Dementia & Delirium Flashcards
Dementia
-impairment of intellectual/cognitive function of sufficient severity to interfere with social or occupational activities
Delirium
-clouding of consciousness (altered clarity of awareness of the environment), with reduced capacity to shift, focus, & sustain attention to environmental stimuli
Diagnostic Criteria for Dementia?
- Impaired short and long term memory
- at least one of: impaired abstract thinking, impaired judgment, other disturbances (aphasia, apraxia, agnosia)
- disturbances in 1 or 2 interferes with work or ADL
- symptoms not occurring exclusively during delirium
- Either: a) evidence from hx, physical exam or lab of organic cause b) in the absence of evidence for organic cause, exclusion of non-organic mental disorder (depression)
Diagnostic Criteria for Delirium?
- Disorientation & memory impairment
- at least 2: a) perceptual distrubance: misinterpretations, illusions, or hallucinations
b) speech that is incoherent at times
c) disturbance of sleep-wake cycel (insomnia or daytime drowsiness)
d) inc. or dec. psychomotor activity - clinical features that dev. over short period (hrs or days) fluctuate
- Evidence from the history, physical exam or lab tests of a spec. organic factor judged to be etiologically related to the disturbance
Key features of Dementia
- cognitive deficit in multiple domains, usually but not always including memory
- progressive deterioration over months to years
- cognitive impairment interferes with activities of daily life
- no disorder of alertness
- irreversible
Key features of Delirium
- acute disorder usually associated with medical illness, drugs, metabolic disorders
- over days to weeks
- fluctuating course
- altered level of consciousness, excitable, delusions, hallucinations
- reversible
Depression
known onset
- family is aware
- short duration
- history of depression
- little effort on tasks
- response to cognit. “don’t know”
- no cortical signs
Causes of Dementia
- Neurodegenerative Diseases
- Vascular Dementia
- Head Trauma
- Drugs, Toxins, Ethanol
- Brain Tumors
- Normal Pressure Hydrocephalus
- Infections
- Metabolic Disorders
- Nutritional (B1, B12, Folate, Niacin deficiencies)
Alzheimer’s Disease
- progressive neurodegenerative dementing disorder characterized by the neuropathological findings of…
1) loss of cerebral cortical neurons
2) neuritic plaques containing beta-amyloid
3) neurofibrillary tangles
Alzheimer’s Disease Diagnostic Criteria
- Essential: neuropsychological tests, deficits in memory plus one or more areas of cognition, progressive worsening of memory plus one other cognitive function, no disturbances of consciousness, onset b/w 40-90, absence of other brain disease to explain dementia
- Supportive: progressive deterioration of single cognitive area, impaired activities of daily living, altered behavior, family history of dementia, lab showing normal CSF, nonspecific EEG, & atrophy on CT or MRI
Consistent Features for Alzheimer’s
- plateaus in course
- association depression, insomnia, incontinence, delusions
- non-specific neurological findings later in disease (altered muscle tone, myoclonus, gait ataxia, seizures)
- CT or MRI “normal for age”
Inconsistnet Features in Alzheimer’s
- sudden or acute onet
- focal neurologic findings (hemiparesis)
- seizures or gait disorder at onset or early in disease
Epidemiology of Alzheimer’s Disease
-500,000 new cases in US each year
-5-10% of population >65% and 40-45% >85 will develop Alzheimer’s Disease
~5.4 million people with Alzheimer’s in US
-These numbers are expected to triple over the next 10-20 years as the ‘baby boom’ population enters their 7th and 8th decades
Clinical Presentation of Alzheimer’s Disease
- insidious onset after age 65 of deficits in recent memory followed by deficits in attention, language, visual-spactial, orientation, abstract thinking, judgment, & eventually personality
- premorbid diagnosis is purely clinical (no lab tests)
- postmortem based on neuritic plaques, neurofibrillary tangles, neuron loss
Alzheimer’s Gross
-narrowing of gyri and widening of sulci
Alzheimer’s Micro
- plaques in cortex
- tangles in hippocampus
Alzheimer’s Gene
-Early onset chromosome 21 APP (AD1) 8 mut (Down's) Chromosome 14 presenilin 1 (AD3) > 50 mutation Chromosome 1 presenilin 2 (AD4) 4 mutat. -late onset Chromosome 19 Apo E (AD2) 3 alleles Chromosome 12 a2-Macroglob (AD5) 2 alleles Chromosome 10
Apolipoprotien E
- 3 alleles of APO E (2, 3, 4)
- participates in cholesterol transport
- APO E 4 is a risk factor for Alzheimers
- APO E 4 contributes to 50% of late onset AD
Risk Factors for Alzheimer’s Disease
- age, genetics, Down’s syndrome (mongolism)
- education level, mental inactivity, female gender, head injury, hypercholesterolemia, smoking
Alzheimer’s: Amyloid Hypothesis
- abnormal processing of amyloid precursor protein with amyloid deposition causes AD
- autosomal dominant AD caused by inc. Beta-amyloid synthesis
- late onset AD caused by dec. turnover and aggression of beta-amyloid
- beta-amyloid deposition precedes clinical symptoms
- neurofibrillary tangles and neuronal loss occur secondary to beta-amyloid deposition
Lewy Bodies
- eosinophilic, spherical inclusions with a halo appearance located in the cytoplasm of neurons of the substantia nigra in patients with Parkinson’s Disease
- comprise of neurofilament proteins, alpha synuclein, & ubiquitin
- present with dementia (in neocortex)
- avoid neuroleptic agents in DLB
Frontotemporal Dementias
- degenerations of frontal & temporal lobes
- Neurofibriallary tangles and or Pick bodies comprised of ubiquitin & hyper-phosphorylated tau protein are the hallmark
- “tauopathies”
Clinical Characteristicts of Pick Disease
-uncommon cause of dementia
30-40% are familial with mutation on chromosome 17 for tau protein
-5th decade onset (eariler than AD)
-progressive loss of judgment with disinhibtion, social misconduct, or withdrawal out of proportion with the degree of anterograde amnesia
-progressive loss of language aut of proportion to the degree of anerograde amnesia
Pick Gross/Micro
- atrophy in frontal lobe and tip of temporal lobe
- “knife like” gyri
- Pick Bodies
- Intracytoplasmic, argyrophilic inclusions of 14nm straight filaments and 22nm twisted filaments comprised of tau protein & ubiuitin
Frontotemporal Dementias: Anatomic/Symptom Correlation
-Frontal Lobe Symptoms
disinhibited, socially inappr., impulsive, compulsive, hyperphagic/oral, hypo/hyper sexual, nonfluent aphasia
-Temproal Lobe
fluent (sematic) aphasia, emotionally flat, apathetic
Vascular Dementia: Characteristicts
- 2nd most common cause of dementia death
- multiple infarctions involving large or small vessels
- multiple distribution of infarcted brain
- high incidence in untreated or poorly treated HTN
- considerable overlap with Alzherimer’s Disease in the >65 age group
Workup for Dementia
- Folstein Mini-Mental Status Examine
- total 30, <27 raise concern
