) language
What are 3 types of subcortical dementia?
1) parkinson’s disease (PD)
2) huntington’s disease
3) progressive supranuclear palsy (PSP)
What percent of US population have PD and what gender is it more likely in?
1%
more likely in men than women
PD is a __________ disease that is caused by:
degenerative
deterioration of dopamine producing neurons in the basal ganglia and brain stem (primarily substansia nigra)
What are the 3 primary _________ symptoms of PD?
motoric
1) muscle rigidity
2) tremor
3) loss of balance
What is the evolution of PD?
slow progressive deterioration of motor and mental functions
significant dementia in 30% of pts, 50% show some signs of dementia
What are 3 common signs of dementia PD pts exhibit?
1) memory
2) executive function
3) cognitive impairment
that impacts work and social situations
In pts with PD, what 4 areas of cognition are often impaired?
1) memory
2) attention
3) visual
4) executive
In PD pts, how is memory impaired?
new learning
inferencing
In PD pts, how is attention impaired?
divided
selective
speeded tasks
In PD pts, how is vision related cognition impaired?
visual discrimination
synthesis
In PD pts, how is executive function impaired?
1) problem solving
2) working memory
3) planning
4) set-shifting
5) cognitive flexibility
6) verbal fluency (often the first symptom)
In pts with PD, what 5 areas are typically normal?
1) simple attention
2) memory - recognition
3) language comprehension
4) language expression
5) language naming
What is Huntington’s disease?
inherited degenerative neurogenic disorder, caused by autosomal dominant neurodegenerative diseases affecting the basal ganglia
When is typical onset of HD?
30s-40s
What are characteristics of HD?
1) chorea
2) cognitive decline
3) neurobehavioral symptoms
What is chorea?
ceaseless, rapid, repeated movements
What are 5 neurobehavioral symptoms that might be seen with HD?
1) personality changes
2) agitation
3) depression
4) paranoia
5) delusions
What is the evolution of HD?
appears between ages 40-60 but symptoms can appear before age 20
What are 3 symptoms of HD?
1) chorea (first symptom)
2) increased personality change (emotional outbursts)
3) cognitive deterioration (memory first, and then slowing intellectual functions and compromised attention)
What is the evolution of PSP?
begins between 50-80 years of age, peak in early 60s
What does PSP resemble, and with what 2 symptoms? and what symptoms is different?
Parkinson’s
1) rigidity (neck and trunk vs arms and limbs)
2) slowness of movement
1) absence of tremors in PSP
12% of the time pts with PSP are diagnosed with:
PD
PSP is more common in what gender?
males
What is the neuropathology of PSP? (4)
1) neuronal loss
2) neuronal abnormalities
3) proliferation of glial cells (throughout brainstem and basal ganglia)
4) cortical neurons largely spared
What are 7 symptoms of PSP?
1) loss of vertical movements of the eyes (and increased risk of falls)
2) loss of lateral movements of the eyes
3) stiff and rigid limbs
4) dysarthria
5) dysphagia
6) depression
7) dementia (in middle and late stages)
What is dementia in middle and late stages of PSP like? (3)
1) slowing of mental progresses
2) increasing forgetfulness
3) final stages = mute, immobile, dependent
When is the onset of FTLD?
younger, 40s-50s
What type of progression does FTLD have?
faster
What is frontotemporal lobar degeneration?
group of syndromes resulting from a progressive deterioration of the frontal and temporal lobes
What are the 3 variants of FTLD?
1) behavioral
2) language (PPA)
3) motor
What are 6 symptoms of the behavioral variant of FTLD?
1) difficulty adjusting behaviors in social context
2) hyperoral behaviors
3) repetitive movements
4) deteriorating personal hygiene
5) hyperactive/impulsive behaviors
6) hypersexual behaviors
What are 4 difficulties adjusting behaviors in social context that individuals with the behavioral variant of FTLD?
1) inappropriate
2) lack of empathy
3) apathy
4) decreased awareness
What is the neuropathology of FTLD?
increased tau protein with degeneration in the frontal and temporal lobes
What is the language variant of FTLD the same as?
primary progressive aphasia
What are the 2 types of PPA/FTLD language variant?
1) fluent semantic
2) progressive nonfluent
3) logopenic
What is the motor variant of FTLD questionably tied to?
ALS
How is the motor function affected with FTLD motor variant? (3)
1) dysphagia
2) dysarthria
3) voice
As the motor variant of FTLD progresses what is there a greater risk for?
cognitive decline
What is another potential cause of dementia?
Creutzfeldt-Jakob Disease
How rare is Creutzfeldt-Jakob Disease?
1 in 1 million
What are 3 characteristics of Creutzfeldt-Jakob Disease?
1) rapidly progressive
2) fatal (1 year average)
3) dementia almost always present
What are symptoms of Creutzfeldt-Jakob Disease?
1)
