Congitive Assessment: Geriatrics Flashcards
What happens to the nervous system as we age?
- Decreased number of neurons and increase in size and number of neurological cells
- Decline in nerves and nerve fibers
- Atrophy of the brain and increase in cranial dead space
How to screen for a mental status change?
Perform mini mental status examination
What are some of the components of a mini entail status?
- State of consciousness
- General appearance and behavior
- Orientation
- Memory
- Executive function control
What are the 3 basic components of memory that are tested during the mini mental status examination?
- Immediate recall
*New memory (name objects and have them recall) - Recent memory
*recalling 3 objects after a few minutes - Remote memory
*give details of early life
How to evaluate cognitive function?
- Orientation
*time, place, person, situation - Attention and concentration
*Serial 7, Spell word backwards - Memory
What are ways to test higher cognitive functions?
- Copy diagrams/constructional ability
- Similarities between objects
What is executive function?
Involves the planning, sequencing, and execution of goal-directed activities
*balancing a check book, following a recipe
*Critical to the ability to perform instrumental activities of daily living
How to screen for executive dysfunction?
- Clock-drawing
*Mini-cog
What is the scoring for the mini mental state examination?
24-30: Normal range
20-23: mild cognitive impairment
10-19: Middle-stage/ moderate Alzheimer’s
0-9: Late-stage/severe Alzheimer’s disease
When is a Mini-cog used?
When there is suspicion of cognitive impairment, conduct
1. Three-item recall with
2. Clock drawing
*If the patient fails then continue with standardized instrument
What dos the Mini-Cog specifically test for?
- Memory (3 item recall)
- Executive function (clock drawing)
If a patient cannot remember any words from the three item recall what are they classified as?
Impaired
If a patient can remember 1-2 words from the three item recall, what happens next?
Clock drawing
*Abnormal=Impaired
*Normal=Not impaired
What are the 5 elements for decision making capacity?
- Ability to express a choice
- Understanding relevant information and risk and benefits of planned therapy
- Comprehension of the problem and its consequences
- Ability to reason
- Consistency of choice
How can cognitive impairment be categorized?
- Acute disorders associated with acute illness, drugs, and environmental factors
*delirium - More slowly progressive impairment of cognitive function
*dementia - Impaired cognitive function associated with affective disorders
what happens during age-related cognitive decline?
- Slowed thinking and reaction time
- Mild recent memory loss
- Symptoms are sporadic and do not affect function
What is Mild Cognitive Impairment?
- Impairment in memory, executive function, attention, and language
- Preserved independence in functional abilities
*deficit is not the result of neurological,psychiatric or other medical disorders
What is Delirium?
- Acute or subacute alteration in mental status
- Can persist for days or weeks
- Reversible
What are some key features of delirium?
- Disturbance of consciousness and attention and awareness
- Symptoms develop over short period of time
*hours to days - There is a fluctuation of symptoms and signs
What is a patient presentation of delirium?
- Difficulty sustaining attention to external and internal stimuli
- Fragmented or disordered stream of thought
- Sensory misperceptions
- Neurological signs are uncommon in delirium
How to assess for delirium
3 minute CAM (confusion assessment method)
1. Acute onset and fluctuating course
2. Inattention
AND EITHER
3. Disorganized thinking OR
4. Altered level of consciousness
What are some ways that delirium can be diagnosed?
Intracranial:
1. Infection
2. Seizures
3. Stroke
Extracranial
1. MI
2. CHF
3. Withdrawal
4. giant cell arteritis
Can a laboratory test diagnose delirium?
No
*only a diagnosis of exclusion
Only CAM can diagnose delirium
What is a treatment for Delirium?
Antipsychotics
*Haloperidol
What is dementia?
- Acquired clinical syndrome of decline in memory and at least two of the following cognitive domain
What are some key features of dementia?
- Sustained loss of function which causes dysfunction in daily living
- Gradual onset persistent, and progression
- Diagnosis of exclusion
*need to rule out everything else
What are the most prevalent forms of dementia?
- Alzheimer’s disease
- Vascular dementia
- Dementia with Lewy bodies
- Frontal temporal dementia
What are some components of Alzheimer’s disease?
- Insidious onset and gradually progressive
- Memory is the most commonly affected
- May have impairments in executive function, language
What is vascular dementia?
- Acute onset of cognitive impairment with some stabilization
*stepwise deterioration - mini-stroke happens that leads to death of a small portion of the brain
What is Dementia with Lewy bodies?
- Progressive cognitive decline
- Rigidity and bradykinesia are primary sings
- Complex visual hallucinations
- Sometimes confused with delirium due to fluctuating cognitive impairment
What are some signs and symptoms of frontotemporal dementia?
- Manifests as personality changes
- Compulsive behaviors or behavioral disinhibition
- Decline in executive tasks and relative sparing of memory and Visio spatial function
What are some risk factors of Alzheimer’s disease?
- Older age *
- FHx (genetic predisposition)
- Female sex
What is end-stage Alzheimer’s disease characterized by?
- Near-mutism
- Inability to sit up, hold up head
- Difficulty with eating and swallowing
- Weight loss
- Bladder incontinence
What is the diagnostic criteria for Alzheimer’s disease/
- memory impairment
- ONE or more of the cognitive disturbances
-Aphasia (language disturbance, difficulty finding words)
-Apraxia (impaired motor activities despite intact motor function)
-Agnosia (failure to recognize or identify objects)
-disturbance in executive function
What are the causes of Vascular Dementia?
- Occlusive cerebrovascular disease
- Cerebral embolism
- Arteritis
What are the differences between Vascular Dementia and Alzheimer’s Disease?
Vascular: Step wise deterioration, PMH significant for HTN, stroke, TIA. Exam reveals HTN, neurological signs, emotional liability
AD: Gradual progression, less PMH of HTN, stroke, TIA. Exam reveals LESS HTN, neurological signs etc
What is sundowning?
When there is an increase in confusion that commonly occurs in geriatric patients in the evening hours
What medication should be used to treat AD?
Cholinesterase inhibitors/acetylcholinesterase inhibitors
*delays progression of AD
*Does not stop functional decline
What are the three most common cholinesterase inhibitors?
- Donepezil
- Rivastigmine
- Galantamine
How do cholinesterase inhibitors work?
Boost levels of a chemical messenger involved in memory and judgement
*mild to moderate AD
What are some side effects of cholinesterase inhibitors?
- Nausea
- Vomiting
- Diarrhea
- Bradycardia
What is memantine (Namenda)
- Works by regulating activity of glutamate (chemical messenger involved in brain functions like learning)
- Used in combination with acetylcholinesterase inhibitor
What is Aducanumab?
- A monoclonal antibody that targets amyloid-beta protein and promotes its clearance from the brain
*IV
*for MCI or mild Alzheimer’s
