cognitive disorders

Question 1

delirium: general

Answer 1

• waxing-and-waning change in level of consciousness
• caused by almost any medical d/o
• high morbidity and mortality if untreated

Question 2

delirium: epidem

Answer 2

• 10-30% of admitted medical pts

- common in elderly, ICU, postop, cancer pts

Question 3

delirium: risk factors

Answer 3

• adv age
• brain damage
• prior delirium
• alcohol dependence
• cancer
• sensory impairment, blindness
• malnutrition
• male gender

Question 4

delirium: clinical

Answer 4

MOST common: impairment in recent memory

• disorientation, usually to time/place
• language disturbances, speech changes
• perceptual disturbances, esp visual hallucinations
• sleep disturbances: SUNDOWNING (daytime drowsiness and night-time insomnia)
• disturbed psychomotor behavior
• emotional disturbances
• perseveration

Question 5

delirium: dx

Answer 5

• disturbance of consciousness w/reduced ability to focus, sustain, shift attn
• change in cognition or development of perceptual disturbance (can’t be accounted for by dementia)
• disturbance develops over short period of tie and fluctuates

Question 6

delirium: tx

Answer 6

• r/o life-threatening cause, find underlying condition
• hydration, nutrition
• 1:1, orient patient, good sleep hygiene
• Haldol for agitation
• BZOs only for DTs

Question 7

dementia: general

Answer 7

• impairment of memory and other cognitive fns WITHOUT altered consciousness
• most forms progressive, irreversible
• prevalence doubles every 5 years: 1.5% at 60 yrs, 40% at 90 yrs
• Alzheimer’s most common, vascular dementia 2nd

Question 8

dementia: dx

Answer 8

• multiple cognitive deficits manifested by BOTH: memory impairment and 1+ of: aphasia, apraxia, agnosia, decreased executive fn
• cognitive deficits must cause significant impairment and are significant decline
• do not occur only during delirium

Question 9

dementia: assoc sx

Answer 9

• delusions and hallucinations: 30%
• affective sx: 40-50%
• personality changes

Question 10

dementia: reversible causes

Answer 10

• workup CBC, electrolytes, TFTs, VDRL/RPR, B12/folate, brain CT/MRI
• hypothyroidism

Question 11

Alzheimer: epidem

Answer 11

• most common type of dementia
• women 3x > men
• 1st degree relative –> 4x risk
• Down syndrome –> increased risk

Question 12

Alzheimer: clinical

Answer 12

• gradual progressive decline in cognitive fn
• personality chg, mood swings, paranoia common
• motor and sensory sx absent until late in cours

Question 13

Alzheimer: dx

Answer 13

• clinical, dx of exclusion unless post-mortem
• genes: only 5% of cases; APOe4 gene –> homozygotes have 50-90% chance, heterozygotes 45% chance
• 20% chance overall
• postmortem: diffuse atrophy with enlarged ventricles, flattened sulci
• senile plaques and NF tangles

Question 14

Alzheimer: pathophys

Answer 14

• decrease in ACh - loss of noradrenergic neurons in basal ceruleus and decreased choline acetyltransferase
• excess of Abeta peptides (overprod, decreased clearance)

Question 15

Alzheimer: tx

Answer 15

• cholinesterase inhibs for mild-mod dz
• • tacrine, donepezil, rivastigmine, galantamine
• NMDA antagonists for mod-severe dz
• • memantine

Question 16

vascular dementia: general

Answer 16

• 2nd most common form
• microvascular dz in brain –> multiple small infarcts
• risk factors: stroke, DM, HTN, APOe4, male (2x>women)

Question 17

vascular dementia: clinical

Answer 17

• STEP-WISE deterioration
• lateralizing signs
• depression, anger, paranoia common
• frontal lobe stroke –> SCZ/BiPD/depressive sx

Question 18

vascular dementia: tx

Answer 18

• cholinesterase inhibitors
• antiHTN tx to prevent onset (?)
• symptomatic tx

Question 19

lewy body dementia: pathophys

Answer 19

• lewy bodies and lewy neurites = pathologic aggregations of alpha synuclein in brain
• mostly in basal ganglia

Question 20

lewy body dementia: clinical

Answer 20

• WAXING AND WANING cognition
• visual hallucinations: animals or people, colorful
• paranoid delusions
• parkinsonism
• SENSITIVITY TO NEUROLEPTICS
• REM sleep behavior do

Question 21

lewy body dementia: dx

Answer 21

• onset of dementia w.in 12 mos of parkinsonism sx

Question 22

lewy body dementia: tx

Answer 22

• cholinesterase inhibs (help with VH)
• psychostimulants, levodopa/carbidopa, DA agonists
• atypical neuroleptics
• clonazepam for REM do

Question 23

frontotemporal dementia

Answer 23

• diverse group of dos
• present bw ages 45-65
• approx 20-30% familial - progranulin or MAPT gene
• 4-6 years from illness to death

Question 24

FTD: clinical

Answer 24

• profound chg in personality and social conduct
• disinhibition
• echolalia, overeating, oral fixation
• lack emotional warmth, insight
• cognitive deficits in attn, executive fn
• memory, language, spatial functions PRESERVED

Question 25

FTD: pathophys

Answer 25

• marked atrophy of frontal and temporal lobes

- neuronal loss, microvacuolization, astrocytic gliosis in cortical layer II

Question 26

FTD: tx

Answer 26

• anticholinergics, antidepressants - for behavioral sx only

Question 27

HIV assoc dementia

Answer 27

• caused by neutropenia–>infx and direct viral effects
• risk factors: duration of HIV, low CD4, high VL
• clinical: rapid decline in cognition, behavior, motor; poor memory and concentration, apathy and social w/d, depression
• language PRESERVED

Question 28

HIV assoc dementia: tx

Answer 28

• HAART

- psychostimulants for fatigue and psychomotor retardation

Question 29

huntington dz: clinical

Answer 29

• onset 35-50 yrs
• progressive dementia beginning 1 year before/after chorea
• choreiform movements
• muscle hypertonicity
• depression, psychosis, alcoholism
• INCREASED SUICIDE RATE

Question 30

huntington: dx

Answer 30

• MRI: caudate atrophy, sometimes cortical atrophy

- genetic testing (CAG repeat expansion, chrom 4)

Question 31

parkinson dz: pathophys

Answer 31

• substantia nigra DA neuronal loss –> loss of DA provision to BG
• senile plaques and NF tangles, loss of choline acetyltransferase
• causes: idiopathic, traumatic, drugs, toxins, encephalitic, familial

Question 32

parkinson dz: epidem

Answer 32

• 30-40% develp dementia
• 50% have depression
• men > women

Question 33

parkinson: clinical

Answer 33

• similar to Alzheimer
• dementia rarely initial sx
• parkinsonism
• dementia EXACERBATED by antipsychotics

Question 34

creutzfeld jakob dz: general

Answer 34

• rapidly progressive, degenerative CNS dz
• prion accumulation
• older patients
• small percentage infected via corneal transplants

Question 35

CJD: clinical

Answer 35

• rapidly progressive dementia 6-12 mos after sx onset
• > 90% : MYOCLONUS
• BG and cerebellar dysfn common
• early sx: personality chg, immature behavior, paranoia
• rapid progression to stupor/coma/death

Question 36

CJD: dx

Answer 36

• pathological: spongiform chg in brain tissue
• periodic generalized sharp waves on EEG
• 2+: myoclonus, cortical blindness, ataxia, pyramidal/EPS, muscle atrophy, mutism

Question 37

normal pressure hydrocephalus

Answer 37

• potentially reversible cause of dementia
• enlarged ventricles, increased CSF pressure
• cause: idiopathic or 2/2 CSF obstruction
• Wobbly (gait disturbance), Wet (urinary incontinence), Wacky (dementia)
• tx: shunt
• dementia least likely to improve