Cognitive Impairment Flashcards by Linda Chen

define cognition

the operation of the mind by which we become aware of objects of thought or perception- includes all aspects of perceiving, thinking, and remembering

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define delirium

a clinical state characterized by fluctuating disturbance in cognition, mood, attention, arousal, and self awareness, which arises acutely either without prior intellectual impairment or superimposed on chronic intellectual impairment

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define dementia

a deterioration of intellectual function and other cognitive skills, leading to a decline in the ability to perform ADL

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what is the msot common type of dementia

alzheimer’s

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dementia impacts
1. memory
2. function
3. thinking
4. al of the above and more

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what is the new term in the DSM used for cognitive impairment

neurocognitive disorder

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what is pseudodementia

dementia is mimicked by functional psychiatric illness

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Alzheimer’s has
1. increased worldwide
2. only increased in wealthier countries
3. more effect on men
4. all of the above

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what are some medications that directly cause cognitive impairment`

Anticholinergics
Psychotropic: BZDs, neuroleptics
Ethanol
Opioids

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what are some medications that indirectly cause cognitive impairment

Diuretics (ex- electrolyte abnormalities)- most common
Withdrawal of medications

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what are the 5As of cognitive changes

aphasia
apraxia
agnosia
abstraction
ADL

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difficulty finding the right word is called

aphasia

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not having purposeful movement patterns is called

apraxia

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the inability to recognize and identify objects or people is called

agnosia

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difficulty in realizing and formulating a plan to achieve goals is called

abstraction (lack of)

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describe 2 cognitive screening tests

clock drawing test
MMSE
MoCA
SLUMS, RUDAS
watermelon seeds

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Alzheimer’s is a progressive disease of the brain of _____ etiology characterized by diffuse atrophy throughout the _______ with distinct histopathologic changes termed ________ and ________

unknown
cerebral cortex
senile plaques
neurofibrillary tangles

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name the 6 etiologies of alzheimers

genetics- chromosomes 1, 14, 21- ApoE presence
deposition of foreign bodies
dysreg of NT
inflam
environmental agents
vascular RFs

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what are some modifiable RFs for alzheimers

Smoking
Diabetes
Diet - high trans saturated fats
Obesity- midlife vs late life
Hyperlipidemia
hypertension

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early life RF for alzheimers is

less education

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name 3 ways to decrease risk for alzheimers

Nutrition- fruits and veg, lower saturated fats
Physical exercise
Hearing- address and assess sx
Sleep- addressing OSA< avoiding deprivation
Cognitive training, stimulation- individual or group based
Social engagement and education
Poverty reduction, social engagement
Early life educational attainment
Frailty- manage early
Medications- avoid exposure to anticholinergics
Address modifiable health conditions

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name 3 things that are protective against alzheimers

Periodic and low amongst of alcohol (binge drinking increases risk)
Cognitive reserve- higher education
Physical activity/ exercise
Other
Diet (mediterranean)- low red meat, olive oil, fish, etc
Multilingualism
Marriage
Social activity/ engagement

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describe the characteristics of early alzheimers

Insight retained
Word loss
Minor forgetfulness/ decreased STM

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describe characteristics of intermediate stage AZD

Loss of insight
Behavioral disturbances

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describe the characteristics of late stage AZH

Nonresponsive Loss of language

what is retrogenesis

forgets memories in reverse Forgets retirement → children → marriage → spouses name → etc

what is the prognosis of alzheimer's

up to 20yrs

how are alzheimer's diagnosis made

interview of family/caregivers, neuro and physical exam, CT/MRI head, neuropsychological testing, CXR, ECG, EEG, blood work (CBC, electrolytes, Ca, Mg, etc), review of medications, assessment of substance use

research criteria of AD is

focus on biomarkers and PET

what is a definite AD dx

All criteria for probable AD + histopathologic evidence (brain sample)

what is a probable AD dx

Prog impared memory, cognitive function, multiple domains affected, onset >40yrs No biopsy taken- no NFT or plaques to confirm, but everything else consistent

what is a possible AD dx

Atypical, gradually progressive decline, one domain affected

what is a major neurodegenerative disorder

Evidence of cognitive decline from previous level of performance (ex- used to be a chief and now can’t cook an egg) Interferes with independence in everyday activity Insidious onset and gradual progression of impairment

T or F: there is no cure for AD

what are 2 sx tx for AD

Cholinesterase inhibitors memantine

what are 2 potentially disease modifying AD tx

aducanumab, lecabenab

name the 3 ACh increasing medicatiosn

donepezil rivastigmine galantamine

which ACh med is for mild-severe AD

donepezil

donepezil elimination in the

liver

SEs of ACh increasing meds include

N/V, bradycardia, insomnia, muscle cramps, fatigue, urgency, asthma exacerbation

CIs for ACh meds (6)

active PUD anorexia bradycardia asthma QT prolongation seizures

how effective are AChE-i

med- effect of ~1 point difference which is not v detectable

expectations for AChEi in AD

stabilization and maintenance of cog fxn over time stabilize decline improve caregiver burden

how long should AChEi be trialed

3-6mths

is one AChEi superior to another

when should AChEi be dosed?

Better adherence in morning, but if GI effects or dizziness = PM to sleep through the nausea and SEs + don’t avoid eating all day resulting in more weight loss

T or F: AChEi requires titration

T- initial dose will be subtherapeutic

when is washout necessary for AChEi

if SEs (washout for <7d) and switching to another drug

is you want to switch from donepezil to rivastigmine and pt has no SEs, is washout necessary?

no- just switch to eq dose immediately

what is the bottom line on AChEi effectiveness

Benefit is modest, early initiation is beneficial, SEs often poorly tolerated by older adults

memantine is a

NMDA receptor antagonist

memantine MOA

prevents calcium influx, dysregulation, and cell death from ↑ GLU of AD

can memantine be used with CI

yes- different MOA

memantine indications

Mod-severe AD (can use this after pt progresses on CI) Monotx or as adjunct with CI

mementine is eliminated in the _______ and is _____ dependent

urine pH dependent

SEs of mementine

In first mth, pts may actually have increased confusion, that usually resolves and pt improves- generally well tolerated Increased BP, corneal ADD

which med should AD pts with asthma and bradycardia use

mementine

memantine 20mg saw slight improvements in AD pts in

cog fxn ADL behaviour and mood

what may be used instead of AP in AD pts to manage behaviours

memantine

what is mild cognitive impairment

predementia- not necessarily progressing day to day activities not yet impacted

how should predementia be treated

nonpharm only- exercise, cog training, planning, smoking cessation AChEi harmful

what is the most common type of nonAD dementia

vascular dementia

vascular dementia onset is

sudden or gradual

VaD progression, neuro findings, and memory

progression = slow and stepwise neuro = evidence of focal deficits memory = mildly affected

vascular dementia executive function impairment is

early and severe

vascular dementia type is _________ while AD is ________

subcortical cortical

vascular dementia effect on gait vs AD

vasc = disturbed early AD = normal

describe Lewy body dementia, parkinson disease dementia

If lewy bodies seen first then movement disorder = Lewy body dementia If movement issues seen first, then lewy bodies = PD dementia Brains look the same after few years, even if different start

pathophys of If lewy bodies dementia/ PK dementia

lewy bodies deposited = disruption in substantia nigra + cerebral cortex = Neurotransmitter alterations

how to differentiate between lewy body dementia and PK

duration of PK in relation to dementia

3 core features of Lewy body dementia, parkinson disease dementia

fluctuations in cognition, visual hallucinations, parkinsonism

how to treat Lewy body dementia, parkinson disease dementia

rivastigmine, other CIs

Lewy body dementia, parkinson disease dementia is sensitive to ___________ and should be avoided

neuroleptics

what is frontal dementia

just the frontal lobe affected = personality, emotions, itneractions changed

which has earlier onset: frontal or lewy/ PK dementia

frontal

the main pathophys of frontal dementia is

deficits in 5HT

disinhibition and personality changes describes 1. AD 2. lewy body dementia 3. vascular dementia 4. frontal dementia

how to treat frontal dementia (choose all that apply) 1. AChEi 2. memantine 3. caregiver support 4. SSRIs

SSRIs + caregiver support

5 classifications of BPSD

depression agitation aggression apathy psychosis

how should BPSD be targeted

ABCs to find trigger for behaviour, then change environment

what is the only pharmacotx for BPSD

risperidone PRN trazodone and lorazepam fro agitation