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Psychiatry - Crash Course > Cognitive impairment > Flashcards

Cognitive impairment Flashcards

1
Q

Explicit memory

A

Declarative memory - all stored material of which the individual is consciously aware

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2
Q

Implicit memory

A

Procedural memory - all material that is stored without the individual’s conscious awareness e.g. the ability to speak a language or ride a bike

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3
Q

Semantic memory

A

Knowledge of facts e.g. world capitals

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4
Q

Episodic memory

A

Knowledge of autobiographical events

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5
Q

Dysphasia/aphasia

A

Loss of language abilities despite intact sensory and motor function

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6
Q

Receptive dysphasia

A

Difficulty in understanding commands or other words

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7
Q

Expressive dysphasia

A

Difficulty using words with the correct meaning

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8
Q

Nominal dysphasia

A

Not being able to name items despite knowing what they are - subtype of expressive dysphasia

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9
Q

Dyspraxia/apraxia

A

Loss of ability to carry out skilled motor movements despite intact motor function

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10
Q

Dysgnosia/agnosia

A

Loss of ability to interpret sensory information despite intact sensory organ function e.g. not able to recognise faces as familiar

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11
Q

Amnesia

A

Loss of ability to learn or recall new information, or to retrieve memories that have previously been stored

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12
Q

Executive function

A

Ability to plan and sequence complex activities or to manipulate abstract information (e.g. to plan the preparation of a meal)

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13
Q

Anterograde amnesia

A

Occurs after an amnesia-causing event; the patient is unable to store new memories from the event onwards, but ability to retrieve memories from before is unimpaired

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14
Q

What part of the brain is usually damaged, resulting in anterograde amnesia?

A

Medial temporal lobes, especially the hippocampal formation

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15
Q

Retrograde amnesia

A

Being unable to retrieve memories stored before an amnesia-causing event, although able to store new memories from the event onwards

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16
Q

What part of the brain is usually damaged, resulting in retrograde amnesia?

A

Frontal or temporal cortex

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17
Q

Risk factors for delirium (4)

A
  • An abnormal brain (e.g. dementia or previous serious head injury)
  • Age
  • Polypharmacy
  • Sensory impairment
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18
Q

Delirium

A

Acute and fluctuating cognitive impairment +/- psychotic features

High mortality - 1/3rd due during the presentation

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19
Q

Causes of delirium (systemic illnesses)

A

Infections and sepsis

Anoxia:

  • Respiratory failure
  • Heart failure
  • MI
Metabolic and endocrine:
-Electrolyte disturbances
-Uraemia
-Hepatic encephalopathy
-Porphyria
-Hypoglycaemia
-Hyper/hypothyroidism
-Hyper/hypoparathyroidism
-Cushings/Addisons
Hypopituitarism

Nutritional:

  • Thiamine deficiency (Wernicke’s encephalopathy)
  • Vitamin B12 deficiency
  • Folic acid deficiency
  • Niacin deficiency (pellagra)
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20
Q

Causes of delirium (drugs or their discontinuation)

A

Prescribed:

  • Anticholinergics
  • Benzodiazepines
  • Opiates
  • Antiparkinsonian drugs
  • Steroids

Recreational:

  • Alcohol withdrawal
  • Opiates
  • Cannabis
  • Amphetamines

Poisons:

  • Heavy metals (lead, mercury, manganese)
  • Carbon monoxide
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21
Q

Causes of delirium (intracranial)

A

Space-occupying lesions:
-Tumours, cysts, abscesses, haematomas

Head injury (especially concussion)

Infection:

  • Meningitis
  • Encephalitis

Epilepsy

Cerebrovascular disorders:

  • TIA
  • Cerebral thrombosis or embolism
  • Intracerebral or subarachnoid haemorrhage
  • Hypertensive encephalopathy
  • Vasculitis
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22
Q

Impaired cognitive function in delirium

A
  • Short-term and recent memory impairment with relative preservation of remote memory.
  • Almost always disorientated to time, often to place, rarely to person
  • Language abnormalities: rambling, incoherent speech and receptive dysphasia
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23
Q

Perceptual and thought disturbance in delirium

A
  • Misinterpretations, illusions and hallucinations (especially visual)
  • Transient persecutory delusions and delusions of misidentification
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24
Q

Sleep-wake cycle disturbance in delirium

A

Range from daytime drowsiness and night-time hyperactivity, to a complete reversal of the normal cycle

Nightmares may continue as hallucinations after awakening

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25
Q

Mood disturbance in delirium

A

Depression, euphoria, anxiety, anger, fear and apathy are all common

26
Q

Dementia

A

A syndrome of acquired progressive generalised cognitive impairment associated with functional decline (difficulties with ADL). Consciousness level is normal

27
Q

How long do symptoms need to be present before a diagnosis of dementia can be made?

A

6 months

28
Q

Basic ADLs

A

Self-care tasks such as eating, dressing, washing, toileting, continence and mobility

29
Q

Instrumental ADLS

A

Tasks which are not crucial to life but allow someone to live independently e.g. cooking, shopping and housework

30
Q

BPSD

A

Behavioural and psychological symptoms of dementia - non-cognitive symptoms associated with dementia

  • Behavioural symptoms are common: pacing, shouting, sexual disinhibition, aggression and apathy
  • Depression and anxiety in up to 50%
  • Delusions (especially persecutory) in up to 40%
  • Hallucinations in 30% (visual most common)
31
Q

What percentage of patients with dementia will experience seizures?

A 
Between 10-20%
Primitive reflexes (e.g. grasp, snout, suck), as well as myoclonic jerks
32
Q

Early onset dementia

A

Beginning before 65yrs old

33
Q

Causes of dementia other than neurodegenerative or cerebrovascular disease

A

Space-occupying lesions
• Tumours, cysts, abscesses, haematomas

Trauma
• Head injury
• Punch-drunk syndrome (dementia pugilistica)

Infection
• Creutzfeldt–Jakob disease (including ‘new variant CJD’)
• HIV-related dementia
• Neurosyphilis
• Viral encephalitis
• Chronic bacterial and fungal meningitides

Metabolic and endocrine
• Chronic uraemia (also dialysis dementia)
• Liver failure
• Wilson’s disease
• Hyper- and hypothyroidism
• Hyper- and hypoparathyroidism
• Cushing’s syndrome and Addison’s disease

Nutritional
• Thiamine, vitamin B12, folic acid or niacin deficiency (pellagra)

Drugs and toxins
• Alcohol, benzodiazepines, barbiturates, solvents

Chronic hypoxia

Inflammatory disorders
• Multiple sclerosis
• Systemic lupus erythematosus and other collagen
vascular diseases

Normal pressure hydrocephalus

34
Q

Alzheimer’s disease

A

62%
Gradual onset with progressive cognitive decline
Early memory loss

35
Q

Vascular dementia

A

17%
Focal neurological signs and symptoms
Evidence of cerebrovascular disease or stroke
May be uneven or stepwise deterioration in cognitive function

36
Q

Mixed dementia

A

10%

Features of both Alzheimer’s disease and vascular dementia

37
Q

Lewy body dementia

A

4%
Day-to-day (or shorter) fluctuations in cognitive performance
Recurrent visual hallucinations
Motor signs of parkinsonism (rigidity, bradykinesia, tremor) (not drug-induced)
Recurrent falls and syncope
Transient disturbances of consciousness
Extreme sensitivity to antipsychotics (induces parkinsonism)

38
Q

Frontotemporal dementia

A

2% (includes Pick’s disease)
Early decline in social and personal conduct (disinhibition, tactlessness)
Early emotional blunting
Attenuated speech output, echolalia, perseveration, mutism
Early loss of insight
Relative sparing of other cognitive functions

39
Q

Parkinson’s disease with dementia

A

2%
Diagnosis of Parkinson’s disease (motor symptoms prior to cognitive symptoms)
Dementia features very similar to those of Lewy body dementia

40
Q

Ddx for cognitive impairment

A 
Delirium
Dementia
Mild cognitive impairment
Subjective cognitive impairment
Stable cognitive impairment post insult, e.g. stroke, hypoxic brain injury, traumatic brain injury Depression (‘pseudodementia’)
Psychotic disorders
Mood disorders
Intellectual disability
Dissociative disorders
Factitious disorder and malingering
Amnesic syndrome
41
Q

Mild cognitive impairment

A

Objective cognitive impairment (confirmed with a standardised test)
Around 10-15% of patient convert to dementia each year, but in some cases impairment remains stable, or even improves

42
Q

Subjective cognitive impairment

A

When a patient complains of cognitive problems but scores normally on standardised tests.
Can reflect anxiety or depression, or represent early deterioration in a highly educated individual

43
Q

Stable cognitive impairment

A

Impairment of one or more aspects of cognition caused by a ‘one-off’ insult, without progressive deterioration (e.g. CVA, hypoxic brain injury, viral encephalitis, traumatic brain injury)

44
Q

Amnesic syndrome

A

Severe disruption of memory (anterograde and retrograde, with recent memories most affected), with minimal or no deterioration in the other cognitive functions. Also confabulation, lack of insight and apathy
Usually results from damage to the hypothalamic-diencephalic system or hippocampal region - commonest cause is Wernicke’s encephalopathy

45
Q

Confabulation

A

Filling of gaps in memory with details which are fictitious, but often plausible

46
Q

Causes of amnesic syndrome (Diencephalic damage)

A 
Vitamin B1 (thiamine) deficiency, i.e. Korsakoff’s syndrome:
 - Chronic alcohol abuse
 - Gastric carcinoma
 - Severe malnutrition
 - Hyperemesis gravidarum
Bilateral thalamic infarction 
Multiple sclerosis
Post subarachnoid haemorrhage
Third ventricle tumours/ cysts
47
Q

Causes of amnesic syndrome (hippocampal damage)

A

Bilateral posterior cerebral artery occlusion Carbon monoxide poisoning
Closed head injury
Herpes simplex virus encephalitis
Transient global amnesia

48
Q

What are you looking for in a physical examination when you suspect dementia?

A
  • Reversible causes of impairment (hypothyroidism, space occupying lesion)
  • Risk factors for dementia (hypertension, AF)
  • Evidence of past CVA
  • Complications of impairment (self-neglect, injuries from a fall)
49
Q

AMT (Advantages and disadvantages)

A

Abbreviated Mental Test

A: Fast

D: Not sensitive to mild-moderate impairment

50
Q

MMSE (Advantages and disadvantages)

A

Mini Mental State Exam

A: Covers most cognitive domains

D: Not sensitive to mild impairment, does not test executive function, influenced by premorbid IQ, language and culture

51
Q

Clock Drawing Test (Advantages and disadvantages)

A

A: Tests praxis and executive function, resistant to influence from premorbid IQ, culture and language

D: Not sensitive to mild impairment, very influenced by poor motor control or visual impairment

52
Q

ACE-R (Advantages and disadvantages)

A

Addenbrooke’s Cognitive Examination-Revised

A: Tests all cognitive domains, sensitive to mild impairment

D: Lengthy, influenced by premorbid IQ, language and culture

53
Q

What investigations should you perform (according to NICE) to exclude reversible causes of dementia?

A

Vitamin B12/folate level
TFTs, calcium, glucose, U&Es
CT/MRI head scan

54
Q

CT appearance of normal ageing

A

Progressive cortical atrophy and increasing ventricular size

55
Q

CT appearance of Alzheimer’s disease

A

Generalized cerebral atrophy
Widened sulci
Dilated ventricles
Thinning of the width of the medial temporal lobe (in temporal lobe-oriented CT scans)

56
Q

CT appearance of vascular dementia

A

Single/multiple areas of infarction
Cerebral atrophy
Dilated ventricles

57
Q

CT appearance of frontotemporal dementia

A

Greater relative atrophy of frontal and temporal lobes Knife-blade atrophy (appearance of atrophied gyri)

58
Q

CT appearance of Huntington’s disease

A

Dilated ventricles

Atrophy of caudate nuclei (loss of shouldering)

59
Q

CT appearance of Creutzfeldt-Jakob disease

A

Usually appears normal

60
Q

CT appearance of nvCJD

A

Bilaterally evident high signal in the pulvinar (post-thalamic) region

Psychiatry - Crash Course (11 decks)

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