dementia

Question 1

neurocognitive domains

Answer 1

learning and memory- immediate and recent
complex attention- sustained or selective attention, processing speed
language- expressive and receptive

Question 2

executive functions of cognitive domain

Answer 2

planning, decision making, working memory, responding to feedback/error correction, overriding habits/inhibition, mental flexibility

Question 3

perceptual-motor functions of cognitive domain

Answer 3

visual perception, visuoconstructional, praxis (integrity of learned movements), gnosis (awareness and recognition)

Question 4

social cognitive functions of cognitive domain

Answer 4

recognition of emotions, theory of mind

Question 5

neurocognitive domains

Answer 5

complex attention, executive function, learning and memory, perceptual-motor, social cognition, language

Question 6

mild vs major NCDs: cognition and independence

Answer 6

mild: cognitive decline, usually only one cognitive domain impaired, preservation of independence
major: cognitive decline, significant cognitive impairment in 1+ domains, loss of independence

Question 7

mild neurocognitive d/o criteria

Answer 7

1- cognitive deficits don’t interfere with IADLs but may require greater effort, compensation, or accommodation
2- deficits not exclusively during delirium
3- not better explained by another mental d/o

Question 8

lab testing to do in pts with mild NCD

Answer 8

RPR, HIV

also blood chem, CBC, LFT, urinalysis, TFT, b12 level, folate level

Question 9

when to consider brain imaging for NCDs

Answer 9

onset occurs before 65yo, sx for less than 2 years
asymmetric or focal deficits
recent fall or head trauma
suggestion of normal pressure hydrocephalus

Question 10

differential dx of cognitive sx in elderly

Answer 10

normal aging, major/minor NCD, depression, delirium

Question 11

cognitive changes in normal aging

Answer 11

no progressive deviation on memory testing, some decline in processing and recall of new info, reminders work, no significant effect on ADL or IADL d/t cognition

Question 12

delirium (vs. dementia)

Answer 12

acute onset, cognitive function fluctuations over hours-days, impaired consciousness and attention, altered sleep cycles

Question 13

depression vs dementia

Answer 13

similar sx but in depression, dec motivation in cognitive testing, cognitive complaints exceed measured deficits, maintain language and motor skills

Question 14

etiologies of NCD

Answer 14

1- Alzheimer’s
2- vascular cognitive impairment
*m/c in under 55yo is HIV/AIDS
also: frontotemporal degeneration, Lewy body, TBI, substance/med, prions, PD, HD

Question 15

Alzheimer’s disease features

Answer 15

gradual onset (8-10 y), F>M
memory sx w difficulty learning new info, rare motor sx (apraxia later)
deposition of amyloid B42 (reduced level in CSF)
imaging: global atrophy possible, small hippocampus, reduced glucose metabolism in parieto-temporal and post cing cortices

Question 16

NCD d/t Alzheimer’s DSM5 criteria

Answer 16

1- major or mild NCD criteria met
2- insidious onset, gradual progression of impairment in 1+ cognitive domains
3- decline in learning/memory and another cognitive domain, steadily progressive, no evidence of mixed etiology

Question 17

vascular NCDs: subtypes

Answer 17

multi-infarct: large-vessel disease with multiple strokes
strategic infarct: single strategically located cortico-subcortical stroke
Binswanger’s dz: ischemic paraventricular leukoencephalopathy (white matter dz)

Question 18

features of vascular NCD

Answer 18

sudden (infarct) or gradual (white matter) onset, M>F
delays in info processing, executive fxn and short term memory deficits
motor sx depend on area affected

Question 19

NCD d/t vascular cause DSM5 criteria

Answer 19

1- criteria met for mild/major NCD
2- onset of deficits related temporally to 1+ cerebrovascular events or evidence of decline in complex attention and frontal-executive fxn prominent
3- evidence of cerebrovascular dz from hx, PE, or imaging
4- not explained by other d/o

Question 20

NCD w Lewy bodies criteria

Answer 20

gradual onset (faster than AD), M>F (slight)
fluctuation in cognition, esp alertness and attention
complex visual hallucinations, Parkinsonian motor sx (1 y post cognitive sx)
imaging: nrl hippo volume, global atrophy possible, generalized low uptake on functional scans

Question 21

NCD w Lewy bodies DSM5 criteria

Answer 21

1- mild/major NCD criteria met
2- d/o has insidious onset and gradual progression
3- meets combo of core and suggestive dx features for Lewy body dz (REM disorder, neuroleptic sensitivity)

Question 22

supportive features of Lewy body NCD

Answer 22

frequent falls/syncope
transient losses of consciousness
autonomic dysfunction (orthostasis, urinary incontinence)

Question 23

frontotemporal NCD features

Answer 23

gradual onset (faster than AD), 6th decade, M>F
disinhibition (inappropriate, not embarrassed, etc), neglect of hygiene
apathy, low motivation, aspontaneity, no motor sx
imaging: hypometabolism/ atrophy in medial frontal and ant temp lobes

Question 24

frontotemporal NCD DSM5 criteria

Answer 24

1- meets criteria for major/mild NCD
2- insidious onset, gradual progression
3- meets criteria for behavioral variant or language variant
4- sparing of learning/memory and perceptual-motor function
5- not better explained by substance, another disorder, or cerebrovascular disease

Question 25

criteria for behavioral variant of frontotemporal NCD

Answer 25

1- 3+ of: behavioral disinhibition, apathy/inertia, loss of symp/empathy, compulsive ritualistic behavior, hyperorality and dietary changes
2- prominent decline in social cognition and/or executive abilities (mental rigidity)

Question 26

criteria for language variant of frontotemporal NCD

Answer 26

prominent decline in language abililty, in form of speech production, word finding, object naming, grammar, or word comprehension

Question 27

pts with dementia and behavioral or psychological problems

Answer 27

80-90% patients develop at least one psychotic sx or behavioral disturbance, which may cause nursing-home placement
*potentially treatable

Question 28

psychotic features and NCDs

Answer 28

m/c in mild-moderate major NCDs d/t AD, Lewy body dz, and FT degeneration
commonly paranoid/persecutory delusions
hallucinations, visual are m/c

Question 29

mood disturbances and NCDs

Answer 29

depression common in early major and all mild NCD d/t AD and PD
elation more common in FT degeneration

Question 30

agitation and NCDs

Answer 30

common in many NCDs, disruptive motor or vocal activity (loss of acceptable behavior)
verbal outburst, physical aggression, resistance to care needs, restless activity
*may accompany psychotic sx

Question 31

agitation: differential dx

Answer 31

medical/ physiologic condition: pneumonia, UTI, arthritis, pain, angina, constipation, pain, hunger, thirst, sleepiness
meds toxicity
env: stressor, daylight changes, new routine or people, over/understimulation, other pts being disruptive

Question 32

tx for dementia

Answer 32

non-pharm: cognitive rehab, env modification, physical and mental activity, family and caregiver support and education
pharm: cholinesterase-inh (donepezil, rivastigmine, galantamine), memantine

Question 33

sundowning

Answer 33

more frequent occurrence of confusion and behavior problems in late afternoon and evening in people with dementia

Question 34

symptoms to manage in dementia pts

Answer 34

sundowning, psychosis, apathy (DA agonist), depression (SSRI), aggression, agitation

Question 35

treatments and side effects for psychosis in dementia

Answer 35

anti-psychotic agents

warnings: hyperglycemia, cerebrovascular events, inc all-cause mortality in pts with dementia