Alzheimers, Parkinsons, Stroke, And Depression Flashcards
Dementia
Evidence of substantial cognitive decline from a previous level of performance in one or more domains based on the concerns of the individual, a knowledgeable informant, or the clinician; and a decline in neuro cognitive performance, typically involving test performance in the range of two or more standard deviations below appropriate norms on formal testing
- the deficits are significant enough to interfere with independence
- a diagnosis of dementia should not be made during the course of a delirium
- Alzheimer’s 50-60% of all dementia
Cognitive domains
- complex attention
- executive function
- learning and memory
- language
- perceptual motor function
- social cognition
Complex attention
includes sustained attention, divided attention, selective attention and information processing speed
Executive function
Planning, decision making, working memory, responding to feedback, inhibition and mental flexibility
Learning and memory
Free recall, cued recall, recognition memory, semantic and autobiographical long term memory and implicit learning
Language
Object naming, word finding, fluency, grammar and syntax, and receptive language
Perceptual motor function
Visual perception, visuoconstructional reasoning and perceptual motor coordination
Social cognition
Recognition of emotions, theory of mind, and insight
Non alzheimers dementias
Lewy body dementia Vascular Picks disease (frontotemproal dementia) Subcortical dementia Metabolic Drug induced
Alzheimer’s disease
- neurofibrillary tangles and plaques
- tangles are intracellular and result of abnormal phosphorylation of protein tau
- plaques are extracellular and composed of beta amyloid
- ACH production is reduced
- the only sure way to Dx by pathology is after death
- genetically related begins at age 40, <5%
- around 10% of adutls over 65 and over have dementia
Genetics of Alzheimer’s
- Alzheimer’s 1-amyloid precursors protein <5%. Found on chromosome 21
- Alzheimer’s 2- apolipoprotein E4
- alzheimers 3-presenilin 1-effect most families with early onset type
- Alzheimer’s 4-presenlinin2 - <2%
- most cases are sporadic-nogenetic pattern
Alzheimer’s (DSM-5)
Probable if APP ,PS1 or PS2 was identified, or if the individual has clear evidence of progressive decline without extended plateaus in memory and learning and in at least one of the other five cognitive domains that is confirmed by serial neuropsychological testing
- cause impairment of social or occupational functioning
- DSM-5 does not currently include biomarker testing
Alzheimer’s is characterized by
Gradual cognitive decline
Alzheimer’s is not characterized by
Substances
Other causes of dementia
Alzheimer’s does not occur during
Delirium
Also not accounted for by depression
Clinical work up for Alzheimer’s
MRI or CT PET scan SPECT scan fMRI Bilateral depression temporal bone Cerebral atrophy
Manifestations of Alzheimer’s
- calculation ability
- recall
- aphasia, apraxia, agnosia
- apathy, depression
- delusions-tend to be auditory early on
- behavior problems
Visual problems in Alzheimer’s
- construction disturbance
- visual perceptual disturbance
- visual spatial problems
- environmental orientation problem
- object recognition
- face recognition
Constructual apraxia
Copying
Block assembly
Clock drawing
Visual perceptual and Alzheimer’s
Figure ground confusion
Visual closure
Visual completion
Spatial agnosia and alzhmeirs
Balint’s syndrome
Balint’s syndrome
- oculomotor apraxia-cant look into the peripheral field
- optic ataxi-visually guided movements
- simultagnosia-cannot perceive two objects at once
Visual agnosia
- Inability to name objects by sight
- Apperceptive- more severe
- associative-can make a connection by other modality
Environmental orientation and alzheimers
Loses way
Wandering behavior
Inability to read map
Prosopagnosia and alzheimers
- I abiltiy to recognize faces
- mirror sign
- capgras syndrome
Eye movement abnormalities and alzheimers
- saccadic pursuits
- increased saccadic latency
- hypometric saccades
- fixation instability
- anticipatory saccades
Basic vision functions and alzheimers
- contrast sensitivity (mixed research)
- field loss (mixed research)
- flash VEP (increased latency, reduced mag)
- reduced stereo (mixed research)
- magnocellular pathway (preponderance of evidence suggest problem here)
- none are reliably able to distinguish normal vs mild cognitive impairment vs Alzheimer’s disease
OD role and alzheimers
- screen for dementia
- understand visual symptoms
- counsel family
Screening for dementia
- folstein mini mental state exam
- short blessed
- Mattis
Reasons for hope in Alzheimer’s disease
- 12/15 lipoxygenase
- pluripotent stem cells to generate neurons
- bexarotene
- transcranial stimulation
- epothilone D
- bapineuzumab-failed phase 3
- aducanumab-in phase 3, done in 20/20
Parkinson’s disease
- depletion of dopamine at the basal ganglia
- increase after age 60, 1.5mill older adults have it
- tremor at rest
- cogwheel rigidity
- akinesia
- bradykinesia
- gait impairment
- stooped posture
Signs of Parkinson’s
Loss of motivation Depression Tip of the tongue thought Perseveration Sleep disturbance Lewy body dementia
Parkinson’s from the result of too many blows to the head
Parkinson’s pugilistica
Other problems with Parkinson’s
- seborrheic dermatitis
- orthostatic hypotension
- drooling
- constipation
- UTI
Parkinson’s eye signs
- blepharospasm
- decreased blink rate
- cogwheel saccades
- saccadic pursuits
- gaze palsy
- convergence paresis
- oculogyric crisis
- blepharitis
Parietal-occipital syndromes of Parkinson’s
- constructional apraxia
- visual agnosia
- hemispatial neglect
- achromatopsia (rare)
- reduced stereo (rare)
Visual spatial neglect
- right hemisphere
- 50% in acute CVA involving visual pathway
- 1-25% persist
- poor rehab prognosis
Eye movement abnormalities and Parkinson’s
Gaze palsy=frontal lobe
Saccadic pursuits
Pursuit abnormalities
Neglect vs field
- most common in right brain damage
- VF occur with or without neglect
- severe or subtle
Testing
- line bisection
- line cancellation
- letter/star cancellation
Rehab for Parkinson’s
- hemispatial patching
- visual scanning
- biofeedback
- repetitive therapy
Depression
- 6-9% major depression
- 15% persistent depression
- 1/3 of older adults have depressive symptoms
- more common among institutionalized population than general ambulatory population
- suicide rate highest among older white males
Symptoms of depression
Depressed mood with 3 of
- weight loss or gain
- insomnia
- psychomotor retardation
- feeling of worthlessness
- difficulty concentrating
- suicidal ideation
Visual effects of depression
- functional overlay common
- unexplained vision loss
- nondescriptive facial pain
OD role in depression
- screen for it: geriatric depression scale-clinical in older adults, NIMH screener, CES-D used in studies
- recognize “visual” from depression
- Bite the Bullet, make the referral
- if have concurrent functional vision loss, can use that to normalize need for psychologist/psychiatrist
