Cognitive Disorders Flashcards
3 causes of a disorientated patitent
Amnesia
Dementia
Delirium
Cognition
ability to acquire new information and understand it
Impaired cognition AKA
Disorientation
Orientation is defined as
knowledge of person, time and place
Causes of disorientation
Fever/Infection
Alcohol/drugs
Hypoglycaemia
Electrolyte Abnormalities
Delirium
Dementia
Amnesia is defined as
loss of memory
What is amnesia often caused by?
CNS injury
Types of amnesia
Retrograde
Anterograde
Dissociative
Retrograde amnesia
Loss of memories in the past
Retained ability to make new memories
E.g. patient wakes up post-concussion and doesn’t remember his close ones
Anterograde amnesia
Inability to make new memories
Remembers the past
E.g. patient spends 5 days at the hospital post-concussion but forgets the previous day
Dissociative amnesia
Special form not caused by CNS injury
Usually as a result of psychological trauma/stress
Inability to remember autobiographical info
What type of amnesia leads to a loss of past memories, but retains the ability to make new memories?
Retrograde
What type of amnesia leads to an inability to make new memories, but remembers the past?
Anterograde
What type of amnesia is NOT caused by CNS injury? What is it usually a result of?
Dissociative, usually aa result of psychological trauma/stress
What type of amnesia results in an inability to remember autobiographical info?
Dissociative amnesia
What can severe dissociative amnesia lead to?
Dissociative fugue
NB: Dissociative fugue isa symptom where a person with memory loss travels or wanders. That leaves the person in an unfamiliar setting with no memory of how they got there. This symptom usually happens with conditions caused by severe trauma.
What causes of amnesia are associated with vitamin B1 (Thiamine) deficiency and acoholism?
Wernicke-Korsakoff
Triad of Wernicke
Confusion, Ataxia and Ophthalmoplegia
Treatment of Wernicke
B1 infusion
Difference between wernicke and korsakoff
Wernicke causes acute encephalopathy
Korsakoff is a permanent neurologic condition
Korsakoff is ALWAYS preceded by Wernicke
Features of Korsakoff
Triad of Wernicke - Confusion, ataxia and opthalmoplegia
+ amnesia (anterograde>retrograde), confabulation (making things up) and personality changes
What type of amnesia is more common in korsakoff?
Anterograde
What is confabulation?
brain makes up memories to fill in things that their amnesia has caused them to forget
Which of Wernicke-Korsakoff is reversible?
Wernicke
What is dementia?
Chronic progressive decline in mental state
Is dementia reversible?
No
Do you get LOC with dementia?
No
Causes of dementia
Alzheimer’s (60%)
Vascular dementia (20%)
Lewy Body (HaLEWYcinations)
Rare: Pick’s disease, Creutzfeldts-Jakobs, HIV, vitamin deficiencies, Wilson’s
Pseudodementia
Most common cause of dementia
Alzheimer’
2nd most common cause of dementia
Vascular
Dementias in order of prevalence
Alzheimer’s disease (70% dementia)
Vascular Dementia (VD)
Lewy Body Dementia (DLB)
What part of brain is affected in Alzheimer’s first?
Hippocampus
Which brain regions are predominantly involved in Alzheimer’s?
Cortex and hippocampus
NOTE: Hippocampus affected first
What proteins are involved in Alzheimer’s?
Amyloid, Tau
Biggest risk factor for Alzheimer’s
Increasing age
How does Alzheimer’s present?
THINK: 4 A’s
Amnesia - Recent memories lost first; disorientation occurs early
Aphasia - Aphasia in finding correct words (Broca’s), speech muddled/disjointed
Agnosia - Typically “Visual” (i.e. prosopagnosia – recognising faces)
Apraxia - Typically “Dressing” (skilled tasks, despite normal motor functioning)
Which memories are lost first in Alzheimer’s?
Recent memories lost first, disorientation occurs early
What region of the brain causes the aphasia in Alzheimer’s?
Broca’s –> aphasia in finding correct words
Aphasia in finding correct words
Broca’s area affected
What type of agnosia is typically seen in Alzheimer’s?
“Visual” (i.e. prosopagnosia – recognising faces)
What is prospagnosia? What is it seen in?
Inability to recognise faces, seen in Alzheimer’s
What type of cognitive deterioration is seen in Alzheimer’s?
Gradual
What condition is Alzheimer’s linked HEAVILY with?
Depression
Table showing common dementia pathologies and how to differentiate them
What type of cognitive deterioration is seen in vascular dementia?
Stepwise
NOTE: Gradual deterioration seen in Alzheimer’s
RFs for vascular dementia
CVD Hx or RF
Features of Lewy Body Dementia
Fluctuating confusion with lucid intervals
Visual hallucinations – often small people/animals
Parkinsonism
What type of hallucinations are seen in lewy body dementia?
Visual hallucinations – often small people/animals
Which type of dementia presents with parkinsonism?
lewy body dementia
What is seen in frontotemporal dementia?
Change in behaviour and personality
Frontotemporal dementia AKA
Pick’s Disease
How to differentiation Lewy body and Pick’s disease?
Visual hallucination –> lewy body
Auditory hallucination –> Pick’s disease (frontotemporal dementia)
What vitamin deficiency can cause dementia?
B12
What autosomal recessive GI condition can cause dementia?
Wilson’s: kaiser’-Fleischer rings + dementia
What is pseudodementia?
reversible dementia that occurs secondary to severe depression –> treat depression and will treat dementia
How to treat pseudodementia?
Treat depression and dementia will resolve
What bedside tests can be done to investigate for dementia?
AMTS - <7 indicates cognitive impairment, MMSE, MOCA
NOTE: MoCA –> Montreal Cognitive Assessment
What Bloods can be done to test for dementia?
FBC
U&Es and dipstick (infection, diabetes)
TFTs (hypothyroid → cognitive decline)
LFTs (Korsakoff’s)
HbA1c (diabetes)
Vitamin B12 and folate, Calcium,
IMPORTANT STI TO EXCLUDE IF PRESENTING WITH DEMENTIA WITH RISK FACTORS
Syphillis –> neruosyphillis can cause dementiaW
What imaging/further tests may be done for dementia?
Alzheimers - MRI; check for grey matter atrophy, wide ventricles,
Vascular - ECG, CT/MRI
Memory Assessment Clinic - Risk assess patient and conduct MMSE for cognition assessment
What may be seen on MRI in Alzheimer’s?
check for grey matter atrophy, wide ventricles
Can dementia be diagnosed in primary care? Where do they need assessment?
NO, NEED ASSESSMENT IN A MEMORY ASSESSMENT CLINIC
Biological Management of Alzheimer’s
1st line: Anticholinesterases - Donezapil, Galantamine, Rivastigmine (THINK: Dementia Got Real)
2nd line: NDMA (glutamate receptor) antagonist – Memantine
What are the 1st line medication for Alzheimer’s? Give examples
Anticholinesterases - Donezapil, Galantamine, Rivastigmine (Dementia Got Real)
Besides Alzheimer’s, what else can anticholinesterases be used for? Give examples of Acetycholinesterases
Used for mild alzheimers, lewy body and parkinsons dementia
Donezapil, Galantamine, Rivastigmine (Dementia Got Real)
SEs of acetylcholinesterases
GI effects (N+V, diarrhoea, sweating), muscle spasm, bradycardia, miosis
NOTE: Used for mild alzheimers, lewy body and parkinsons dementia
2nd line management for Alzheimer’s, when is it used?
NDMA (glutamate receptor) antagonist – Memantine
Used for severe Alzheimers, usually for behavioural and psych symptoms or if they’re resistant to acetylcholinesterases
PACES: Psycho/Social management for Alzheimer’s
Psycho
Structural group cognition stimulation sessions, group reminiscence therapy, validation therapy
CHARITIES TO HELP WITH CARER SUPPORT (dementia UK uses admiral nurses)
Mental health issues can arise due to dementia dx so provide appropriate aid and sign posting here.
Social
Optimise current health
Identify future wishes and discuss LPA, advanced directives
Care package involvement
Identify any other social support measures (meal support, ADL support, day centre availability, alt accom)
Orient the patient (e.g. visible clocks and calendars)
Safety measures (e.g. changing gas to electricity, door mat buzzers).
Follow up every 6 months with dr and named care manager
PACES: Useful charity for dementia
Dementia UK
PACES: Ways to orient patient with dementia
visible clocks and calendars
PACES: Safety measures for patients with dementia
changing gas to electricity, door mat buzzers
How often is follow up needed in Alzheimer’s? Who by?
Follow up every 6 months with dr and named care manager
Difference between delirium and depresssion
Delirum is reversible, Depression is not
Features of Delirum
Loss of focus and attention
Disorganized thinking
Hallucinations (usually visual)
Sleep-wake disturbance i.e. up at night, sleeps during the day (classic for inpatients)
What type of hallucinations are typically seen in delirium?
Visual
Causes of delirium
Infection is the classic one
Alcohol use or withdrawal
Certain drugs: HIGH YIELD, especially in elder population e.g. anticholinergics, benzodiazepines, antihistamines, antidepressants
MOST COMMON CAUSE OF DELIRIUM IN ELDERLY PATIENTS
UTI
What drugs can cause delirium? Why?
anticholinergics, benzodiazepines, antihistamines, antidepressants
NOTE: Can cross BBB
Difference on EEG between delirium and dementia
EEG is normal in dementia, abnormal in delirium
Management of delirium
Fix the underlying cause
Abx for infection
Meds for withdrawal
Treat pain
Hydrate, calm and quiet environment
Haloperidol (Vitamin H) if everything has failed
What medication can be used in delirium if all else fails?
Haloperidol
What must be done before giving haloperidol in an agitated patient with delirium?
try and get patient to calm down, isolate them, de-escalate them
Which lobes in the brain are most affected by Alzheimer’s?
Temporal
Medical management of Lewy body dementia
Donepezil or rivastigmine should be given to patients with mild- to- moderate dementia with Lewy bodies.
Galantamine can be considered only if treatment with both donepezil or rivastigmine is not tolerated. Memantine can be considered if acetylcholinesterase inhibitors are contra-indicated or not tolerated.
What are lewy bodies made of?
alpha-synuclein protein deposits in the brainstem and neocortex
Where in the brainstem is predominantly affected in lewy body dementia?
brainstem and neocortex
What do the lewy body plaques lead to reduced levels of in the brain?
Alpha-synuclein deposits (Lewy Body) lead to reduced levels of acetylcholine and dopamine in the brain.
Which lobes are affected in Pick’s Disease
Involves atrophy of the frontal and temporal lobes, without features of Alzheimer’s.
What are pick’s bodies in frontotemporal dementia?
Neurones in this area are abnormal and swollen: Pick’s bodies
What protein is affected in Pick’s disease?
Concerns a mutation in the tau gene of the microtubules.
Subtypes of frontotemporal dementia
Frontal type presents with emotional and behavioural changes. This can include criminal or sexual behaviours.
Progressive non-fluent aphasia presents with a progressive difficulty in language. This indicates a dominant peri-sylvian atrophy.
Semantic dementia is a loss of the meaning of words. It is a fluent aphasia, suggesting damage to the dominant temporal lobe.
Sub-type of Pick’s disease that presents with emotional and behavioural changes
Frontal type presents with emotional and behavioural changes. This can include criminal or sexual behaviours.
Sub-type of Pick’s disease that presents with progressive difficulty in language
Progressive non-fluent aphasia presents with a progressive difficulty in language. This indicates a dominant peri-sylvian atrophy.
Sub-type of Pick’s disease that leads to a loss of the meaning of words
Semantic dementia is a loss of the meaning of words. It is a fluent aphasia, suggesting damage to the dominant temporal lobe.
Management of Pick’s disease
No reccomended medical management –> mainly supportive
What is charles-bonnet syndrome characterised by?
persistent or recurrent complex hallucinations (usually visual or auditory), occurring in clear consciousness.
Is consciousness altered in Charles Bonnet syndrome?
No, occurs in a clear consciousness
What is there a background of in Charles Bonnet syndrome?
background of visual impairment:
Age related macular degeneration
Glaucoma
Cataracts
What must charles bonnet syndrome occur in the absence of?
any other significant neuropsychiatric disturbance
Table showing difference between normal and abnormal grief reaction
Features of a normal grief reacftion
Follows cycle: denial, anger, depression, bargaining, acceptance
Can last up to 2 years but diagnosed generally if lasting >6months
Features of an abnormal grief reaction
Delayed onset of grief (e.g. after 1 year)
Greater intensity
Not ‘progressing’ through cycle of grief so ‘stuck’ in grief
Suicidal/psychotic symptoms
More likely if sudden death/problematic relationship/lack of support
What are pseudohallucinations? Who are they most often seen in?
false sensory perception in the absence of external stimuli when the affected is aware that they are hallucinating. This phenomenon is common in grieving people.W
What is adjustment disorder? When are they often seeen in response to?
Subjective distress <6months, usually interfering with social functioning, arising in the period of adaption (1month) to a significant life change e.g. divorce, death, unemployment, moving
Phenomenons that can occur in grief reactions
Pseudohallucinations
Adjustment disorder
