8. Clinical Approach to Dementia

Question 1

What is a decline in memory and at least one other cognitive function such as aphasia, apraxia, agnosia, or a decline in an executive function such as planning, organizing, sequencing or abstracting?

Answer 1

Dementia

Question 2

The decline associated with Dementia IMPAIRS social or occupational functioning in comparison with previous functioning, the deficits should not occur exclusively during the course of delirium and should not be accounted for by another psychiatric condition such as schizophrenia or?

Answer 2

depression

Question 3

There are many causes of dementia, some being degenerative including the MC being alzheimer’s disease and the second most common is what? Note: the only way to know for sure if it is dementia is via autopsy

Answer 3

Diffuse Lewy Body disease (memory loss + visual hallucinations + parkinsons movements)

Question 4

Other degenerative causes of dementia include parkinson’s disease, frontotemporal lobar degen (picks dementia), huntingtons, supranuclear palsy. Vascular causes of dementia include single stroke, binswangers disease (HTN), vasculitis, SAH, and MC?

Answer 4

Multiple infarction

Question 5

Infectious causes of dementia include *syphilis/AIDS**, fungus, creutzfeldt jakob dz, post herpes encephalitis (Cognitive impairment seen), psych causes include depression, alcohol abuse, drug abuse, personality disorder and anxiety, toxic/metabolic causes include toxins, heavy metals, liver/renal/cardiac/resp failure, thyroid deficiency and mc?

Answer 5

Vitamin B12 deficiency- cognitive impair may be irreversible

Question 6

History is the most important when evaluating patients with dementia from patient and family, patient often denies they have a problem, questions include short term memory problems, time course (rapid/slow), functioning of patient, safety, Hx of head injury, toxin exposure, infection and family history of?

Answer 6

Dementia

Question 7

Examination of a dementia patients should include a short mental state test like Folstein Mini Mental State Examination*** or Montreal Cognitive assesment MOCA- less used, look for cardiovascular risk factors such as HTN, bruits, arrythmias and heart murmurs and also do a full?

Answer 7

neurological exam

Question 8

Laboratory studies for a dementia patient include CBC, chemistry panel, sed rate, thyroid function studies, B12 level, RPR and CT or MRI of head, EEG (cruetzfeldt jakob/ encephalitis), lumbar puncture- rapid course (CA, infxn, vasculitis), CXR, HIV testing, drug screen, SPECT/PET scan and what kind of screen?

Answer 8

Heavy metal screen

Question 9

What diagnosis requires the following: dementia estabished via MMSE or confirmed w neuropsychological tests, deficits in 2+ areas of cognition, progressive worsening of memory and cognitive fxns, no disturbance of consciousness, between 40-90 (avg 65), and an absence of systemic disorders or other brain diseases?

Answer 9

Alzheimer’s Disease

Question 10

findings that support Alzheimer’s Disease include progressive deterioration of specific cognitive functions (aphasia/apraxia/agnosia), impaired daily living and behavior, fam hx of similar disorders, LP and EEG is usually normal and what would be seen on MRI/CT of brain?

Answer 10

Progressive atrophy- big canals w neurofibrilary tangles and plaques

Question 11

Tx for Alzheimer’s Disease is to SLOW progression of the disease, including donezipil/rivastigmine/galantamine which are all acetylcholinesterase inhibitors, these are given with what, which is an NMDA receptor antagonist indicated for mod/sev demential?

Answer 11

Memantine

also consider B complex, lipid lowering agent and aspirin

Question 12

What impairment is defined by memory issues, and is tested as abnormal memory for age but does not meet criteria for dementia, usually a precursor to Alzheimer’s Disease, pt w MCI are 5x more likely to devel AD than age matched controls, and this impairment is treated with AChE inhibitors to slow progression to AD?

Answer 12

Mild Cognitive Impairment - they are AWARE they have memory problems

Question 13

Vascular dementia must meet the following criteria: 1) cerebrovascular dz defined by presence of focal signs on neuro exam, such as hemiparesis, lower facial weakness, babinski sign, sensory deficit, hemianopia, consistent w stroke AND 2) evidence of relevant cerebrovascular dz at brain imaging including multiple large vessel infarcts or single situated infarct as well as multiple basal ganglia/white matter lesions and white matter lacunes or extensive periventricular?

Answer 13

White matter lesions - or a combo of all

Question 14

Vascular dementia also requires a relation between cognitive problems and vascular events manifested or inferred by the presence of one or more of the following: onset of dementia within 3 months after stroke, fluctuating, stepwise progression of cognitive deficits OR abrupt deterioration in?

Answer 14

Cognitive functions (degenerating all around)

Question 15

What type of dementia/degeneration is the only one to occur early in the 45s and progress very rapidly?

Answer 15

Frontotemporal Dementia

Question 16

Diffuse Lewy Body Disease has a tetrad of sx including dementia, parkinsonian sxs (bradykinesia/rigidity but WITHOUT tremor), visual hallucinations- usually of small animals or children and illusions like imposter syndrome, and they have extreme sensitivity to?***

Answer 16

Antipsychotic agents like haldol

Question 17

Lewy Body Disease progresses more rapidly than alzheimers, symptoms generally vary a great deal more from one day to the next compared to AD, commonly have unexplained periods of markedly increased confusion that lasts days to weeks and closely mimics?

Answer 17

Delirium

Note: everything comes up normal on work up

Question 18

With lewy body, parkinsonian features present early, bradykinesia, rigidity and falls are prominent, tremor is absent- poor response to Levodopa, dysautonomia common- psychotic sx much more common compared to AD, BEWARE most patients experience severe life threatening adverse reactions to ?

Answer 18

antipsychotic agents - use newer IF necessary such as olanzapine or quetiapine

Question 19

Lewy body has cortical lewy bodies (all over) with early cortical dementia, parkinson’s had MIDBRAIN lewy bodies and executive dementia occuring late in illness with resting tremor and little autonomic dysfunction, what is a common occurence and difference between lewy and parkinson?

Answer 19

Lewy body has visual hallucinations commonly while parkinson ONLY has hallucinations due to drugs

Question 20

What degeneration includes several forms of dementia characterized by a slowly progressive deterioration of social skills and changes in personality, along with impairment of intellect* memory* and language* with core symptoms of loss memory, lack spontaneity, cant think or concentrate and disturbance of speech?

Answer 20

Frontotemporal Degeneration

EEG shows marked* slowing in 42y/o
Younger pts w atrophy of frontal and temporal lobes- no cure, progress 2-10 years

Question 21

What has a triad of dementia, gait disturbance, and urinary incontinence which are potentially reversible with ventriculoperitoneal shunting- but GAIT disturbance is MOST likely to be reversed with shunting?

Answer 21

Normal Pressure Hydrocephalus

Question 22

What disease has onset between 40-50, a hereditary stroke disorder-defect of NOTCH3 on chr19, causing progressive degeneration of smooth muscle cells in BV, manifests as MIGRAINES, TIAs or strokes, with MRI showing KEY finding of multiple areas of ischemia years prior, progresses to a subcortical dementia, test genetics and biopsy to look for arteriopathy- no treatment?

Answer 22

Cerebral Autosomal Dominant Subcortical Infarcts and Leukoencephalopathy

CADASIL’s Disease