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Neuro > Dementia & Delirium > Flashcards

Dementia & Delirium Flashcards

1
Q

What is dementia?

A
  • Loss of intellectual ability –> impairment of functioning
  • Must involve memory impairment + at least 1 other domain (memory, attention, language, mood)
  • Can be static, progressive or remitting BUT it’s acquired and irreversible
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2
Q

Dx of Dementia - Strategy and Tools

A
  • Goal = r/o other possible causes of cognitive effects
    • Patient and informant interview
    • MRI - r/o stroke or subdural hemorrhage & look for hippocampus or medial parietal atrophy
    • PET - can see hypoperfusion or hypometabolism
    • CSF - may show AlphaBeta or tau
    • Bloodwork to look for treatable causes of dementia - TSH, B12, inflammatory markers, etc
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3
Q

AD Risk Factors (5)

A
  • AGE
  • ApoE
  • Cardiovascular - hypertension, DM, stroke
  • High educ is protective
  • Head trauma
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4
Q

AD Symptoms In Order

A

**follow time course as pathology progresses to additional brain networks

  • 1- episodic memory deficits; forgetfulness; problems w/ consolidation of new declarative memory (entorhinal cortex/hippocampus)
    • 2- aphasia, visual-spatial, executive function deficits + anxiety/depression if amygdala involved (heteromodal or different unimodal areas)
    • 3- Motor/sensory changes (primary motor, auditory and visual cortex) + retrograde amnesia
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5
Q

3 Types of AD Pathology

A
  • Amyloid = extracellular
    • APP (amyloid precursor protein) is transmembrane; can be cut by multiple proteases; if cleaved in certain way –> amyloid Beta produced which is insoluble
    • Mainly in limbic system
  • Tau = intracellular
    • Hyper-phosphorylated tau protein forms tangles
    • Mainly in temporal lobes
    • More linked to symptoms
  • Acetylcholine
    • Loss of cholinergic cells in basal forebrain (moderately improved w/ acetylcholinesterase inhibitors)
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6
Q

DLB v. PDD

A
  • DLB if… dementia w/in 1 yr of Parkinsons onset + early visual hallucinations
  • PDD (Park Disease w/ Dementia) if… dementia only after&raquo_space;1 yr and visual hallucinations later
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7
Q

DLB Features

A
  • Core Features - dementia, parkinsonism, fluctuating cognition (min to hrs rather than days like AD), visual hallucination are form and threatening
  • Suggestive Features - REM sleep behavior (act out dreams), neuroleptic snesitivity
  • Others - repeated falls, autonomics (constipation, orthostatic hypertension), delusions, depression, etc
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8
Q

DLB Time Course

A

**represents spread of pathology

  • 1- early autonomic problems w/ orthostatic hypertension, constipation, incontinence (brainstem)
    • 2- Motor/Parkinsonian symptoms (midbrain - substantia nigra pars compacta)
    • 3- Visual hallucinations and attention lapses (Ach –> cortex)
    • 4- Executive function and memory (limbic system)
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9
Q

DLB Pathology

A
  • Lewy Bodies = intracellular or intra-axonal deposits of alpha - synuclein
  • Can identify them immuno-histochemically
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10
Q

What drugs should you avoid in those w/ DLB?

A
  • Typical anti-psychotics to treat hallucinations; they have neuroleptic inc sensitivity to them b/c already have depleted Ach and these drugs inc dopamine at expense of Ach; makes symptoms worse
  • Can lead to deterioration - Neuroleptic Malignant Syndrome
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11
Q

Delirium v. Dementia

A
  • Both acquired and present w/ cognitive impairment in mult domains
  • Differ in time course - delirium is acute, time-limited, reversible and fluctuates in type and severity
  • Delirium includes impairment in attention, hallucinations, drowsiness and agitation (but these can all also be seen in dementia); attention/arousal problems usually not seen until later in dementia course
  • **Dementia is a risk factor for delirium
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12
Q

Delirium DSM V Criteria

A
  • Disturbance in attention and awareness that develops over short period of time and fluctuates in severity over course of day (v. dementia which is gradual progression)
    • Reduced ability to adjust, shift, focus attention
  • Must have 1 additional disturbance - includes memory deficit, disorientation, perception disturbances, etc
  • Cannot be better explained by evolving neurodegenerative disorder OR coma
  • Not direct results of med, intoxication, withdrawal, etc
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13
Q

Epidemiology of Delirium

A
  • 80% ICU patients
  • Common in hospitalized pts (esp elderly post-op)
  • Inc hospital time, inc mortality, inc D/C to facilities
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14
Q

Risk Factors for Delirium (7)

A
  • Age
  • Cognitive impairment (Dementia)
  • Severity of illness
  • Vision, hearing impairment
  • Dehydration (High BUN/Cr)
  • Chronic medical illness
  • Orthopedic and cardiac surgery
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15
Q

Clinical Features of Delirium + 3 Types

A
  • Arousal (can be inc or dec), awareness, attention (easy to distract and cannot keep up w/ sequences), perceptual disturbances (hallucinations) and sleep-wake disturbances (sleepy in day then sundowning- agitated at night)
  • 3 Types - hyperactive, hypoactive, mixed
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16
Q

Delirium Pathology (anatomic and chemical)

A
  • Anatomical - paralimbic areas (temporal, thalamus); brainstem (arousal); parietal lobes (R>L)
  • Altered Neuronal Metabolism - hypoxia, inflammatory cytokines (infection), glutamate problem in liver problem
  • Chemical -
    • Ach - dec w/ age; acetylcholine metabolism is sensitive to brain hypoxia; affected by anti–cholinergic meds
    • Dopamine - too much dopamine –> delirium and hypoxia also inc dopamine levels; can treat these patients w/ dopamine antagonist anti-psychotics
    • Histamine - promotes arousal; anti-histamines can induce delirium
17
Q

Common Causes of Delirium (9)

A
  • Vascular- Stroke
  • Infection- URINARY TRACT INFECTION ; sepsis, encephalitis, meningitis, pneumonia
  • Trauma- sub-dural hemorrhage
  • Anoxia/Hypoxia
  • Medications!!
    • Anticholinergics, Antihistamines, Dopaminergic
    • Anesthetics
    • Illicit drugs (PCP, Cocaine, Stimulants, Ecstasy)
  • Metabolic
    • Diabetes (hypo/hyperglycemia)
    • Hepatic failure
    • Kidney failure
    • Dehydration
  • Iatrogenic- sleep deprivation/ medical procedures
  • Neoplastic
  • Seizures/ Structural
18
Q

6 Steps of Delirium Dx

A
  • 1- Good hx and test attention (spell WORLD backwards or name months backwards)
  • 2- Find cause
    • General exam - infection, pain, abdomen
    • Neuro exam - any focal findings?
    • Review chart - meds, labs, nutrition, predisposing conditions
  • 3- CBC, electrolytes, LFs, UA, TSH, CXR, B12/thiamine
  • 4- Consider neuroimaging if no known cause - MRI (usually low yield)
  • 5- EEG - in case non epileptic SE
  • 6- Brain infection?? - do lumbar puncture
19
Q

Delirium Management

A
  • Treat underlying cause (ex - tx UTI)
  • Watch electrolytes and nutrition - be proactive
  • Dec unfamiliarity - calendar, clock, personal objects, family pictures & reorient w/ family visits
  • Dec staff changes, dec TV and ambient noise
  • Discontinue any unnecessary meds
  • Use low dose atypical anti-psychotics if needed (risperidone, quitiapine, olanzapine, aripiprazole)
20
Q

4 Cardinal Executive Functions

A

working memory, inhibition, initiation, monitoring (keep track of stimulus and re-evaluate occasionally)

21
Q

Cortical Regions of Executive Function (3)

A
  • Orbital Prefrontal - internal response to environmental stimuli; emotional processing; judgment
    • Lesion can lead to impulsive behaviors, poor insight and social skills
  • Medial Prefrontal - (ant angular cortex) motor responses to stimuli; reward centerl decisions and response selection (DOPAMINE)
    • Damage can lead to akinetic mutism
  • Lateral Prefrontal - working memory, attention, regulate external behavior in response to environmental stimuli; top-down processing
    • “lose train of thought”
22
Q

Subcortical Regions of Executive Function

A

caudate, substantial nigra, globes plaids, thalamus (medial dorsal thalamus specifically)

23
Q

Frontotemporal Dementia

A
  • 2nd most common dementia in those under 65
  • Behavioral variant and language variant
  • Pathology - tau inclusions, Tar-DNA binding protein inclusions (TDP 43)
  • Dx - may use MRI and look for more atrophy in frontal and temporal lobe… if negative can use PET/SPECT
  • Clinical
    • See behavioral, OCD, socially inappropriate problems 1st; then cognition and visuospatial problems come later
    • May pass all cognitive bedside tests

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