Dementia and Delirium Flashcards
1
Q
Why do we care about dementia?
- “_______” population
- By 2030, there may be 70 million elderly in the US (currently around 35 million)
- Current prevalence rates of dementia
- 6-8% if older than ___
- 30% if older than ___
A
- “Graying” population
- By 2030, there may be 70 million elderly in the US (currently around 35 million)
- Current prevalence rates of dementia
- 6-8% if older than 65
- 30% if older than 80
2
Q
Screening for Cognitive Impairment: Policy Update
- _________ benefit: Annual Wellness Visit
- Cognitive assessment for ______ detection
- Personalized health ____ assessment (HRA) and _____ plan
- Incentives
- For patients: ___ deductible or co-pay
- For physicians: _________ equivalent to Level 4 E/M
A
- Medicare benefit: Annual Wellness Visit
- Cognitive assessment for early detection
- Personalized health risk assessment (HRA) and prevention plan
- Incentives
- For patients: no deductible or co-pay
- For physicians: reimbursement equivalent to Level 4 E/M
3
Q
What is Dementia?
- Impairment in ______ function affecting more than one ______ domains
- Interferes with s_____ or o______ function
- De____ from a previous level
- Not explained by de_____ or major ______ disease
A
- Impairment in intellectual function affecting more than one cognitive domains
- Interferes with social or occupational function
- Decline from a previous level
- Not explained by delirium or major psychiatric disease
4
Q
Cognitive Domains
- (1) (frontal, hemispheric white matter)
- (1) (medial temporal lobes/hippocampus)
- (1) (left hemisphere, usually)
- (1) (occipital, parietal)
A
- Executive function (frontal, hemispheric white matter)
- Memory (medial temporal lobes/hippocampus)
- Language (left hemisphere, usually)
- Visuospatial (occipital, parietal)
5
Q
Aphasia
- Able to in____ and m______ a conversation
- Impaired com________
- Intact (2) however the speech is _____ with _____phasias, cir______, t_______and often using non______ phrases (“the thing”)
- Later language can be severely impaired with m_____, e______
A
- Able to initiate and maintain a conversation
- Impaired comprehension
- Intact grammar and syntax however the speech is vague with paraphasias, circumlocutions, tangential and often using nonspecific phrases (“the thing”)
- Later language can be severely impaired with mutism, echolalia
6
Q
Apraxia
=
Contributes to loss of (1)
A
Inability to carry out motor activities despite intact motor function
Contributes to loss of ADLs
7
Q
DSM 5 Criteria
(5)
A
- Dementia of the Alzheimer’s Type (DAT)
- Dementia of the Vascular Type
- Dementia with Lewy Bodies
- Frontotemporal Dementia
- Delirium
Collaboration, collaboration, collaboration, + consulting* (geriatric specialist)
8
Q
Dementia Subtypes
- Early onset =
- Represents what % of cases?
- Strong _____ link
- Tends to progress more ______
- Late onset =
- Represents _____ of cases
A
- Early onset: before the age of 60
- Less than 5% of all cases of AD
- Strong genetic link
- Tends to progress more rapidly
- Late onset: after age 60
- Represents the majority of cases
9
Q
Alzheimer Disease
=
- ______ neurodegenerative and dementing disease
- Prevalence ____ every 5 years after 65, ~___% of those older than ___
- Confirmation of Diagnosis =
A
Progressive neurological condition characterized by the buildup of proteins in the brain called “plaques” and “tangles”
- Commonest neurodegenerative and dementing disease
- Prevalence doubles every 5 years after 65; ~50% of those older than 85
- Confirmation of Diagnosis is dependent on brain biopsy after death*
10
Q
Alzheimer’s Risk Factors
- A___
- (1) positivity
- ______ History in (1) (especially if ______ onset)
- (1) (diabetes, heart disease, etc)
- Low (3)
- ______ sex
A
- Age
- ApoE-e4 positivity
- Family History in first degree relative (especially if younger onset)
- Vascular risk (diabetes, heart disease, etc)
- Low education and physical/social activity
- Female sex
11
Q
Alzheimers Clinical Features
- First noticeable symptom?
- Earliest cognitive symptoms (2)
- Pattern of decline?
- Other domains develop when?
A
Increasing memory loss over time is often the first noticeable symptom
Earliest cognitive symptoms are usually poor short term memory; loss of orientation
Smooth, usually slow decline without dramatic short-term fluctuations
Other domains involved with time
12
Q
Alzheimers Common Signs
- Getting stuck for _____ or ______ difficulties
- ________ things (names, dates, places)
- loss of (1)
- difficulty in solving (1) or performing (1)
- mis_____ things
- poor or decreased (1)
- changes in m_____, b_____, and overall p________
- Easily dis______, even in ______ surroundings
A
- Getting stuck for words or language difficulties
- Forgetting things (names, dates, places)
- Loss of interest in things previously interested in
- Difficulty in solving problems or performing everyday tasks
- Misplacing things
- Poor or decreased judgment
- Changes in mood, behavior, and overall personality
- Easily disorientated, even in familiar surroundings
13
Q
Alzheimers Behaviors and Psych
- (1), anxiety
- _____ty, _____ty, _____thy
- D______, H______
- S____-w____ changes
- S_________
- Ag______
- Important to also screen for depression using (1)
A
- Depression, anxiety
- Irritability, hostility, apathy
- Delusions, hallucinations
- Sleep-wake changes
- Sundowning
- Agitation
- Important to also screen for depression using Geriatric depression scale
14
Q
Anatomical Changes of the Brain
Mild/Moderate vs. Severe Alzheimers
A
- Shrinkage of hippocampus, Cortical shrinkage, Moderately enlarged ventricles
- Extreme shrinkage of hippocampus, Extreme shrinkage of cerebral cortex, Severely enlarged ventricles
15
Q
Lewy Body Dementia
- % of all dementias?
- Relatively earlier (2) degeneration
- Similar to _______ disease dementia
A
- 20% of all causes of dementia
- Occipital and Basal Ganglia degeneration
- Similar to Parkinson disease dementia
16
Q
Lewy Body Dementia Characteristics
- Progressive decline in N_______ functioning
- D_______, Le_____
- Lengthy periods of ______ into _____
- Disorganized ______
- Visual _______* or delusions
- Motor symptoms including muscle _____ and loss of (1)
- ________ is also common
A
- Progressive decline in Neurocognitive functioning
- Drowsiness, Lethargy
- Lengthy periods of staring into space
- Disorganized speech
- Visual hallucinations* or delusions
- Muscle rigidity, loss of spontaneous movement
- Depression is also common
17
Q
Lewy Body Dementia
Earliest symptoms (2)
A
Visuospatial and Executive
- Executive like balancing checkbook, visuospatial like climbing stairs
- Concerned for delirium on top of dementia
18
Q
Lewy Body Dementia Core Features
- ________ism
- Recurrent early (1)*
- Fl________ (clue: recurrent (1) evaluations)
- Suggestive features include (1) (dream enactment) & neuroleptic sensitivity
A
- Parkinsonism
- Recurrent early visual hallucinations
- Fluctuations (clue: recurrent DELIRIUM evaluations)
- Suggestive features include REM sleep disorder (dream enactment) & neuroleptic sensitivity
19
Q
Frontotemporal Dementia (FTD)
Arises from?
Originally known as?
Characterized by changes in (2) lobes that control (4)
A
Pathologic aggregates of Tau protein (TDP-43)
Pick’s disease
Frontal and Temporal lobes of the brain that control reasoning, personality, social behavior, and speech
20
Q
Frontotemporal Dementia Prevalence
Usually seen in what population?
Can you diagnose it with an MRI?
A
- Usually are YOUNG and need to screen for PSYCHIATRIC DISORDERS*
- MRI is not diagnostic but will show structural abnormalities can help indicate FTD vs. LBD vs. Alzheimers*
21
Q
Frontotemporal Dementia Characteristics
- FTD manifested by changes in (2)
- (2) change (may be initially misdiagnosed as a psychiatric disorder)
- E______ dysfunction
- Progressive non-fluent _______
- May see ____sonism or _____ weakness
A
- Behavior and Language
- Behavior and personality change (may be initially misdiagnosed as a psychiatric disorder)
- Executive dysfunction
- Progressive non-fluent aphasia
- May see parkinsonism or muscle weakness
22
Q
Vascular Dementia
=
“Evidence of (1) disease involving subcortical _____ matter”
- This finding is nondiagnostic and very _____ with age
- Changes may or may not be ______
- Don’t tell patients what?
A
Caused by multiple infarcts that lead to a disruption in blood flow to the brain
“chronic small vessel disease involving subcortical white matter”
- common with age
- may or may not be symptomatic
- Don’t tell patients “your scan showed strokes” - this is chronic small vessel/vascular dementia, not actual CVAs”
23
Q
Vascular Dementia
Suspect when
- Onset is (1) and/or (1) decline
- Course is (1)
- H/O (1)
A
- abrupt, stepwise decline
- fluctuating
- H/O stroke
24
Q
Vascular Dementia
Often associated with _______ dysfunction, ____ disorder, A_____, In_______
- Common presenting symptoms include
- C_______, ____ term memory deficits
- W_______, getting lost in ______ places
- Gait is (2)
- Loss of (2) control
- (2) inappropriately
- Difficulty following _______ and problems counting/making _____ transactions
A
Executive dysfunction, Gait disorder, Apathy, Incontinence
- Confusion, short term memory deficits
- Wandering, getting lost in familiar places
- Rapid, shuffling gait
- Loss of bowel and bladder control
- Laughing or crying inappropriately
- Difficulty following instructions and problems counting/making money transactions
25
Q
What type of Dementia is this?
- Gradual impairment in memory, functional status, and other areas of cognition
- Plateaus in course of progression, associated depression, insomnia
A
Alzheimer’s
26
Q
What type of Dementia is this?
- Sudden onset of cognitive impairment in setting of stroke and/or risk factors of stroke
- Focal neurological signs on exam; neuroimaging evidence of previous stroke; presence of HTN, DM, CAD, ⇡ lipids
A
Vascular (multi infarct) Dementia
27
Q
What type of Dementia is this?
- Deficits in attention and executive function. Memory impairment may no be evident
- Fluctuating cognition, recurrent visual hallucinations, motor features of parkinsonism, recurrent falls
A
Lewy Body Dementia
28
Q
What type of Dementia is this?
- Gait disorder mimicking Parkinson’s, dementia, urinary incontinence
- Shuffling, broad based gait, improvement following large volume spinal tap
A
Normal Pressure Hydrocephalus
Normal pressure hydrocephalus - usually treated/cured with shunt placement, patient will get better
29
Q
Steps to take in Dementia Evaluation
- H_____
- P_____ and N______ Exam
- C______ Screening Test
- Rule out _______ Causes
- Neuro______
- Consider the Et______
- Treatment or R_______ (**in NY there are many memory centers, but PCP may be required for basic labs and imaging)
A
- History
- Physical and Neurological Exam
- Cognitive Screening Test
- Rule out Reversible Causes
- Neuroimaging
- Consider the Etiology
- Treatment or Referral (**in NY there are many memory centers, but PCP may be required for basic labs and imaging)
30
Q
History Taking
- Patient will “_____” their memory problems
- Get history from ____ or _____, if possible.
- Memory impairment may be evidenced by repetitive ______, ____writing, _____ objects, etc
- Ask about ______ impairment
- Ask about (1) to assess functioning
- Dementia is not just (1)!
- Next step = _______ screening test
A
- Patient will “forget” their memory problems
- Get history from caregiver or spouse, if possible.
- Memory impairment may be evidenced by repetitive questioning, list writing, lost objects, etc
- Ask about memory impairment
- Ask about daily activities to assess functioning
- Dementia is not just memory impairment!
- Next step = cognitive screening test
31
Q
Features Associated with Dementia
- Ag____
- Ag________
- S_____ disturbances
- A______ (can be misdiagnosed as depression)
- De______ or an____
- P______ changes
- B______ disinhibition
- _______ insight
- (1) (visual more common than auditory)
- (1) (often paranoid or persecutory)
A
- Agitation
- Aggression
- Sleep disturbances
- Apathy (can be misdiagnosed as depression)
- Depression or anxiety
- Personality changes
- Behavioral disinhibition
- Impaired insight
- Hallucinations (visual more common than auditory)
- Delusions (often paranoid or persecutory)
38
Q
Mini Mental Status Exam
- O______ (10 points)
- Re________ (3 points)
- A______ and Ca________ (5 points)
- Re_____ (3 points)
- L_______ (8 points)
- V________ (1 point)
- Total=___, if less than ____, consider dementia, ___-___= moderate,
A
- Orientation (10 points)
- Registration (3 points)
- Attention and Calculation (5 points)
- Recall (3 points)
- Language (8 points)
- Visuospatial (1 point)
- Total=30, if less than 25, consider dementia, 13-20 = moderate, <12 = severe
39
Q
Clock Drawing Test
Part of the (1)
There are certain times providers are suggested to use, ie (1)
A
Mini Cog
11 after 9
40
Q
Mini Cog
=
- More sensitive than CDT
- Same advantages as CDT
- Not as commonly used as MMSE, but FAST
- Involves visuospatial, executive and planning, and memory functions
- “Positive” = ___ word recall/ ______ clock
A
Clock-Drawing + three item memory test
- More sensitive than CDT
- Same advantages as CDT
- Not as commonly used as MMSE, but FAST
- Involves visuospatial, executive and planning, and memory functions
- “Positive” = 2 word recall and/or abnormal clock
42
Q
Cognitive Decline
What is CJD?
A
Creutzfeldt-Jakob disease (prion disease that is asctd with mad cow disease (eating bad meat) - outcome is usually poor, has a rapid decline)
43
Q
Types of Dementia
A
Types of Dementia
45
Q
Imaging
- Most Treatment Guidelines call for _______
- (1) usually adequate (w/o contrast)
- (1) if Vascular Dementia is suspected
A
- Most Treatment Guidelines call for Imaging
- CT usually adequate (w/o contrast)
- MRI if Vascular Dementia is suspected ***MRI W/O contrast is first choice - however if pt has agitation, paranoia, underlying breathing problem, MRI may not be first choice or may require sedation however sedation or contrast requires collaboration
56
Q
Common Doses
- Donezepil
- Galantamine
- Rivastigmine
- Memantine
A
- 5mg/day, 10mg/day target dose after 1m
- 4mg BID, 24mg/day target dose, increase by 4mg BID every 1m
- 1.5mg BID, 6-12mg target dose, increase by 1.5 BID every 1m
- 5mg/day, 10mg BID target dose, increase by 5mg daily every week
61
Q
Diagnosing Dementia and Clarifying Goals of Care
A
62
Q
Fast Scoring Dementia
Scale (1)
A
Functional Assessment Scale (FAST)
67
Q
Hyperactive vs. Hypoactive Delirium Chart
A
Fill in the blanks
71
Q
Beers Criteria
High Risk Drugs in Delirium
(11)
BONAAAATHAB
A
- Benzodiazepines
- Opioid analgesics (especially meperidine)
- Nonbenzodiazepine sedative hypnotics (ie zolpidem)
- Antihistamine (1st gen sedating agents doxylamine and diphenhydramine)
- Alcohol
- Anticholinergics (oxybutynin, benztropine)
- Anticonvulsants (primidone, phenobarbital, barbital, phenytoin)
- Tricyclic antidepressants (especially tertiary amines - amitriptyline, imipramine, doxepin)
- Histamine H2 receptor blockers
- Antipsychotics (especially low potency typical antipsychotics like chlorpromazine and thioridazine)
- Barbiturates
73
Q
CAM Diagnostic
- Only ___-___% of delirium cases are recognized.
- Systematic reviews support the (1) as the most useful bedside assessment tool.
- The CAM algorithm establishes the diagnosis of delirium according to the presence or absence of (4) features
A
- Only 12 to 35% of delirium cases are recognized.
- Systematic reviews support the Confusion Assessment Method (CAM) as the most useful bedside assessment tool.
- The CAM algorithm establishes the diagnosis of delirium according to the presence or absence of four features:
- acute change in mental status with a fluctuating course
- inattention, and either
- disorganized thinking or an
- altered level of consciousness.
77
Q
Medications for Delirium
(6)
A
Haloperidol
Risperidone
Olanzapine
Quetiapine
Ziprasidone
Lorazepam
