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Geriatrics > Dementia > Flashcards

Dementia Flashcards

1
Q

what is the definition of dementia?

A

an acquired and irreversible CNS neurodegenerative process that affects:
Cognition: memory, apraxia(inability to execute learned purposeful movements), agnosia, visual-spatial aphasia, executive function

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2
Q

What can dementia cause

A

neuropsychiatric symptoms: depression, psychosis, wandering, physically assaultive, sleep disturbances

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3
Q

what affects does dementia have outside of physiological

A

occupational, social functioning

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4
Q

what is the cost to treat dementia

A

200 billion

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5
Q

what is the prevalence of dementia

A

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

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6
Q

A person is diagnosed with dementia every how many seconds?

A

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

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7
Q

what are the dementia subtypes

A 
Alzheimer's 
Vascular 
Mixed dementia 
Lewy Body Parkinson's 
Frontal tempora lobe
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8
Q

what is the most common type of dementia

A

Alzheimer’s 50% prevalence among pt’s with dementia

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9
Q

what is the prevalance of vascular dementia?

A

10-20%
multi-infarct lacunar infarct
stoke or diabetes

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10
Q

what is mixed dementia?

A

combination of Alzheimer’s and Vascular Prevalence is higher that what is currently estimated

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11
Q

What is the percent of lewy body dementia?

A

10-20% of dementia cases

Increasing incidence

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12
Q

what is the prevalence of Parkinsons dz

A

41% dementia needs to be distinguished from LBD

Parkinson start more with movement

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13
Q

what is frontal temporal dementia?

A

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,

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14
Q

How did Dr. Alois Alzheimer identify 1st patient with dementia?

A

he identified amyloid deposits also called “senile plaques” and neurofibrillary triangles
Auguste Deter

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15
Q

what is the pathophysiology of Alzheimer’s dementia?

A

neurofibrillary tangles are hallmark of AD

Tau proteins

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16
Q

Tau proteins found in which diseases?

Tau proteins are found in which parts of the brain?

A
  • 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
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17
Q

what is the effect of anticholinergics in Alzheimer’s disease?

A

they deplete acetylcholine

-Scopolamine, Atropine, Benadryl, Cogentin, Ditropan, Antivert, Zyprexa, Paxil, Thorazine

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18
Q

Where are amyloid plaques found?

what are they associate with?

A

hippocampus
ABeta 42 in CSF/Serum
precedes symptoms and found in normal aging

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19
Q

where are triangular neurofibrillary tangles found?

A

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

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20
Q

what is the epidemiology of Alzheimer’s dz

A

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

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21
Q

what are risk factors alzheimer’s dz?

A

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

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22
Q

what are the three realms of dementia?

A

emotional
perceptual
behavioral

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23
Q

what are the emotional symptoms

A

Depression
anger
apathy

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24
Q

what are the perceptual symptoms

A

delusions
hallucinations
sensory

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25
Q

what are the behavioral symptoms?

A 
Problems at work (red flag)
Irritability
Lack of sleep
eating disruption
Euphoria
marital problems
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26
Q

Mild neurocognitive disorder is defined as?

A

decreased ability to learn or remember new information but ADL, iADLs (executive function) remain generally intact

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27
Q

advanced neurocognitive is defined as

A

decreased function in memory, language, and ADLs

,iADL

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28
Q

ADL are

A

bathing, eating, walking, dressing, toileting, brushing teeth

29
Q

iADLs are

A

shopping, driving, cooking, paying bills, using computer phone, new gadgets, medication management

30
Q

What should you never do with a patient who has dementia

A

never take their history from them, they are an unreliable historian, need to confirm with caregiver

31
Q

what should a dementia care work up consist of?

A

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

32
Q

what are vascular dementia risk factors?

A 
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
33
Q

How is vascular dementia diagnosed

A

MRI is needed to diagnose vascular dementia

preventricular infarct

34
Q

parkinson dementia is marked by?

they also have what other symptoms?

A 
motor symptoms 
Non motor symptoms (behavioral)
difficult to treat and include:
depression/psychosis
REM disturbances
MSK
35
Q

what percent of PD patients will develop dementia in accumulation of what

A

20-50% of PD will develop dementia due to accumulation of lewy inclusion bodies in the cortex clumps of alpha synuclein

36
Q

what are characteristic of lewy body dementia?

A

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

37
Q

huntington’s chorea with dementia?

A

genetic disease
involuntary muscular dysregulation
High incidence of depression and psychosis:
dementia begins slowly but progresses with advanced stages

38
Q

HIV dementia

A

need to confirm HIV status and immune state
neuropsychological testing
physical, neurological, psychiatric exam
motor abnormalities:
movement d/o, impaired memory retrieval, depression

39
Q

frontal temporal dementia pathology

A

FT atrophy w/deepening of sulci, w/ gliosis, neuronal loss

40
Q

what are the symptoms with frontal temporal dementia?

A 
sociopathic tendencies
pt has little insigh
Obsessions
Psychosis
Motor apraxia 
Progressive aphasia
41
Q

What should be done with dementia?

A

must rule out reversible dementias

42
Q

what types of reversible dementia are there?

A 
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
43
Q

what is the etiology sundowning syndrome

A

dementia symptoms are exacerbated

  • external stimuli, such as light and personal orienting are diminished
  • can be d/t circadian rhythm disturbance
44
Q

what are the risk factors for sundowning syndrome

A 
Vaso dementia, lewy body
overly sedated (BZD)
Dementia w/ delirium
-secondary to drug-drug interaction
-underlying medical condition, pain, fever metabolic derangement, head trauma
45
Q

How to prevent complications of behavioral symptom escalation

A 
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
46
Q

what are triggers for stress and aggressive behaviors

A

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

47
Q

what are symptoms of frank dementia with non cognitive behavioral symptoms

A

intensifying negative behavior characteristics, aggression, paranoid delusions
severe dis-inhibition and impulsivity

48
Q

non cognitive behavioral symptoms and reasons for most psych consults

A 
80% will develop symptoms
Depression, apathy, mood changes, inappropriate sexual behaviors
sleep disorders
psychosis
agitation
agression
suicidal ideation
homocidal ideation
49
Q

What is the treatment for dementia?

A

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

50
Q

What is the side effect profile for anticholinesterase inhibitors

A 
HR<60 DO NOT give
HR of ≥60/min give low dose
GI/diarrhea, constipation
agitation,confusion
syncope
sleep disturbances
arrhythmias
leg cramps
51
Q

what is namenda’s MOA
what do you have to check a patient for before prescribing?
S/E?

A

NMDA receptor antagonist
Check renal function
S/E:
Confusion,Anxiety, Constipation, High or low BP,

52
Q

Non-cognitive behavioral symptoms

A 
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
53
Q

Treat depression related dementia with?

A

SSRI, SNRI, Remeron, Wellbutrin
AVOID TCA
marked apathy, weight loss

54
Q

How to treat behavioral complications

A

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

55
Q

what is the tx for later stages of AD?

A

antipsychotic: low dose haldol

keep pt on cholinesterase inhibitors they do worse when you stop them

56
Q

when to stop AD tx?

A

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

57
Q

what are complications of dementia?

A

Death
-urosepsis, aspiration pneumonia, decubitis ulcers w/bacteria
-prognosis for AD
10 years after dx is made

58
Q

what is the screening for dementia

A

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

59
Q

what is the definition of delirium?

A

MC psychiatric
an acute change in consciousness fluctuating between lucidity, confusion and mental obtundation, halluncinations
associated with higher morbidity/mortality

60
Q

what are the clinical presentation of delirium

A

hyperactive delirium
hypoactive delirium
mixed delirium with fluctuations between states

61
Q

where does delirium occur?

A

occurs mostly where sickest pts are found
ER=80% elderly
SICU/MICU-20%
ER= non-elderly 2/2 drug intoxication

62
Q

what are risk factors for delirium?

A 
CVA, Dementia, TBI, neoplasms
elderly, polypharmacy
withdrawing from addictive rxns
Alcohol misuse
Medically compromised (AIDS, transplants, end stage dz, burn pts)
63
Q

what is the pathophysiology of delirium?

A

multifactorial
-neurotransmitter abnormalities
-inflammatory process
pshysiologic stress

64
Q

what conditions do you rule out with delirium

“I WATCH DEATH”

A 
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
65
Q

What should be done in the medical evaluation of delirium?

A

Psych Hx
Medications/allergies/OTC/Drug
Hx of Trauma
Exposure to infx/travel

66
Q

what is MDAS

A

memorial delirium assessment scale

67
Q

what is the Tx for delirium?

A 
treat cause of delirium
provide adequate hydration/nutrition
prevent self injury behavior
reorient pt frequently
provide a quiet calm surrounding
ensure sensory correction
68
Q

What neurotransmitter deficits are there in Alzheimer’s disease?

A

Acetylcholine
Norepinephrine
Serotonin

Geriatrics (9 decks)

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