Dementia and Delirium -Heh Flashcards
What is the difference in EEG findings seen in delirium vs. psychosis?
Delirium will show diffuse slow waves while psychosis will show a normal EEG
(anti-psychotics can give you diffuse slow waves too)
What is delirium?
- Disturbance in consciousness
- Impaired attention
- Memory deficit, disorientation, language disturbance, or perceptual disturbance
- Flucuates and relatively quick onset
- *Usually you can find medical/organic reasons for the Delirium
- ->Treating cause will fix delirium
- disturbed sleep wake cycle
- agitation
- illusions
- hallucinations
- paranoia
- many w/underlying dementia
What are possible etiologies of delirium?
- Metabolic disturbances/dehydration
- Infection
- Hypoxia
- Hypoglycemia
- Drug intoxication/withdrawal/adverse rxn
- Stroke, absess, trauma, post-ictal state
- New onset afib, cardiac ischemia
What should be part of the assessment in a delirium pt?
- physical exam/vitals
- neurological signs–> weakness
- frontal lobe release signs
- labs: UA, CBC, CMP, CXR, CT head, EKG, EEG, Tox screen, ABG, LP (in some)
What are some treatment options for delirium?
-Correct underlying medical problem
- can use physical restraints or chemical (if necessary)
- resynchronize the sleep wake cycle
- ground the pt
- diminish external stimuli
What is dementia?
-Syndrome consisting of impaired cognition functions that interfere with his/her ability to function
- Can involve the 4 A’s:
- aphasia (language problems)
- amnesia (impaired memory)
- apraxia (inability to carry out motor activities)
- agnosia (inability to recognize)
-most are irreversible
What are some signs of early dementia?
-personality, memory or attention changes
- appear more apathetic
- loss of interest in hobbies
- unwilling to try new things
- unable to adapt to change
- poor judgement and make poor decisions
- take longer with routine jobs
- more forgetful
- repeat themselves or lost the thread of their conversation
- become irritable or upset if they fail at something
What is the difference between mild and moderate dementia?
Moderate dementia has similar features as mild dementia but the problems are more apparent and disabling
What is severe dementia?
the person is severely disabled and needs total care.
- Lose their ability to understand or use speech.
- Be incontinent.
- Show no recognition of friends and family.
- Need help with eating, washing, bathing, using the toilet or dressing.
- Fail to recognize everyday objects.
- Be disturbed at night.
- Be restless, perhaps looking for a long dead relative.
- Be aggressive, especially when feeling threatened or closed in.
- Have difficulty walking, eventually perhaps becoming confined to a wheelchair.
- Have uncontrolled movements.
- Immobility will become permanent and, in the final weeks or months, the person will be bedridden.
What is pseudo dementia? Is it reversible?
- depression that causes dementia
- reversible*
- Effort dependent testing (give up)
- Cognition improve with mood
- No “sundowning”
- Recent weight loss
- Crying spells, suicidal thoughts
- No apraxia, no agnosia, no aphasia
What mini mental status exam score SUGGESTS dementia?
What score indicates definite impairment?
> 25/30 suggest impairment
> 20/30 definite impairment
What are the different levels of consciousness?
- coma (unresponsive)
- stupor (responsive to pain)
- lethargic (drowsiness)
- alert (full awareness)
“Clouded consciousness”
What are normal verbal fluency test scores?
- naming words that start with F in one minute: normal=11+
- animals in 1 min: <12=abnormal
What is the most common cause of degenerative dementia?
Alzheimer’s disease
What pathological changes occur intracellularly in Alzheimer’s Disease?
- Neurofibrillary Tangles form from Hyperphosphorlyated Tau proteins causing abnormal microtubules to collapse (intracell)
- Hirano bodies (intracellular aggregates of actin)
- Granulovacuolar degeneration (intracellular vacuoles within the cell body, each with a small, dense inclusion)
What pathological change occurs extracellularly in Alzheimer’s disease?
What can speed up this process?
beta amyloid oligomers form plaques that cause neuronal death
Oxidative stress can fuel this process (sleep deprivation, brain injury, PTSD)
What areas of the brain are degenerated in AD? What does this result in?
- Nucleus basalis (ACh producing) –> memory and cognitive processes
- raphe nuclei (serotonin producing)–> loss of mood regulation
What are some risk factors for Alzheimer’s Disease?
- Head injury with loss of consciousness
- Older age
- Family history of dementia
- Familial AD autosomal dominant/mutation 21,14,1
- e4 allele of apolipoprotein gene Chromosome 19
- Family history of Parkinson’s disease
- Down’s syndrome
- Very low education (< 6 years)
- Diabetes ? (Metformin)
- Female gender (mildly increases the risk because women live longer)
- Late Life Depression ?
What have PET scans of NFL players who experienced many sub-concussive blows shown?
- high signals in the amygdala, midbrain, thalamus, and caudate regions
- this hyperactivity gives neuropathological findings consistent with AD and dementia (tau and plaques)
- more concussions=more tau proteins
What are the treatment options for AD?
Acetylcholinesterase inhibitors:
- Doneepezil
- Galantamine
- Rivastigmine
NMDA blocker:
-Memantine
What should you NOT give to a patient with dementia due to a blackbox warning??
Antipsychotics
can lead to increased mortality and sudden death
What are some features of dementia with Lewy bodies?
- Similar to AD, progressive, irreversible, but more malignant
- Visual hallucinations and Parkinsonian features
- Lewy bodies-eosinophilic inclusion bodies cortex/brainstem
- Sensitive to psychotropics, especially EPS of conventional antipsychotics
What are some features of frontotemporal dementia?
- Tau positive inclusions/some with PK symptoms
- Pick’s Disease is a type of FT Dementia
- changes in behavior
- problems with speech
- memory is the last to go!
What are early signs of Huntington’s Disease? What will imaging show?
behavioral changes
difficulty learning new things
speech difficulties
imaging: flattened caudate head and enlarged ventricles
