Cognitive impairment and dementia Flashcards
t/f: 1 in 7 older americans has dementia
True
What are the 3 parts of cognitive function and how are they related to dementia?
Cognition: how things work Memory: data storehouse Language: story of memory Disruption of any component can result in dementia Alzheimer's loses all 3
What does cognition include?
Knowledge acquisition, comprehension, thinking, knowing, remembering, judgement, problem solving, imagination, planning
What parts of cognition are included in the temporo-parietal areas?
Knowledge acquisition, comprehension, thinking, knowing, remembering
What parts of cognition are included in the frontal area?
Judgement, problem solving, imagination, planning
What are parts of our memory?
Sensory memory: less than 1 second
Working memory: less than 1 minute
Long term memory: lifetime
What are parts of long term memory?
Long term–> explicit memory (conscious)–> declarative memory (facts, events)–> episodic memory (autobiography) and semantic memory (facts, concepts)
Long term–> implicit memory (unconscious)–> procedural memory (skills)
What are the roles of the different lobes of the brain in cognition?
Occipital lobe: what is it?
Temporal lobes: how does it relate to me?
Limbic system: how do I feel about it?
Frontal lobe: what do I think about it?
When does the brain begin to age?
Brain aging begins between ages 20 and 30: decreased capillary and arteriole density, decreased blood flow, decreased brain weight, increased ventricular volume, increased subarachnoid space
What are changes in the brain as we age?
Increased risk for brain injury
Increased reliance on procedural memory
Decisions replaced by routine and ritual
What are characteristics of delirium?
Disturbance of consciousness Change in cognition Acute onset (hours to days) Fluctuating symptoms Evidence of medical etiology
T/F: delirium is a strong predictor of poor functional and cognitive status in the year following hospital admission
True
What is CAM?
Confusion Assessment Method 1) acute onset and fluctuating course 2) altered level of consciousness 3) inattention 4) disorganized thinking Diagnosis of delirium requires presence of both 1 and 2, and either 3 or 4
What is MCI?
Mild cognitive impairment: impairment in thinking and memory that do not interfere with everyday activities
Amnestic type- memory only
Multi-domain- judgement and/or language
About 10-15% convert to dementia each year
About 80% convert within 6 years
What are symptoms of MCI?
Forgets names, loses objects, forgets items on a list, forgets multiple tasks, forgets phone numbers, unable to recall info after distraction, score more than 1 SD below mean on memory test
How is MCI detected?
Reaction time, dual task performance, word fluency, category fluency, delayed verbal recall, narrative recall, name face pair recall, complex figure copying
What is dementia?
Syndrome of impairment in memory and at least one other cognitive ability: language (coherent speech or ability to understand spoken or written language), visuospatial function (recognition of common objects), executive function (motor function, abstract and complex thought, and/or judgment)
What are early signs of dementia?
Forgetfulness, confusion, weight loss, sleep disturbance, gait abnormalities, ADL deficits
What are the different types of dementia?
Alzheimer's disease Vascular dementia Frontotemporal dementia Lewy body dementia Parkinson's dementia Huntington's dementia Normal pressure hydrocephalus
what are some statistics of AD?
degenerative, irreversible, and fatal Accounts for 70% of dementias 6th leading cause of death 17 billion hours of unpaid care Value of $202 billion per year
What is pathology of AD?
Beta amyloid protein accumulation outside neurons (plaques)
Tau protein accumulation inside neurons (tangles)
Genetic factors: mutations (rare), ApoE4 (increases risk)
What are cognitive AD symptoms?
Disorientation, loss of logical reasoning, loss of insight, poor judgement, perceptual problems, inability to perform arithmetic, inability to learn, loss of attention, language impairment, apathy, withdrawal, impaired ADLs
What are non cognitive AD symptoms?
Paranoia, delusions, sleep disturbance, hallucinations/illusions, agitation/aggression, wandering/sundowning, anxiety, depression, hostility, fear, jealousy, insecurity
What are the stages of AD?
Stage 1 (2-4 years): repeats questions, anhedonia, word finding problems, frequently loses items, personality changes Stage 2 (2-10 years): becomes lost easily, confusion over recent events, ADL impairments, argumentative, pacing, anxiety/depression, delusions Stage 3 (1-3 years): unable to perform ADLs, impaired speech/comprehension, unable to recognize family/friends, unable to recognize self
t/f: average survival time from diagnosis in AD is approximately 8 years?
True
What are the current guidelines for diagnosis of AD?
Deficit in memory and at least one other cognitive domain
Decline from previous function that interferes with social or occupational functioning
Gradual onset and continuous decline (more than 6 months)
Not due to other systemic, CNS, psychiatric, or drug inducing condition
Consciousness remains unaltered
What are proposed changes to diagnostic criteria for AD?
3 stages: preclinical, MCI, and dementia
Elevated beta amyloid and/or tau levels
Evidence of neurological degeneration
What are characteristics of vascular dementia?
2nd most common cause of dementia
Sub divided into: cortical, sub cortical, strategic, hypo perfusion, hemorrhagic, mixed (AD and VD)
What are symptoms of VD?
Hemiparesis, visual deficits, incontinence, pseudobulbar signs, executive deficits, psychomotor impairment, personality/mood change, hyper reflexia, gait disturbance
What are types of VD?
Multi-infarct dementia
Binswanger’s disease: subcortical, progressive, psychomotor deficits
CADASIL (cerebral autosomal dominant arteriopathy with sub cortical infarcts and leukoencephalopathy): inherited genetic mutation, strong association with migraines, palliative treatment
What are fronto temporal dementias?
Clinical syndromes of varying pathologies
Orbitofrontal: monitoring
Anterior cingulate: motivation
Dorsolateral prefrontal: executive function
What is the lund-manchester criteria for fronto temporal dementias?
Two or more of the following: loss of personal awareness, strange eating habits, perseveration, mood change
PLUS
One or more of the following: executive dysfunction, impaired speech, intact visuospatial function
What is the FTD work group criteria for fronto temporal dementias?
Cognitive deficits marked by: early progressive personality or behavioral changes, early progressive expressive semantic language changes
Impairment in social or occupational function
Gradual onset and continual decline
Not due to other medical or psychiatric condition
Absence of delirium
What is Pick’s disease?
Characterized by pick bodies and cells- abnormal formation and accumulation of tau proteins in neurons
Selective for frontal and temporal lobes
What are signs of Pick’s disease?
Aggressive, inappropriate behavior Early onset of language pathology Incontinence Sociopathic, obsessive, or stereotyped behaviors May occur with parkinsonism
What is semantic dementia?
Associated with left temporal dysfunction
Loss of semantic memory and knowledge
Initial sparing of episodic memory and other cognitive functions
Impairment in language syntax, phonology may occur
Most progress to full FTD in 5-10 years
What is PPA?
Primary Progressive Aphasia
Loss of expressive language
Comprehension often spared, especially in early stages
Most progresses to full FTD
What is Lewy Body Dementia?
3rd most common form of dementia
Accumulation of alpha synuclein protein inside neural nuclei
Close association with Parkinson’s disease and AD
What are symptoms of LBD?
Striking fluctuations in cognition
Visual hallucinations
Bradykinesia
Parkinsonian posture and gait
Tremor is less common, usually less severe
Visual cortex involvement may be distinguishing feature
T/F: about 40% of AD patients have lewy bodies, and 80-90% of those with LBD have features of AD
True
What are other forms of dementia?
Parkinson’s disease: approx. 20% develop dementia, basal ganglia interacts with pre frontal cortex
Huntington’s chorea: early onset behavioral changes
Prion diseases: kuru, creutzfeld-jacob
Normal pressure hydrocephalus
How do we assess behavior in patients with dementia?
patient, problem, environment, caregiver What is the problem? Whose problem is it? What is the cause? What can be done?
What are questions we ask when we specifically identify action and setting for assessing patients with dementia?
What was happening at time of problem? What happened before problem? What happened after problem? What were the consequences of the behavior? Was appropriate behavior ignored?
What are considerations for “whose problem is it”?
Behaviors often occur at the same frequency throughout the day, but have greater impact at different times of day (or night)
Most adverse behavior occurs at peak activity times: 7-10 am, 12-2 pm, 4-7 pm
What are considerations for “what is the cause”?
Personal factors: patient’s wants, needs, preferences
Medication side effects
Medical complications: communication, visual or hearing loss; pain; infection; dental disease; bowel dysfunction
Environmental factors
People with cognitive impairment cannot….
Comprehend the environment
Adapt to the environment
Cope with the environment
How do we develop interventions for patients with cognitive impairments?
Stay calm
Tailor activities to patient preference
Use familiar, personal items when possible
Maintain non stressful, familiar environment
Provide orientation
Provide daily, weekly structure
Avoid boundary violations
