Cognitive and Behavioural Changes in Healthy Aging Flashcards
True or False: Age-related cognitive changes are linear and uniform in the affected domains.
False
Least to most change:
1) Vocab
2) LT factual memory
3) Immediate memory
4) Delayed memory
5) Visuospatial skills
6) Executive function
7) Psychomotor speed
What are 5 RFs of dementia?
Non-modifiable:
1) Age
2) Female
3) Genetics (eg. AD Alzheimer’s in APOE gene)
4) Down’s Syndrome
5) FHx
Modifiable
6) Lower cognitive reserves
7) Less education
8) Hearing loss
9) Brain Trauma
10) HTN
11) Alcohol (>21 units/week)
12) Obesity
13) Smoking
14) Depression
15) Social isolation
16) Physical inactivity
17) Air pollution
18) DM
What are cognitive reserves?
Capacity beyond what is needed for daily functioning, so as to be able to be more resilient / adaptive to brain pathology
What is dementia?
Progressive and disabling acquired syndrome of decline in memory and other cognitive domains sufficient to affect daily functioning
- clinical diagnosis
What are 8 reversible causes of dementia?
DEMENTIA
Drugs: Anticholinergics, H2 blockers, benzos
Emotional: Depression
Metabolic: Hypothy, HyperCa
Eyes/Ears: Sensory isolation
N: NPH
Tumours/SOL
Infection: Syphilis, HIV
Anemia: B12 Deficiency, alcoholism
What are 3 irreversible causes of dementia?
1) Degenerative brain disease
- Alzheimer’s, LBD, Frontotemporal dementia, Parkinson’s, PSP, Genetic (Huntington’s, Wilson’s)
2) Vascular dementia
3) Prion diseases
How does Alzheimer’s disease present?
Progressive/gradual (8-10years on average)
4As + 1E:
1) Amnesia
2) Apraxia
3) Aphasia
4) Agnosia
5) Executive dysfunction
→ Loss of independence in ADLS
What are 2 features of Alzheimer’s on brain imaging?
1) Medial temporal lobe atrophy
2) Small hippocampal volumes
What is the #1 cause of dementia?
Alzheimer’s Disease
How does Alzheimer’s differ from other DDx of Dementia?
1) Rapidly evolving dementias
- temporal profile + labs
2) Vascular dementia
- stepwise decline + focal deficits
3) LWB
- EPS, visual hallucinations
4) Frontotemporal dementias
- behaviour, language
What is depression?
Mental disorder characterized by low mood and loss of interest
- Presents with affective, physical or cognitive symptoms
- Can become chronic or recurrent
- Leads to substantial impairments in an individual’s ability to take care of one’s everyday responsibilities
What are 4 types of minor/subsyndromal depression?
1) Minor depression
2) Recurrent brief depression
3) Dysthymia
4) Mixed anxiety/depression
(more common in F and elderly)
What are 10 RFs for depression?
Physical:
1) Diseases (e.g. CVA, thyroid, cancer)
2) Chronic medical conditions
3) Chronic Pain
4) Impairment in physical function
5) Drugs (e.g. B-blockers)
6) Sensory deprivation
Psychological:
7) Dementia
8) Anxiety
9) Substance abuse
Biological:
10) Family history
11) Past history of depression
12) Aging changes in neurotransmission
Social:
13) Loss of family and friends (bereavement)
14) Isolation
15) Loss of job
16) Loss of income
What are 3 clinical features of depression?
1) Affective (mood)
- low mood, apathy, guilt, feelings of worthlessness, suicidal ideation
2) Behavioral
- psychomotor slowing/agitation, fatigue, poor sleep, altered appetite
3) Cognitive
- poor memory/ concentration/ decision-making
What is the difference between early and late-onset depression?
Late-onset:
- by definition: after 65y/o
Others:
- Less likely to have family history of mood disorder
Higher risk of developing dementia
- Greater association with co-morbid conditions e.g. “vascular depression” in patients with hypertension, IHD and stroke
- Presentation: More emphasis on physical (somatic) and cognitive symptoms, and fewer mood symptoms
What is 3 reasons why late-onset depression is often under-diagnosed/treated?
1) Mistaken for normal aging
2) Symptoms attributed to medical illness
3) Reluctance to stigmatize patient with psychiatric diagnosis
4) Non-specific and atypical presentation
5) Overlapping symptoms with other conditions
6) Stigmatisation
Why is it so important to treat depression?
If untreated:
1) Over-investigation of somatic symptoms
2) Increased physician visits and hospitalizations
3) Decreased quality of life
4) Can aggravate certain medical conditions (e.g. IHD)
5) Increased caregiver stress
6) Increased nursing home placement
7) Risk of suicide
What is delirium?
Non-specific neuropsychiatric manifestation of a generalized disorder of cerebral metabolism and neurotransmission
- aka acute confusional state, altered mental status, organic brain syndrome, toxic/metabolic encephalopathy
Why is delirium a common atypical presentation of many illnesses?
Disease presentation depends on the organ of lowest reserve (i.e. ‘weakest link’) rather than organ of insult
E.g. Pneumonia can present as confusion in a dementia patient
What are 5 RFs and 5 precipitating factors of delirium?
RFs:
1) Dementia
2) Functional impairment
3) Comorbidities
4) Age
5) Sensory impariment
6) Alcohol (Hx of use)
Precipitating factors:
1) Major surgery
2) ICU
3) Acute illness
4) Psychoactive medications (eg. benzo)
5) Fluid/electrolyte imbalances
6) Uncontrolled pain
7) Sleep deprivation
8) Restraints/in-dwelling devides
9) Retention (urinary/constipation)
What are 5 causes of delirium?
DELIRIUMS
Drugs
Eyes/ears
Low SpO2 (eg. AMI, stroke, GI bleed)
Infection
Retention
Ictal
Underhydration/nutrition
Metabolic
SDH
What is the diagnostic criteria for delirium?
Confusion Assessment Method (CAM):
Acute onset or fluctuating course
AND
Inattention
AND
either (i) disorganised thinking or (ii) altered level of consciousness
What is the diagnostic criteria for dementia?
DSM IV:
1) Decline from baseline
2) Impact on occupation/social functioning:
Amnesia + 1 of:
- agnosia (eg. trouble identifying objects)
- aphasia (eg. word finding difficulties)
- apraxia (eg. motor function)
- executive dysfunction (eg. packing angpow, cooking, grocery shopping)
DSM V:
1) Evidence of significant cognitive decline in any:
- learning & memory
- executive function
- perceptual motor
- language
- complex attention
- social cognition
2) Interferes with independent functioning
3) Not better explained by another mental disorder
When should mental function be assessed in a patient?
Any memory or other cognitive complaint, or if suspicious for memory issues even in the absence of symptoms
Eg.
1) Geriatric syndrome presentations (eg. delirium, recurrent falls)
2) Non-compliance to medication/treatment plans
3) Medicolegal decisions (eg. making a well) if questionable competency
4) Strong FHx of dementia
What is a cause of a FN in an AMT?
Ceiling effect of high education level (eg. cognitive reserves)
What are 3 causes of FP in an AMT?
1) Language barriers
2) Hearing impairment
3) Speech impairments
What are 3 examples of brief mental status tests?
1) Abbreviated mental test (AMT)
2) Chinese Mini Mental State Examination (CMMSE)
3) Montreal Cognitive Assessment (MoCA)
4) Elderly Cognitive Assessment Questionnaire (ECAQ)
What are the cutoffs for an AMT?
Unadjusted: <8
> 6years education: <9
<6 years education: <7
True or false:
Acute confusion is always delirium until proven otherwise.
True
Why is it important to identify delirium?
1) Prototypical geriatric symptoms
- medical emergency
2) Independent RF for poor outcomes
3) Common
4) Potentially reversible and preventable
True or false:
Dementia is a normal part of aging.
False
How can geriatric depression be screened for?
GDS-15 (aka GDS-4, GDS-5)
How are dementia, delirium and depression differentiated?
Onset:
Dementia: gradual
Delirium abrupt
Course:
Dementia: progressive
Delirium: worse in pm
Depression: worse in am
Attention:
Dementia: normal
Delirium: impaired
Perception:
Delirium: impaired
Dementia/depression: normal
Psychomotor behaviour:
Dementia: normal/loss of coordination
Delirium: very active/unusually quiet and still
Depression: retardation/agitation
