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Neurology Module > Dementia > Flashcards

Dementia Flashcards

1
Q

Types of Dementia

A 
Alzheimers
Multi-infarct dementia
Dementia with Lewy Bodies
Frontotemporal Lobar Degeneration
NPH
Medications
Vitamin B12 deficiency
Alcohol related dementia and Wenicke’s encephalopathy
Progressive supranuclear palsy
Other causes of dementia
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2
Q

Acutely disturbed state of mind that occurs in fever or intoxication or other disorders and is characterized by restlessness, delusions, and incoherence of speech and thought

A

Delirium

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3
Q

Chronic or persistent disorder of the mental process caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning.

A

Dementia

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4
Q

Onset of Delirium

A

Acute

Subacute

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5
Q

Onset of Dementia

A

Insidious

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6
Q

Duration of Delirium

A

Days-weeks

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7
Q

Duration of Dementia

A

Months-years

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8
Q

Course of Delirium

A

Fluctuating

Reversible

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9
Q

Course of Dementia

A

Progressive

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10
Q

Level of Consciousness in Delirium

A

Altered/variable

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11
Q

Level of Consciousness in Dementia

A

NL - Unless of Severe

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12
Q

Attention in Delirium

A

Impaired

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13
Q

Attention in Dementia

A

Initially Intact

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14
Q

Psychomotor in Delirium

A

Variable - usually slow

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15
Q

Psychomotor in Dementia

A

+/- Normal

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16
Q

Sleep in Delirium

A

Disrupted

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17
Q

Sleep in Dementia

A

Less disruption

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18
Q

Predominant Symptoms of Delirium

A

Hyperactivity- irritation, combativeness
Hypoactivity- sedation, lethargy (more common in the elderly)
Mixed

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19
Q

Causes/Risk Factors of Delirium

A 
Age >60
Prior brain injury (vascular or traumatic)
Insomnia, sleep deprivation
Decreased visual and/or auditory function
Hospitalization
Polypharmacy
Poor nutritional status
Renal/hepatic failure
Alcoholism
Infection

Pneumonia, UTI, meningitis/encephalitis

CV: hypoxia, CHF, dehydration, MI

Metabolic: hypo/hyperthyroidism, hypercalcemia (or other electrolyte imbalances), thiamine deficiency (Wernicke’s encephalopathy)

Neuro: CVA, seizures

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20
Q

Drugs to be avoided in the elderly

A

The Beer’s List for Potentially Inappropriate Medication Use in Older Adults

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21
Q

Beers List - Sedating Antihistamines

A

diphenhydramine

promethazine

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22
Q

Beers List - Benzodiazepines for anxiety or insomnia

A

May be appropriate in some settings (Seizure)

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23
Q

Why are TCAs on the Beers list?

A

Hypotension

Sedation

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24
Q

Beers List antibiotics

A

Nitrofurantoin

Causes Pulmonary Toxicity

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25
Q

CV drugs on the Beer’s List

A

Alpha blockers (doxazosin, terazosin, prazosin, clonidine)
Antiarrhythmics- amiodarone (rate control more beneficial than rhythm control)
Digoxin (toxicity)
Spironolactone (hyperkalemia)

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26
Q

Why are antipsychotics on the Beer’s List?

A

Increased risk of stroke

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27
Q

Express caution with diabetic medications with:

A

SSI

Longer acting sulfonylureas - glyburide

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28
Q

Meoclopramide in elderly can cause

A

extrapyramidal effects

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29
Q

Long-term NSAIDs in elderly can have

A

increased risk of GI bleeding

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30
Q

Muscle relaxants in teh elderly?

A

Avoid

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31
Q

Most common type of dementia in the elderly

A

Alzheimer’s Dementia

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32
Q

Presentation of Dementia

A 
New information is difficult to learn and retain
Complex tasks difficult to perform
Unable to solve simple problems
Getting lost in familiar surroundings
Difficulty expressing oneself
Irritable or aggressive behavior
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33
Q

Prevalence of Dementia

A

Age >65 10%

Age > 90 50%

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34
Q

Types of Dementia

A

Cortical - Alzheimer’s metabolic
Subcortical - vascular dementia
Mixed - Parkson’s, Lewy body

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35
Q

Cortical (Alzheimer’s metabolic) dementia has:

A

Short term memory loss

Aphasia

Apraxia- inability to perform purposeful movement; inabilit to use objects properly (not due to sensory/motor deficits)

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36
Q

Subcortical (Vascular Dementia) has

A

Motor slowing

Mood disturbances

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37
Q

Mixed Dementia includes:

A

Parkinson’s Disease, Lewy Bodies

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38
Q

Risk factors for dementia

A 
Age >65 yo
Female
Family hx
Low education level
Head trauma
Long standing htn/MI
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39
Q

Alzheimer’s Genetic Link

A

Apolipoprotein E (ApoE)

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40
Q

How many subtypes of ApoE exist?

A

3 subtypes

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41
Q

What is associated with alzheimers?

A

E4

Mechanism?
Increased amyloid deposition?

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42
Q

Chromosome linkage for early onset dementia:

A

21
14
1

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43
Q

Abnormal cleavage of protein leads to formation of βamyloid protein which deposits in blood vessels and activates glutamate

A

Amyloid Plaques

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44
Q

Helical filaments (tau proteins) stabilizers in cells/neurons; when hyperphosphylated, form tangles; hippocampus, medial temporal lobe, frontal lobe, parietotemporal area

A

Neurofibrillary Tangles

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45
Q

Pathophysiology of Alzheimers

A

Amyloid Plaques
Neurofibrillary tangles

Death of cholinergic neurons – decreased Ach (involved with memory)
Death of serotoninergic neurons- decreased serotonin
Death of adrenergic neurons- decreased norepinephrine
+/- Inflammation

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46
Q

“Deaths” associated with Alzheimers

A

Death of cholinergic neurons – decreased Ach (involved with memory)

Death of serotoninergic neurons- decreased serotonin

Death of adrenergic neurons- decreased norepinephrine

+/- Inflammation

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47
Q

DMS Criteria for Alzheimers (294.1)

A

The development of multiple cognitive deficits manifested by both:

Memory impairment (impaired ability to learn new information or to recall previously learned information).

One (or more) of the following cognitive disturbances:

  • Aphasia (language disturbance)
  • Apraxia (impaired ability to carry out motor activities despite intact motor function)
  • Agnosia (failure to recognize or identify objects despite intact sensory function)
  • Disturbance in executive functioning (ie. Planning, organizing, sequencing, abstracting)

The cognitive deficits in A1 and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning

The course is characterized by gradual onset and continuing cognitive decline

48
Q

Diagnosis of Alzheimers

A

Diagnosis of exclusion!

CT/MRI- cortical atrophy; volume loss medial temporal lobe

PET scans- hypometabolism

49
Q

Treatment of Alzheimer’s Disease

A

Cholinesterase Inhibitors
Donepezil (Aricept) 5mg daily x 4-6 weeks; 10mg daily
Rivastigmine (Exelon) - Pill or patch
Galantamine (Reminyl, Razadyne) - 4mg BID, titrate Q4 wks to 24mg daily

NMDA Receptor Antagonist

  • N-methyl-d-aspartate
  • Glutamate overstimulation of NMDA receptors allows increased calcium influx
  • Memantine (Namenda) 10mg BID
50
Q

Goal of pharmacotherapy in Alzheimer’s

A

Slow progression of Disease

51
Q

Cholinesterase Inhibitors and NMDA Receptor Antagonists have

A

Similar Efficacy

GI side effects

52
Q

Prognosis for Alzheimers

A

11.8 years

53
Q

Cholinesterase Inhibitors for Alzheimers

A

Donepezil (Aricept) 5mg daily x 4-6 weeks; 10mg daily

Rivastigmine (Exelon) - Pill or patch

Galantamine (Reminyl, Razadyne) - 4mg BID, titrate Q4 wks to 24mg daily

54
Q

NMDA-Receptor Antagonists for Alzheimers

A

N-methyl-d-aspartate

Glutamate overstimulation of NMDA receptors allows increased calcium influx

Memantine (Namenda) 10mg BID

55
Q

Risk factors for multi-infarct dementia

A 
Diabetes
CAD
Htn
CVA 
Smoking
Men>women
56
Q

Treatment of multi infarct dementia

A

Manage risk factors

Alzheimers meds not effective

57
Q

Pathonemonic for Dementia with Lewy Bodies

A

Visual Hallucinations!!

Can have auditory or olfactory

58
Q

Characteristics of Dementia with Lewy Bodies

A

Shares characteristics of Alzheimers and Parkinson’s
Visual hallucinations (auditory, olfactory)
Fluctuations in alertness and attention
Periods of staring into space
Affects men more than women

59
Q

Pathophysiology of Dementia with Lewy Bodies

A

Lewy bodies- protein deposits in nerve cells

Develop plaques and tangles (AD)

Movement disorders- Parkinsonian sxs

60
Q

Treatment of Dementia with Lewy Bodies

A

Same meds as Alzheimers
Parkinsonian sxs- meds for Parkinson’s
+/- anti-psychotics

61
Q

Prognosis for Dementia with Lewy Bodies

A

Death ~5-7 years after diagnosis

62
Q

Frontotermporal Lobar Degeneration AKA

A

Pick’s Disease

63
Q

Frontotermporal Lobar Degeneration onset

A

40-70

64
Q

Frontotermporal Lobar Degeneration risk factors

A

Family History

65
Q

What is found in structures of “Picks Disease”?

A

Named “Pick’s disease” for abnormal protein-filled structures found on pathology

66
Q

Frontotermporal Lobar Degeneration presentation

A 
Inappropriate behaviors and actions
Decreased empathy
Lack of judgement/inhibitions
Apathy
Repetitive compulsive behaviors
Lack of hygiene
Speech and language disorders
\+/- Movement disorders
Lack of awareness of behavioral changes
67
Q

Classifications of Frontotermporal Lobar Degeneration

A

Behavioral Variant FTD
Semantic Dementia
Progressive nonfluent aphasia

68
Q

Behavioral variant FTD presents as

A

Decline in social skills, behaviors, emotional lability
Poor hygiene
Compulsive behaviors

69
Q

Semantic Dementia presentation

A

Effortless speech that lacks meaning

Failure to recognize faces of famous people

70
Q

Progressive nonfluent aphasia

A

Stuttering, poor grammar, difficulty with word finding, decreased comprehension

71
Q

Treatment of Frontotemporal Lobar Degeneration

A

SSRIs- behavioral issues
+/- antipsychotics
+/- (experimental) Alzheimers meds- cholinesterase inhibitors

72
Q

Prognosis for Frontotemproal Lobar Degeneration

A

8.7 years duration

73
Q

Pathophysiology of NPH

A

Communicating hydropcephalus”

No obstructive mass

Decreased CSF absorption due to scarring/fibrosis of the arachnoid villae

Ventricles become distended and compress the preiventricular tissues/vessels- ischemia

74
Q

Causes of NPH

A

Idiopathic

Contributing factors: head injury, SAH, meningitis

75
Q

NPH Triad

A

Gait Instability
Urinary Incontinence
Dementia

Wobbly - Wet- Wacky

Can’t think, can’t walk, can’t pee

76
Q

Testing for NPH

A

MRI

Lumbar Puncture

77
Q

NPH - MRI will show

A

Ventriculomegaly
Cerebral parenchyma preserved
Medial hippocampus and temporal regions preseverved

78
Q

NPH - Lumbar Puncture Results

A

Pressure at upper limits of normal

Not needed for diagnosis but often will remove CSF and monitor response to see if shunting will be beneficial

79
Q

NPH Treatment

A

Shunt system to drain spinal fluid from ventricles into abdomen.

80
Q

Medications causing Dementia

A 
Beer’s List (review)
Intoxication/Withdrawal
Opioids
Benzodiazepine
Corticosteroids
Metoclopramide (Reglan)
Antihistamines
TCAs
81
Q

Vitamin B12 Deficiency is caused by

A 
Pernicious anemia (lack of intrinsic factor)
Surgery
Crohn’s, celiac
Long term use of PPIs
Autoimmune conditions:  Graves, SLE
82
Q

Signs and Symptoms of Vitamin B12 deficiency

A 
Weakness
Sore tongue
Easy bruising, bleeding gums
Pallor
Paresthesias
Mood changes
Dementia/memory loss
83
Q

Short term memory loss

Lack of thiamine (B1)

A

Wernicke-Korsakoff Syndrome

“wet brain”

84
Q

Impaired planning, apathy (mimics depression)

A

Alcohol related dementia

85
Q

Other neuro effects caused by EtOH

A

peripheral neuropathy,
cerebellar ataxia,
depression,
psychosis

86
Q

Questions to ask to determine severity of dementia:

A

When was the last time their thinking and memory was completely normal?
Is there any time you thought they may have had a stroke?
Do they repeat, misplace, forget names, rely more on calendars/notes?
Who is in charge of meds? Finances?
Word finding difficulty?
Get lost driving?
Do you feel comfortable leaving them home alone? Overnight? Weekend? Week?
Can they perform ADLs?
Are they depressed? Anxious? Agitated? Restless?
Do they have hallucinations?
Sleep? Incontinence?
Hx head trauma?

87
Q

Important PMH for dementia diagnosis

A 
Neuro:  seizures, strokes, Down’s syndrome
CV:  CAD, seizures
Endocrine:  DM, thyroid
GI:  hepatic disease
Renal:  failure- dialysis
Psych:  anxiety/depression
Oncology
88
Q

Important Social History regarding dementia

A

EtOH
Ilicit Drug Use
Exposures - HIV, syphilis, TB

89
Q

Important FH regarding dementia

A 
Dementia
Psychiatric illness
Endocrine
Cancer
Cardiac
90
Q

Dementia Physical Exam Findings

A

General appearance- facies, basic mental status, grooming

Cranial nerve exam: Pupillary response, EOMs, Symmetry

Presence/absence of dysarthria

Motor: Tremor, Lateralized weakness/spasticity, Cogwheeling/rigidity, Atrophy/fasiculations (ALS)
Sensory: Hyperreflexia- stroke/vascular dementia, Hypo- neuropathy

Gait/balance

91
Q

Dementia Initial Labs

A

Mini-Mental Status Exam
Labs: CBC, CMP, B12, folate, TSH, UA
Imaging: CT or MRI (preferrable)

Second line labs or as indicated in history: ESR, Syphilis serology VDRL/RDR, Lyme titer, LP, EEG, heavy metal screening, ceruplasmin, HIV

92
Q

Nutrition issues with Dementia

A 
Avoid enteral nutrition if possible
Dysphagia diet
Strongly flavored foods
Liquid supplements
Easy access to food
Preferred treats
Swallowing ability
93
Q

Wandering Issues with Dementia

A 
Common reason for nursing home placement
Increase daytime activity
Sleep hygiene
Visual barriers/alarms
ID bracelets
Safe areas
94
Q

What administration of medications are an issue with dementia?

A

Self-Administered

30% dementia patients still have active license

95
Q

Driving in Dementia

A

Double risk for accident

96
Q

Is depression an issue with dementia?

A

YES!!!

Depression may go away later on in dementia.

97
Q

Symptoms worsening toward the evening

A

Sun Downing

98
Q

Alcohol Related Dementia Ages

A

Age 50-70

Correlates to amount of alcohol/tiem period

99
Q

Protection effect of alcohol related dementia

A

4 glasses daily may protect from dementia but more can increase risk

100
Q

Diagnosis of Alcohol Related Dementia

A

Similar criteria to Alzheimers WITH
-Significant EtOH (35 d/wk for men; 28/wk female) x 5 years
-Onset of dementia within 3 yrs of cessation
More supportive: other end-organ damage, peripheral neuropathy, cerebellar degeneration

101
Q

EtOH Dementia Treatment

A

EtOH cessation
Thiamine replacement
Experimental research- Alzheimers meds?

102
Q

S/S Wernicke’s Encephalopathy

A

Ataxia
Confusion
Opthalmoplegia
Vertical and horizontal nystagmus

103
Q

Prognosis of Wernicke’s Encephalopathy

A

Death occurs in 20% cases

Those that survive, 85% will develop Korsakoff’s disease

104
Q

Short term memory loss

Confabulation

A

Korsakoff’s Disease

105
Q

Treatment Korsakoff’s Disease

A

Improvement in 75% patients with treatment

Treatment:

  • Thiamine 100-200mg IM or IV
  • Maintenance 50 mg PO daily
106
Q

Progressive Supranuclear Palsy

A

Rare

Related to Parkinsons and FTD

107
Q

Risk Factors of Progressive Supranuclear Palsy

A

Age

Familial

108
Q

Supranuclear Palsy Symptoms

A 
Blurred vision
Loss of balance
Stiffness and bradykinesia similar to Parkinsons
Dysphagia
Dysarthria
Emotional labile
Apathy/depression
109
Q

Progressive Supranuclear Palsy Symptoms

A

Masked facies
“Startled appearance”

Paralysis of vertical gaze

Overcome with vestibulaocular reflex (VOR)

Later stages- horizontal movements impaired

110
Q

Progressive Supranuclear Palsy Treatment

A

Vision/speech- no treatment
Movement disorders- Parkinsons
SSRIs- mood
+/- Alzheimer’s meds

111
Q

Infectious Diseases that cause Dementia

A

Syphilis (tertiary)

AIDS/HIV

Infection- toxoplasmosis, Lyme disease, PML, encephalitis

Prion disease- Jacob-Creuzfeldt

112
Q

Infections that cause Dementia

A

Taxoplasmosis
Lyme Disease
PML
Encephalitis

113
Q

Other Diseases that can cause dementia

A

Hyper/Hypothyroidism
Neoplasms
Parkinson’s Disease
Depression

114
Q

Rare causes of dementia

A 
Wilson's Disease
Paraneoplastic Syndromes
Sarcoidosis
SLE
Whipple's Disease
MS
ALS-late
115
Q

Evaulation of Dementia

A

Age

Source- patient vs. family member

Onset: acute, subacute, chronic, initiating event?

Pace: slow vs. rapid; plateaued, fluctuating

Cognitive domains involved: attention, memory, executive function, calculation

Behavior: irritability, lability, social w/drawal, disinhibition

Degree of disability/independence

Associated symptoms: weakness, HA, fever, incontinence, falls/ataxia, depression

Neurology Module (7 decks)

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