8. Neurocognitive disorders Flashcards
ICU Triad
Delirium
Pain
Agitation
Timing of delirium symptoms
Fluctuate throughout the day
Worse at night
Medications that induce delirium
TCAs Anticholinergics Benzodiazepines Nonbenzo hypnotics "Z-drugs" Corticosteroids H2 blockers Meperidine
Most common causes of delirium in kids
Fever
Meds
Manifestation of delirium on EEG?
Diffuse background slowing
*Exception: delirium tremens (fast activity)
Likely diagnosis: Delirium + hemiparesis or other focal neuro signs
cerebrovascular accident or mass lesion
Delirium + elevated BP + papilledema
Hypertensive encephalopathy
Delirium + Dilated pupils + tachycardia
Drug intoxication
Delirium + fever + nuchal rigidity + photophobia
Meningitis
Delirium + Tachycardia + tremor + thyromegaly
Thyrotoxicosis
Typical symptoms of delirium
Short attention span Disorientation Fluctuations in level of consciousness visual hallucinations Impairment in recent memory
Most common type of delirium?
Mixed: psychomotor activity remains stable at baseline or fluctuates rapidly between hyperactivity and hypoactivity
Type of delirium most likely to go undetected?
Hypoactive: decreased motor activity, drowsiness to lethargy to stupor. More common in elderly.
ICU psychosis type of delirium
Hyperactive: agitation, mood lability, uncooperative.
More common in drug withdrawal or toxicity
Tool for evaluation of a patient with suspected delirium. High sensitivity and specificity
Confusion Assessment Method (CAM)
Once delirium has been diagnosed, the cause should be sought by obtaining what tests/procedures?
Finger-stick blood glucose
Pulse-oximetry
Arterial blood gases
ECG
Labs: BMP
CBC with diff
Urinalysis
Urine culture
Urine drug screen Blood alcohol level Therapeutic drug levels (Ex. Lithium, digoxin, antiepileptics) Hepatic panel Thyroid hormone levels CXR depending on presentation
Head imaging: CT or MRI
EEG
LP
*If focal neurological defecits present or cause of delirium cannot be identified with initial workup
Preferred agent for treatment of agitation
Haloperidol (D2 antagonist)
Avoid using benzos to treat delirium unless it is due to?
Alcohol or benzo withdrawl
Causes of neurocognitive disorders that present like dementia but progression may be halted/reversed with treatment
Vit B12 def.
Thyroid dysfunction
Normal pressure hydrocephalus
Likely diagnosis for: cognitive impairment with stepwise increase in severity + focal neurological signs
Vascular disease
*Get head CT or brain MRI
Cognitive impairment + cogwheel rigidity + resting tremor
Lewy body disease
Parkinson’s disease
*Clinical dx
Cognitive impairment + gait apraxia + urinary incontinence + dilated cerebral ventricles
Normal pressure hydrocephalus
*Get head CT or brain MRI
Cognitive impairment + fatigue + cold intolerance + coarse hair + constipation
Hypothyroidism
*Get TSH, free T4
Cognitive impairment + parasthesias + diminished position and vibration sensation + megaloblasts on CBC
Vitamin B12 deficiency
*Get serum B12
Cognitive impairment + tremor + Fleischer rings + abnormal LFTs
Wilson’s Disease
*Get ceruloplasmin level
Cognitive impairment + diminished position and vibration sensation + Argyll Robertson Pupils (accomodation response present, response to light absent)
Neurosyphillis
Get CSF FTA-ABS and VDRL
How may hYPERthyroidism present in the elderly?
“Apathetic thyrotoxicosis”
Depression and lethargy
5 categories of the MMSE
Total points?
Orientation Registration Attention Recall Language
30 points
Most common etiology of major neurocognitive disorder?
Alzheimer’s disease
Primary cognitive domains affected in Alzheimers?
Memory
Learning
Language
Found in brain of Alzheimer’s disease?
Senile plaques and neurofibrillary tangles
Only way to definitively diagnose Alzheimer’s disease
Postmortem path exam
Accumulation of what (where?) is associated with progressive brain atrophy in Alzheimer’s disease?
Extraneuronal Beta-amyloid plaques
Intraneuronal tau protein tangles
What protein mutations cause autosomal dominant Alzheimer’s diseae? This makes up 1 % of AD
Single gene mutations in either:
Amyloid precursor protein
Presenilin 1
Presenilin 2
Risk factor for early onset Alzheimer’s disease?
Having the Epsilon-4 variant of the apolipoprotein gene
Fraction of patients diagnosed with AD that are women?
2/3
Class of drugs that is associated with increased mortality in patients with dementia
Antipsychotics
2nd most common cause of major NCD?
Vascular dementia
Cognitive domains typically affected in vascular dementia small vessel disease?
*These are lacunar infarcts
Complex attention and executive functions
Antipsychotics that can be used for psychotic symptoms in Lewy Body Dementia
Quetiapine or Clozapine
Treatment of REM sleep disorder in Lewy body dementia
Melatonin or clonazepam
Core features of Lewy body dementia
Waxing and waning cognition
Visual hallucinations
Extrapyramidal signs (Parkinonism)
Suggestive features of lewy body dementia
REM sleep behavior disorder: violent movements during sleep
Pronounced antipsychotic sensitivity
Clinical manifestation of frontotemporal dementia
defecits in attention, abstraction, planning, problem solving
Behavioral variant: disinhibited verbal, pysical, or sexual behavior, lack of emotional warmth, overeating, apathy, perseveration, decline in social cognition
Language variant: Difficulties with speech and comprehension
Treatment of frontotemporal dementia?
Serotonergic meds may help reduce disinhibition, anxiety, impulsivity, etc.
Most common infectious agent known to cause cognitive impairment
HIV
*HAART improves cognition in some patients
Inheritance of Huntington Disease
Autosomal dominant
Primary cognitive domain affected in Huntington Disease
Executive function
Patient’s often aware of deteriorating mentation
Hungtington Disease
Symptom tx of Huntington Disease
Tetrabenazine
or atypical antipsychotics
Rapidly progressive cognitive decline + myoclonus
Creutzfeldt Jakob Disease
3 W’s of Normal pressure hydrocephalus
Wet=urinary incontinence
Wobbly= gait disturbance
Wacky=cognitive impairment
