Dementia, Delirium, Geri Depression Flashcards
what is dementia?
Acquired, persistent, and progressive impairment characterized by decline in cognition
what cognitive domains does dementia involve deficit in one or more?
- learning and memory
- language
- executive function (balancing checks)
- complex attention
- perceptual-motor
- social cognition
for dementia, the pt’s deficit must represent what? what must it be severe enough to do?
a decline from previous level of fxn
must be severe enough to interfere with daily function and independence
what is the most frequent form of dementia in the elderly?
alzheimer disease
what are the 4 main types of dementia in the elderly?
- Alzheimer disease (M/C)
- Vascular dementia
- Lewy body dementia
- Frontotemporal dementia
what pathology is seen in Alzheimer disease?
Amyloid plaques/oligomers
what pathology is seen in Frontotemporal dementia?
tau or ubiquitin proteins
what pathology is seen in Lewy body dementia?
α-synuclein inclusion bodies
what is the classic triad of findings for Alzheimer’s?
- Memory impairment
- Visuospatial problems
- Language impairment
what functions in AD are spared until later stages?
motor/sensory function
what are the sx’s like in early AD?
- Patients able to retain social functioning
- Ability to accomplish overlearned tasks
- Have difficulty in more complicated tasks (balancing checkbook)
what is a common sx of AD?
disorientation
what do pts with AD have disorientation to at first?
time/place/person -> reason why we ask these things first
language d/o in AD begins with what and progresses to what?
begins with subtle anomic aphasia and progresses to fluent aphasia and then mutism
what behavioral changes are common in AD?
Apathy and irritability (esp when dress and grooming)
Depression
Psychotic sx’s (delusions, hallucinations, paranoia) - in advanced stages
what is vascular dementia dx based on the presence of?
Dx based on presence of clinical/radiographic evidence of cerebrovascular disease in pt. with dementia
what supports the dx of vascular dementia?
- Sudden onset after stroke
- Step-wise decline in functioning
- Focal neuro sign on PE
what is step-wise decline in functioning in vascular dementia?
Something happens before each decline in functioning -> NOT PROGRESSIVE
4 causes of vascular dementia
- untreated HTN
- DM
- high cholesterol
- heart disease
what are the 3 neurologic signs of vascular dementia?
- Pronator drift
- Gait instability
- Slowing of motor performance
vascular dementia is a result of what?
damage to brain caused by problem with the arteries serving brain or heart
tx of vascular dementia?
control future infarct by controlling CVD risk factors
what are the 3 core features of Lewy body dementia?
- Parkinsonism
- Fluctuation in cognitive impairment
- Detailed visual hallucinations
when does Parkinsonism develop with Lewy body dementia?
after (or concurrent with) development of dementia
sx’s of Parkinsonism?
rigidity and bradykinesia
fluctuations in cognitive impairment for Lewy body dementia are seen in what?
level of alertness, cognitive functioning, functional status
what are the visual hallucinations like in Lewy body dementia?
vivid (often of animals, people, mystical things)
unlike psychosis, most DLB pts can distinguish hallucinations early on and not be bothered by them
at what decade/age does Frontotemporal Dementia develop?
early age, 5th decade
what is Frontotemporal Dementia characterized by?
early changes in personality and behavior (go to bank naked)
what are some sx’s that are highly suggestive of FTD?
- Hyperorality
- Early personality/behavior changes
- Early loss of social awareness (disinhibition)
- Compulsive/repetitive behaviors
- Progressive reduction in speech
who usually brings dementia problem to attention of provider?
spouse/informant (not the pt)
what is a good predictor of alter development of dementia?
informant-reported memory loss
pts with dementia have difficulty with one or more of the following:
- Retaining new information (trouble remembering events) -> Old memory is intact
- Handling complex tasks (balancing a checkbook)
- Reasoning (unable to cope with unexpected events)
- Spatial ability and orientation (getting lost in familiar places)
- Language (word finding)
- Behavior
what are useful questions for pt with dementia or information?
“When did you first notice the memory loss?”
“How has the memory loss progressed since then?”
can depression and dementia occur in the same pt?
YES
what should first appointment for pt with dementia focus on?
the hx
what must be r/o for pt presenting with dementia?
atypical presentation of medical illness
what part of the hx for dementia is particularly important?
drug hx -> POLYPHARMACY IS A MAJOR REASON FOR DEMENTIA
PE for dementia should be combined with?
a neuro exam
what should the neuro exam in dementia focus on?
focal neurologic deficits that may be consistent with:
- prior CVA
- signs of Parkinson disease (PD)
- gait abnormalities/slowing
- eye movements
what sx’s does AD not generally present with compared to other dementia?
no motor deficits in AD at presentation
evidence of decline for dementia dx based on what?
- Individual/informant/clinician concerned about significant decline in cognitive function
- A substantial impairment in cognitive performance (preferably documented by standardized neuropsychological testing)
what are the 2 cognitive tests for dementia?
MMSE and Mini-Cog
what does it mean when there is an agreement b/w hx and mental status exam?
strongly suggestive of dementia
what does it mean when hx of dementia pt suggests cognitive impairment, but mental status exam is normal?
- Mild dementia
- High intelligence or education
- Depression
- Misrepresentation on the part of the informants (rare)
what does it mean when mental status exam suggests cognitive impairment, but the family and pt deny any problems?
- Acute confusional state
- Very low intelligence or education
- Inadequate recognition by the family -> DENIAL
what is the MOST widely used cognitive test for dementia? how long does it take? scoring?
MMSE
takes approx 7 min to complete
max score of 30; < 24 dementia/delirium
what score on MMSE means dementia/delirium?
<24
what categories does MMSE test?
- Orientation
- Recall
- Attention
- Calculation
- Language manipulation
what is the mini-cog exam for dementia?
consists of a clock drawing task (CDT) and an uncured recall of 3 unrelated words
what does it mean if pt recalls NONE of the words on mini-cog exam?
demented
what does it mean if pt recalls ALL 3 WORDS on mini-cog exam?
non-demented
what does it mean if pt recalls 1-2 words on mini-cog exam?
classified based on the CDT
- abnormal = demented
- normal = non-demented)
what are advantages of the mini-cog exam over the MMSE?
high sensitivity for predicting dementia status, short testing time relative to the MMSE, ease of administration, and diagnostic value not limited by the subject’s education or language
what is the CAM-Confusion Assessment Method test for?
it tests for delirium
-acute onset of mental status changes or a fluctuation course AND inattention AND disorganized thinking OR altered LOC
what are the lab studies used for in dementia? what are the labs?
to r/o potentially treatable causes of dementia
-CBC w/electrolytes, Cr, glucose, LFTs, Vit B12 def, thyroid fxn, serum Ca
when would you do imaging for dementia?
if think pt has a reversible cause such as:
- subdural hematoma
- normal pressure hydrocephalus
- treatable cancer
what imaging is done in the routine initial evaluation of all patients with dementia?
non-contrast head CT or MRI
head CT or MRI is important for what patients?
pts with acute onset of cognitive impairment and rapid neurologic deterioration
focal neuro deficit -> CT
cancer -> MRI
what is the MAINSTAY of tx for dementia?
symptomatic
- modify behavior
- environmental manipulations to support fxn (use velcro)
- counseling w/ respect to safety issues
what meds do you NOT use in tx of dementia?
Antipsychotics (don’t use as 1st choice for behavioral/psych sx’s of dementia)
Benzo’s (don’t use as 1st choice for insomnia, agitation, or delirium)
nutrition and dementia
inadequate nutrition common in pts with AD
use oral nutritional supplements to help them weight gain
what are the 2 types of rehabilitation txts for dementia?
Cognitive rehab
-helps pts in early stages of dementia to maintain memory and higher cognitive fxn and to devices strategies to compensate for declining fxn
Exercise programs
-exercise improves physical functioning and slows progression of functional decline in pts with AD
what is Delirium?
acute change in mentation w/fluctuating course (pt is fine, then not fine)
what is delirium precipitated by?
underlying condition or event in vulnerable persons
what is delirium characterized by?
inattention, disorganized thinking, and/or altered LOS
how many people admitted to hospital experience delirium?
Approx. 1/3rd of pts >70yrs admitted to hospital experience delirium
what is the #1 RF for delirium?
dementia/cognitive impairment
what is the MOST COMMON reversible cause of delirium?
meds
what 3 stressors can cause delirium and how?
Trauma, Surgery, Infection
All release of pro-inflammatory cytokines, cause elevated cortisol
what are some RF’s for delirium?
age >65 y/o
dementia
depression (high association)
polypharmacy
hx of delirium
what are high risk meds that can cause delirium?
Meds with Anti-Cholinergic Effects
Benzo’s
Dopamine agonists
what are some meds with anti-cholinergic effects?
- Oxybutynin
- Ranitidine
- Amitriptyline, nortriptyline
- Hydroxyzine
- Digoxin
confusion vs delirium
confusion
-can’t think w/normal speed, clarity, or coherence
delirium
-talk fast, know what they are saying, but it sounds crazy
what is the HALLMARK sx of delirium?
distractibility (evidence in conversation)
sx’s of delirium?
Distractibility (HALLMARK)
acute change in MS, inattention, disorganized thinking, altered LOC
what is the most common presentation of delirium in elderly?
quiet, withdrawn state -> SCARED
what labs are done before imaging for delirium?
CBC, BMP
***UA (confusion in elderly -> think UTI)
Too screen of blood/urine if cause not immediately obvious (elderly ppl drink)
LP when cause unclear
ABG
what imaging is usually performed for delirium?
CXR
-pneumonia can be a cause of confusion
head CT if think bleed/MRI if think lesion
what is the behavioral/environmental tx for delirium?
- Reorientation, calendars, clocks
- Room near nursing station
- Lights on/off during day/night
- Windows
- Family/familiarity
- Hearing aids, glasses
***Avoid restraints
what is the pharmacological tx for delirium?
Haloperidol (antipsychotic med)
- no anticholinergic effects, no hypotensive effects
- Risk of EPS (akathisia), rare with IV route
is depression a normal consequence of aging?
NO
what people are at a high risk for completed suicides that also have depression?
white men >65 y/o
how many nursing home residence are depressed?
50%
depressed mood may be the first symptoms of what medical conditions affecting the elderly? what should you always check for elderly pt that is depressed?
stroke, DM, cancer, hypothryoidism, and coronary disease
***ALWAYS CHECK A TSH
when do most elderly suicide victims try to kill themselves?
in their 1st episode of depression and had seen a physician w/in the last month of life
sx’s of depression
Persistence of anhedonia or depressed mood for 2 wks. with four or more of the following:
- Worthlessness or guilt
- Decreased ability to concentrate
- Fatigue
- Psychomotor agitation or retardation
- Insomnia or hypersomnia,
- Changes in appetite or weight
- Recurrent thoughts of suicide or death
depression in elderly is less likely when what?
if pt has affection from family and caregivers, retains humor, looks forward to visits, and accepts assistance and care
-> all decrease risk of suicide
what are 2 screening questions for depression?
“During the past month, have you been bothered by feeling down, depressed or hopeless?”
“During the past month, have you been bothered by little interest or pleasure in doing things?”
questions to dx getriatic depression? scoring?
(1) Are you basically satisfied with your life?
(2) Do you often get bored?
(3) Do you often feel helpless?
(4) Do you prefer to stay at home rather than going out and doing new things?
(5) Do you feel worthless the way you are now?
-2/5 depressive responses (“no” to question 1 or “yes” to questions 2-5) suggests dx of depression
what is the PREFERRED meds for tx of depression in older adults?
SSRI’s (citalopram, escitalopram, and sertraline -> fewer DDIs or cognitive risks)
who should you ALWAYS consult when pt has depression?
Psychiatry
what does the FIRST-LINE tx of depression consist of?
psychotherapy (CBT) and somatic therapy (med or ECT)
ECT FIRST LINE tx for pts at risk for what? Who is ECT highly effective in?
ECT first-line treatment for patients at serious risk of suicide or life- threatening poor intake due to a major depressive disorder
ECT highly effective in major depressive disorder and mania in older adults
