- reactivity tom voice and physical stimulation - cranial nerves, vestibule-ocular reflex - motor exam

delirium, dementia, concussions Flashcards by Dylan Plocki

Confusional state

a more profound deficit that includes disorientation, bewilderment, and difficulty following commands.

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Lethargy

consists of severe drowsiness in which the patient can be aroused by moderate stimuli and then drift back to sleep.

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Obtundation

a state similar to lethargy in which the patient has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states.

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Stupor

means that only vigorous and repeated stimuli will arouse the individual, and when left undisturbed, the patient will immediately lapse back to the unresponsive state

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Coma

state of unarousable unresponsiveness

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Response to motor examination in comatose patients

reaction to noxious stimuli
Localizing responses, such as moving the examiner’s hand away from the body, are not consistent with coma
Flexion and extension responses to painful stimuli are consistent with coma, and some patients have no response at all

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determining coma:

reactivity tom voice and physical stimulation
cranial nerves, vestibule-ocular reflex
motor exam

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coma mimics:

locked-in
catatonic states
severe abulia

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Locked-in syndrome

a form of paralysis from injury to the anterior brainstem with sparing of the RAS, leaving the patient awake and aware but with limited ability to communicate.

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Catatonic states and severe abulia

syndromes that inhibit the patient from responding appropriately due to limited, not global, impairment of the brain.

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A few clinical signs suggest the diagnosis of a locked-in syndrome, abulia, and catatonic states.

In locked-in syndrome, most patients have spared vertical gaze (particularly upward gaze) allowing them to follow commands.
Abulic patients will have occasional spontaneous purposeful movements.
Catatonic patients often have limb position postures that are not typical of coma.

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what percent of elderly hospitalized its experience delirium?

30%

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what type of drugs can cause delirium?

anticholinergics

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delirium. conical presentation:

Altered cognition
Altered consciousness
Elderly
Hours to days
Other findings:
psychomotor agitation
sleep-wake reversals
irritability, anxiety
emotional lability

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what test detects delirium?

Confusion assessment method (CAM)

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delirium management:

Treat the underlying condition
Supportive care

Agitation
Reassurance, reorientation, limit aggravating factors
Constant observation
Pharmacologic? Antipsychotics with limited evidence

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Dementia:

Mild cognitive impairment
Alzheimer’s 
Lewy Body
Parkinson’s 
Frontotemporal 
Rapidly progressive
Normal pressure hydrocephalus

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dementia laboratory eval:

B12
Thyroid function
Blood count
Metabolic panel 
Additional tests depending on history:
RPR/T.pallidum, HIV, autoimmune testing
Lumbar puncture

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dementia imaging:

MRI preferred over CT
Better resolution
Old infarcts
Atrophy
Ventricular size

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alzheimers dementia clinical features:

Memory impairment
Executive dysfunction
Neuropsychiatric symptoms
Sleep disturbance
Also noted:
Olfactory changes
Seizures
Apraxia

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alzheimers imaginign:

MRI:
Generalized and focal atrophy
Reduced hippocampal volume
Atrophic medial temporal lobe

-Functional brain imaging with [18F] FDG-PET, functional MRI (fMRI), perfusion MRI, or SPECT reveals distinct regions of low metabolism (PET) and hypoperfusion (SPECT, fMRI)
hippocampus, the precuneus (mesial parietal lobes), the lateral parietal and posterior temporal cortex

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how do you measure Alzheimers progression?

-measured with MMSE, MoCA, and the clinical dementia rating scale

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what is the most common type of dementia?

alzheimers

what is the second most common type of dementia?

dementia with Lewy bodies

pathologic hallmark of dementia with lewy bodies?

Lewy Body | abnormal aggregates of protein in the cytoplasm

features of Lewy body D?

``` Dementia Other features Fluctuating cognition Visual hallucinations Parkinsonism ```

differentiating dementia with lewy bodies and Parkinson's:

In DLB, dementia should occur before or concurrently with onset of parkinsonism -in parkinsons, Parkinson's comes first, then dementia

DLB prognosis:

Similar to slightly faster rate of cognitive decline than AD | Shorter survival time than AD

DLB Tx:

same as AD, but neuroleptics with care ~30 - 50% have severe sensitivity to neuroleptics Worsening parkinsonism

Parkinsons:

``` Neurodegenerative disease Mostly motor symptoms Pathophysiology: Death of cells in the substantia nigra Alpha-synuclein aggregates ```

parkinsons motor symptoms:

Tremor Rigidity Akinesia Postural instability (walking/gait difficulty)

parkinsons dementia:

``` Cognitive decline usually later ~30% of PD patients Risk factors: Older age Age of onset of PD >=60 Increased severity of parkinsonism ```

cardinal features of Parkinson's dementia:

executive dysfunction impaired visuospatial function less prominent memory deficits relatively preserved language function

parkinsons dementia tx:

Symptomatic | No therapies have been shown to modify the course of the disease or influence prognosis

Frontotemporal dementias:

``` Changes in behavior, personality, language Behavioral variant (bvFTD) Primary progressive aphasias: -Nonfluent -Semantic ```

behavioral changes of frontemporal dementia:

Disinhibition Compulsive behaviors Hyper-orality

FTD diagnosis:

Diagnosis may be difficult Rule out psychosis Differential includes Lewy body disease, AD

primary progressive aphasia:

- insidious onset and gradual progression of a language impairment (ie, aphasia) manifested by deficits in word finding, word usage, word comprehension, or sentence construction - Nonfluent vs. Semantic

most common form of prion disease:

creutzfeldt-jakob disease

neuropathology CJD features:

neuronal loss proliferation of glial cells absence of an inflammatory response presence of small vacuoles within the neuropil, which produces a spongiform appearance

CJD clinical features:

Rapidly progressive cognitive decline | Myoclonus (startle)

CJD MRI abnormalities:

T2 hyperintensities in the putamen and head of the caudate | Cortical ribbon

CJD diagnosis:

exclusion

Vascular (multi-infarct) dementia:

Multiple brain insults accumulated over time (step wise decline)

vascular dementia risk factors:

Cardiovascular risk factors | Uncontrolled hypertension, hyperlipidemia, type 2 diabetes, heart disease

Normal pressure hydrocephalus (NPH):

large ventricle size with normal opening pressures

NPH features:

``` Wet Wacky Wobbly Temporal course: Gait difficulty and urinary urgency/incontinence first, then cognitive changes ```

NPH tx:

Lumbar puncture to aid in diagnosis | Ventriculoperitoneal shunt

NPH prognosis:

Shunt placement can lead to improvement in symptoms

most common form of sports-related TBI:

concussion

concussion clinical presentation:

``` Headache* nausea dizziness confusion memory impairment incoordination attention problems behavioral changes ```

Post-concussion syndrome:

When patients report persistent neurobehavioral impairments after concussion Chronic Post-concussion Syndrome when symptoms present >1year after injury

post-concussion syndrome assessment :

Comprehensive neurological examination | Personal and family history of migraine/sleep disturbance/mood disorders

concussion eval on field:

ABCs Seizure? Prolonged loss of consciousness? Evidence of cervical spine disease? Emergency medical services!

concussion diagnosis:

SCAT3

concussion Tx:

``` Remove from participation Direct observation At least four hours Distraction free environment Limited utility of neuroimaging Symptomatic management Arrange follow up with comprehensive neuro exam within 24 hours ```