Dementia Flashcards
Delirium
- define
- confusional state
- acute or subacute disorder of attention
- MC clinical alteration of mentation
- often d/t treatable dz outside nervous system
- true medical emergency!
Delirium
- most often seen what ages
- often mistaken for what
- young and old
- psychiatric illness
Causes of delirium
- Drug OD, withdrawal
- poison
- head trauma
- infections (not just of the nervous system, UTI in elderly ex.)
- metabolic
- seizure
- tumor
- high fever
- intestinal obstruction
- pancreatitis
- fractures (meds to tx)
- fat embolism
- lupus cerebritis
Where do pts with delirium generally present to healthcare industry?
ER (not clinic)
- someone brings them in bc they’re worried the pt is different
How good of a historian is a pt with delirium?
bad - rely on family members, friends, nursing home, etc. for history
Sx of delirium
- disordered attention
- poor memory recent events
- poor insight into illness
- hallucinations, delusions, paranoia, apathy
- tangental communication
- anomia
- agraphia
- R/L disorientation
- acalcula
- retropulsive gait disorder
Anomia
can’t name three objects
Agraphia
can’t write
Delirium dx
- proper hx is important
- standard labs (CB, UA, EKG, CMP, Troponin, tox screen, fsbs)
If first round of testing was inconclusive, waht is second line of w/u for delirium
- CT or MRI
- LP
- ammonia level
Is delirium a disease or a symptom
a symptom (with a cause)
Tx of delirium
- treat underlying cause
- Thiamine before dextrose (to avoid acidosis)
When should sedation be used in delirium
only AFTER dx of cause is made, never before!
Time frame for delirium vs. dementia
- delirium: hours to days
- dementia: months to years
dementia definition
- irreversible progressive decline in intellectual function
- disconnection from the cognitive world
- not a clinical diagnosis (have to have an underlying cause)
What does the ddx of dementia rely on?
early patterns of intellectual decline to help establish etiology and anatomical focus
Four types of memory list
- Exteroceptive (declarative) memory
- Interoceptive (emotional, affective) memory
- Motor (procedural) memory
- Executive memory
Declarative memory
- define
- what parts of brain
- info gained from external senses (facts, data, events)
- hippocampus and posterior neocortex
Emotional/affective memory
- define
- parts of brain
- info gained through experiential phenomena
- amygdala, posterior insula (limbic system), neocortex
Procedural memory
- define
- parts of brain
- info gained through movement
- motor cortex, basal ganglia, cerebellum
executive memory
- define
- parts of brain
- gained through “metacognition” across time (insight, foresight, morals, etc.)
- prefrontal neocortex
name of test to check cognitive status
- cognistat (among others)
- is a snapshot in time, have to test repeatedly to get picture of change over time
DSM 5 criteria for dementia
- memory loss
- 1 or more cognitive impairment
- functional impairment of IADLs
- exclusion of delirium
IADLs
instrumental activities of daily living
- allow you to live independently such as bathe, grocery shop
How to measure IADLs
Lawton’s IADL scale
- no good or bad number, just watch to see how changes over time
List 9 causes of dementia
- cognitive aging
- drugs
- demyelinating diseases (MS)
- hydrocephalus
- masses
- infections
- metabolic issues
- vascular issues
- degeneration
Classic aging/oldtimers dementia
Cognitive aging effect
- decline in multitasking, non-verbal IQ, nominal recall
- mild forgetfulness
- mild word finding problems
drug induced dementia dt what drugs
- anticholinergics (tricyclics, SSRIs, antihistamines)
- anxiolytics - benzo
- neuroleptics
- cardiac meds (bb, alpha agonists, ACEi, statins)
- pts taking more 5+ meds
Types of masses that cause dementia
- meningiomas
- gliomas
- subdural hematomas
Infections that cause dementia
- tertiary syphilis
- Creutzfeld-Jakob disease
- Tubercular or fungal
- HIV encephalopathy
- progressive multifocal leukoencaphalopathy (opportunistic infection)
- toxoplasmosis
Metabolic causes of dementia
- Wilson’s disease
- B12 deficiency
- ETOH abuse
- thyroid disease
Vascular causes of dementia
- CVA
- lacunar infarcts
Degenerative causes of dementia
- Pick disease
- Spinocerebellar degeneration
- Alzheimer’s
- Lewy body disease
Type of dementia seen in pick disease
frontotemporal dementia
rare
What is affected in spinocerebellar degeneration
motor tracks
Alzheimer’s disease
- describe
Insidious onset and gradual decline in activities, behavior, and cognition over time
How many stages of disease in Alzheimer’s?
7
Alzheimer’s Stage 1
no impairment
- not detectable
- no memory problems or other sx
Alzheimer’s stage 2
very mild decline
- minor memory problems
- lose things around the house
- hard to distinguish from aging memory loss
Alzheimer’s stage 3
mild decline
- friends/fam start to notice cognitive problems
- performance on memory/cognitive tests impaired
- lose personal possessions
- trouble with the following:
- finding words
- remembering names of new acquaintances
- planning and organizing
Alzheimer’s stage 4
moderate decline
- clear cut sx of Alzheimer’s
- difficulty with arithmetic
- may forget details about own life
- poor short term memory (what ate for breakfast)
- inability to manage finances/pay bills
Alzheimer’s stage 5
moderately severe decline
- need help with day to day activities
- significant confusion
- can’t recall simple details about self like phone number
- still can bathe and toilet
- still know family members and own family history, esp childhood and youth
Alzheimer’s stage 6
severe decline
- need constant supervision and require personal care
- unaware/confusion of surroundings
- major personality changes
- need assistance with toilet and bathing
- inability to recognize faces except friends/family
- inability to remember most details of personal history
- loss of bowel/bladder function
- wandering
Alzheimer’s stage 7
very severe decline
- nearing death
- lose ability to respond to environment or communicate
- no insight into condition
- require assistance with all activities of daily living
- may lose ability to swallow
Summary of Alzheimer’s
- overt amnestic memory loss
- anomia
- posterior cognitive defects
- loss of social interaction and personal hygiene
- global aphasia
- severe cognitive decline
- retain ability to walk
- bedridden, eventually in fetal position
posterior cognitive deficit seen in Alzheimer’s
- spatial disorientation
- loss of math abilities
- trans cortical sensory aphasia
- paranoia, hallucinations, hoarding, agitation
- sensory aphasia - repetitive speech
Two histological markers seen in Alzheimers’
- Tao protein (tangles)
- Amyloid plaques
- in cortical mass
Brain changes in Alzheimers on CT
- gray matter degeneration
- ventricles appear enlarged
Explain teh cholinergic hypothesis for Alzheimer’s
- cholinergic cells die early
- nucleus basalts, neocortex, temporal lobes
- tx by giving ACh
Common drug used to treat Alzheimer’s
Donepezil (Aricept) 5 mg daily
What is the benefit of donepezil?
Delays entrance to nursing home by about 18 months
Non pharm management of Alzheimer’s
- caregiver to AD support group
- pt wear medic alert ID bracelet
- pt assign POA to caregiver
- Screening labs (B12, TSH, RPR, HbA1c)
- reduce alcohol
- discuss driving issue
What is the effect of ginkgo biloba on AD?
no difference from placebo
Lewy Body dementia
- how common
- sx overview
- second MC after AD
- fluctuating course with prominent neuropsychiatric and parkinsonism sx
Lewy body dementia
- what general effect that AD does not have
- motor problems
Lewy body dementia
- histology
abnormal collections of protein (plaques) but no tangles
Sleep issues in Alzhiemer’s vs. Lew Body
AD: insomnia
Lewy Body: disordered sleep
Three core features in Lewy Body Dx
- fluctuations in alertness during day
- parkinsonism (bradykinesia, rigidity>tremor)
- visual hallucinations
What meds does Lewy body Dementia respond to?
ACH-esterase inhibitors
*but study didn’t go past 24 weeks or have large sample size…
What is effect of NMDA receptor antagonist on Lewy body dementia
stabilizes patients for 6-12 months
How to manage lewy body dementia
- donepezil (Aricept) 5 mg daily for dementia
- Sinemet for parkinsons sx
- clonazepam for sleep issues
- PT to help with motor issues
Vascular dementia
- acute or subacute onset of gait disorder and or memory loss
- related to atherosclerosis: multiple small infarcts over time
- bruits in carotids and subclavian
- end up having massive stroke
Binswanger’s Disease is an extension of what
vascular dementia
- also multi infarct type of disease
How to manage vascular dementia
- donepezil
- same tx as any vascular disease
- reduce bp, cholesterol, the rate (heart rate?)
- daily ASA
Chronic traumatic encephalopathy (CTE)
- related to what histological finding
- who gets it
- tao proteins
- NFL, NHL, professional boxers, veterans from gulf war
