Dementia Flashcards
what is the definition of dementia?
an acquired and irreversible CNS neurodegenerative process that affects:
Cognition: memory, apraxia(inability to execute learned purposeful movements), agnosia, visual-spatial aphasia, executive function
What can dementia cause
neuropsychiatric symptoms: depression, psychosis, wandering, physically assaultive, sleep disturbances
what affects does dementia have outside of physiological
occupational, social functioning
what is the cost to treat dementia
200 billion
what is the prevalence of dementia
5.4 million Americans with dementia
-13%>60 years of age
-50%>85 years of age
It is expected that dementia will double in the next 10-20years
A person is diagnosed with dementia every how many seconds?
Every 68 seconds (was 71 seconds in 2012) someone who is dx’d with dementia by mid century rate will increase to every 33 seconds
what are the dementia subtypes
Alzheimer's Vascular Mixed dementia Lewy Body Parkinson's Frontal tempora lobe
what is the most common type of dementia
Alzheimer’s 50% prevalence among pt’s with dementia
what is the prevalance of vascular dementia?
10-20%
multi-infarct lacunar infarct
stoke or diabetes
what is mixed dementia?
combination of Alzheimer’s and Vascular Prevalence is higher that what is currently estimated
What is the percent of lewy body dementia?
10-20% of dementia cases
Increasing incidence
what is the prevalence of Parkinsons dz
41% dementia needs to be distinguished from LBD
Parkinson start more with movement
what is frontal temporal dementia?
May account for 25% of presenile (before 65) dementia
of onset 20-80 year old, average 58
Progresses more rapidly than AD
Loss of social boundaries/awareness- may take clothes off in street,
How did Dr. Alois Alzheimer identify 1st patient with dementia?
he identified amyloid deposits also called “senile plaques” and neurofibrillary triangles
Auguste Deter
what is the pathophysiology of Alzheimer’s dementia?
neurofibrillary tangles are hallmark of AD
Tau proteins
Tau proteins found in which diseases?
Tau proteins are found in which parts of the brain?
- seen in down syndrome, normal aging, PD dementia, Punch drunk (seen in boxer) (dementia pugilistica)
- Found in hippocampus, cortex, substantia nigra, locus ceruleus, nucleus raphe
what is the effect of anticholinergics in Alzheimer’s disease?
they deplete acetylcholine
-Scopolamine, Atropine, Benadryl, Cogentin, Ditropan, Antivert, Zyprexa, Paxil, Thorazine
Where are amyloid plaques found?
what are they associate with?
hippocampus
ABeta 42 in CSF/Serum
precedes symptoms and found in normal aging
where are triangular neurofibrillary tangles found?
hippocampus
earlier symptoms Tau proteins found in CSF/Serum (thought that if you could measure Tau proteins you might be able to screen for this)
Increased symptomatology
May have role in amyloid plaques
what is the epidemiology of Alzheimer’s dz
As can develop as early as in 4th decade
-HIV, FTD frontal temporal, Familial AD, Alcohol, Vascular Dementia
10% of 70y/o have AD dementia
>50% of 80y/o have AD dementia
what are risk factors alzheimer’s dz?
Genetics (most impt):
-Positive Fam Hx
Especially true with early onset AD
Apolipoprotein E (ApoE) allele homozygous state
Head trauma, Education you dont use it you lose it,
Vascular Dz, DM, HTN, Smoking, Downs, Obesity, sedentary life style
High glycemic Index
what are the three realms of dementia?
emotional
perceptual
behavioral
what are the emotional symptoms
Depression
anger
apathy
what are the perceptual symptoms
delusions
hallucinations
sensory
what are the behavioral symptoms?
Problems at work (red flag) Irritability Lack of sleep eating disruption Euphoria marital problems
Mild neurocognitive disorder is defined as?
decreased ability to learn or remember new information but ADL, iADLs (executive function) remain generally intact
advanced neurocognitive is defined as
decreased function in memory, language, and ADLs
,iADL
ADL are
bathing, eating, walking, dressing, toileting, brushing teeth
iADLs are
shopping, driving, cooking, paying bills, using computer phone, new gadgets, medication management
What should you never do with a patient who has dementia
never take their history from them, they are an unreliable historian, need to confirm with caregiver
what should a dementia care work up consist of?
full medical history with collateral input
Full neuro exam
Cognitive testing
Dementia lab panel to r/o reversible causes
(CBC, BMP, Folate, B12, RPR, TSH/FT4, HIV test, heavy metal urine screen)
CT/MRI
what are vascular dementia risk factors?
HTN, T2DM Presents with cognitive deficits: indication for a head CTscan Infarcts occur globally symptoms progress in a stepwise fashion focal neurological deficits because this affects focal areas of the brain where as AD affects the whole brain
How is vascular dementia diagnosed
MRI is needed to diagnose vascular dementia
preventricular infarct
parkinson dementia is marked by?
they also have what other symptoms?
motor symptoms Non motor symptoms (behavioral) difficult to treat and include: depression/psychosis REM disturbances MSK
what percent of PD patients will develop dementia in accumulation of what
20-50% of PD will develop dementia due to accumulation of lewy inclusion bodies in the cortex clumps of alpha synuclein
what are characteristic of lewy body dementia?
marked by psychosis w/ rapid intermittent course
-hallucinations especially small animals, cats
Rigid bradykinesia to a less exten than PD
Intolerance to antipsychotics- increased EPS
Histopathologic feature: Lewy inclusion bodies in cerebral cortex alpha synuclein metab disturbance
huntington’s chorea with dementia?
genetic disease
involuntary muscular dysregulation
High incidence of depression and psychosis:
dementia begins slowly but progresses with advanced stages
HIV dementia
need to confirm HIV status and immune state
neuropsychological testing
physical, neurological, psychiatric exam
motor abnormalities:
movement d/o, impaired memory retrieval, depression
frontal temporal dementia pathology
FT atrophy w/deepening of sulci, w/ gliosis, neuronal loss
what are the symptoms with frontal temporal dementia?
sociopathic tendencies pt has little insigh Obsessions Psychosis Motor apraxia Progressive aphasia
What should be done with dementia?
must rule out reversible dementias
what types of reversible dementia are there?
normal pressure hydrocephalus Depression (pseudodementia) Medications (steroids, analgesics), psychotropics, sedatives, anticholinergics CNS neoplasm Subdural hematomas Dementia labs to rule out B12, TSH, CBC, BMP/Creat/LFT, glucose
what is the etiology sundowning syndrome
dementia symptoms are exacerbated
- external stimuli, such as light and personal orienting are diminished
- can be d/t circadian rhythm disturbance
what are the risk factors for sundowning syndrome
Vaso dementia, lewy body overly sedated (BZD) Dementia w/ delirium -secondary to drug-drug interaction -underlying medical condition, pain, fever metabolic derangement, head trauma
How to prevent complications of behavioral symptom escalation
Exercise Meditation/Stress reduction Improved cardiovascular health Weight lifting or resistance training Nutrition- mediterranean diet low level wine consumption new learning HTN/DM and lipid control smoking cessation legal affairs while there is still some executive function and cognition
what are triggers for stress and aggressive behaviors
fatigue
>90 mins of activity is risk
Change/loss of any kind
Inappropriate senstory input (TV, too many visitors, difficult trips)
Excessive demands (loss of communication skill increases stress)
Recognize and treat delirium from medical causes
what are symptoms of frank dementia with non cognitive behavioral symptoms
intensifying negative behavior characteristics, aggression, paranoid delusions
severe dis-inhibition and impulsivity
non cognitive behavioral symptoms and reasons for most psych consults
80% will develop symptoms Depression, apathy, mood changes, inappropriate sexual behaviors sleep disorders psychosis agitation agression suicidal ideation homocidal ideation
What is the treatment for dementia?
Anticholinesterase Inhibitors
Aricept-good for mild to severe AD
Razadyne
Exelon- good for PD, lewy body dementia, has shown to have slightly better outcomes for AD
What is the side effect profile for anticholinesterase inhibitors
HR<60 DO NOT give HR of ≥60/min give low dose GI/diarrhea, constipation agitation,confusion syncope sleep disturbances arrhythmias leg cramps
what is namenda’s MOA
what do you have to check a patient for before prescribing?
S/E?
NMDA receptor antagonist
Check renal function
S/E:
Confusion,Anxiety, Constipation, High or low BP,
Non-cognitive behavioral symptoms
Increases caregivers burden Anti-depressants-zoloft, SSRI Low dose benzo short term Anti-convulsants/mood stabilizers: lamictal, depakote Cholinesterase inhibitors NMDA-glutamate blocker atypical antipsychotics
Treat depression related dementia with?
SSRI, SNRI, Remeron, Wellbutrin
AVOID TCA
marked apathy, weight loss
How to treat behavioral complications
Antipsychotics
-use sparingly
-Falls and orthostasis are worrisome
-begin with atypical antipsychotic if needed
Antidepressants
-minimally effective in advanced stages of AD
-useful for anxiety with restlessness in setting of depression
Anxiolytics
-ativan is preferred BZD in geriatrics
what is the tx for later stages of AD?
antipsychotic: low dose haldol
keep pt on cholinesterase inhibitors they do worse when you stop them
when to stop AD tx?
if patients prognosis is ≤6 months—you can stop anticholinesterase inhibitors
ADR, contraindications arise
new medical condition, GI, arrhythmia develop
rapid decline, doesn’t recognize family/close friends
what are complications of dementia?
Death
-urosepsis, aspiration pneumonia, decubitis ulcers w/bacteria
-prognosis for AD
10 years after dx is made
what is the screening for dementia
MCI screening is what lie ahead
Neuropsychiatric testing will become more cost efficient if ANTIAMLOID tc become available
We be part of PCP screening
There needs to be research to identify biological markers that are easily obtained through blood culture
what is the definition of delirium?
MC psychiatric
an acute change in consciousness fluctuating between lucidity, confusion and mental obtundation, halluncinations
associated with higher morbidity/mortality
what are the clinical presentation of delirium
hyperactive delirium
hypoactive delirium
mixed delirium with fluctuations between states
where does delirium occur?
occurs mostly where sickest pts are found
ER=80% elderly
SICU/MICU-20%
ER= non-elderly 2/2 drug intoxication
what are risk factors for delirium?
CVA, Dementia, TBI, neoplasms elderly, polypharmacy withdrawing from addictive rxns Alcohol misuse Medically compromised (AIDS, transplants, end stage dz, burn pts)
what is the pathophysiology of delirium?
multifactorial
-neurotransmitter abnormalities
-inflammatory process
pshysiologic stress
what conditions do you rule out with delirium
“I WATCH DEATH”
I WATCH DEATH I-infection W-withdrawal A-acute metabolic T-trauma C-CNS dz H-hypoxia D-deficiencies E-endocrine A-Acute shock T-Toxins H-heavy metals
What should be done in the medical evaluation of delirium?
Psych Hx
Medications/allergies/OTC/Drug
Hx of Trauma
Exposure to infx/travel
what is MDAS
memorial delirium assessment scale
what is the Tx for delirium?
treat cause of delirium provide adequate hydration/nutrition prevent self injury behavior reorient pt frequently provide a quiet calm surrounding ensure sensory correction
What neurotransmitter deficits are there in Alzheimer’s disease?
Acetylcholine
Norepinephrine
Serotonin
