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Clin med exam 2 > Dementias > Flashcards

Dementias Flashcards

1
Q

Dementia

A

An umbrella term
DECLINE in cognitive impairment
not explained by delirium or other psychiatric disorders

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2
Q

Cognitive impairment involves:

A

at least 2 of these:

visuospatial skills 
language skills 
memory 
judgement, reasoning or handling complex tasks 
changes in personality or behavior
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3
Q

Alzheimer disease

A

most common type of dementia

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4
Q

Risks for Alzheimer

A

Age
FH- autosomal dominant genetic mutations (earlier onset)
lower education level
woman> men

no racial or ethic differences

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5
Q

Pathophysiology for Alzheimer dementia

A

neuritic plaques (made of beta amyloid and other proteins)

neurofibrillary tangles (made from hyperphosphorylated tau)

decreased acetylcholine (acetyl cholinesterase breaks down acetylcholine)

hippocampus first regions to be affected

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6
Q

Clinical presentation of Alzheimer (memory)

A

insidiously and progressively

memory impairment

  • explicit (declarative- factual) memory often declines early (dependent on hippocampus)
  • memory for recent events (anterograde long-term episodic amnesia)

test: repeat words

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7
Q

Clinical presentation of Alzheimer (executive function)

A

less motivated, organized and abstract thinking
finances organization
driving, shopping, housekeeping
job

NOT ADL’s

anosognosia- unaware of deficits

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8
Q

Clinical presentation of Alzheimer (behavioral & neuropsychiatric)

A

apathetic, irritable, socially disengaged

overt agitation, aggression, psychosis, wandering

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9
Q

Clinical presentation of Alzheimer’s disease

A

memory
executive function
behavioral and neuropsychiatric

dyspraxia/apraxia- inability or difficulty to execute a learned motor task- ex: comb hair

olfactory dysfunction

sleep disturbances

visuospatial deficits- copy a shape, read a clock, etc

seizures

changes can destabilize pts- some pts have a set routine, so do not realize there is an issue, taking them out of the routine and environment it is obvious there is a problem

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10
Q

Possible progression of Alzheimer

A

Mild- memory
Mod- impaired language, confusion, apraxia, visuospatial deficiencies interfere with ADLs
Severe- ambulatory and wander or loose ability to talk, delusions, sleep patterns, withdrawn
End- mute, bedridden, death is aspiration

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11
Q

Alzheimer diagnosis

A

histology- tissue sample and see plaques,
clinical dx- most commonly
labs and imaging- rule out others

cognition assessment-

  • MMSE (mini mental status exam): 8th grade and English
  • MoCA (Montreal cognitive assessment)
  • SLUMS
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12
Q

Treatment for Alzheimer- Mild mod dementia

A

Cholinesterase inhibitors

Aricept - most used
-s/e= insomnia, nausea, diarrhea

Exelon (PO or patch)

  • s/e= dizziness, headache, agitation, falling, weight loss, n/v, anorexia
  • oral makes these worst

Razadyne (BID or ER versions)
-s/e= nausea, vomiting

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13
Q

Treatment for Alzheimer- mod-severe

A

if moderate can take both (aricept and namenda)

Namenda
=NMDA receptor antagonist
-s/e= dizziness, headache

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14
Q

Other therapies for Alzheimer

A

vitamin E
selegiline
anti-inflammatory drugs
ginkgo biloba

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15
Q

Managing neuropsychiatric symptoms

A

1- consider delirium from medical cause, medication side effects, inexpressible pain

  1. anit-depressants (ex: celexa)
  2. anti-seizures (ex: gabapentin, tegretol, depakote)
  3. dextromethrophan- quinidine (neudexta)

Avoid using benzodiazepines (a sedative)
- it leads to dementia

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16
Q

Managing neuropsychiatric symptoms- antipsychotics

A

not first choice- increases mortality
used for safety of pt and/or caregiver

Seroquel
Risperidone
Zyprexa

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17
Q

Alzehimer prognosis

A

processive, incurable
8-10 years

causes of death: 
aspiration (most common) 
malnutrition 
secondary infections 
PE
heart disease
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18
Q 
Vascular dementia (VaD) 
(sometimes called multi-infarct dementia)
A

second most common
overlap with Alzheimer

higher rate in those >65

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19
Q

VaD risk factors

A

cardiovascular disease
higher glucose levels/diabetes
HTN
afib

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20
Q

VaD pathophysiology

A

Atherosclerosis–> infarction

  • large infarction (cortical) at level of major cerebral vessels and or
  • lacunar infarcts from small artery infarction (subcortical)
  • chronic (subcortical) ischemia in distribution of small arteries of periventricular white matter
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21
Q

Vascular dementia- cortical presentation

A

speech difficulty
trouble doing tasks
amnesia
executive dysfunction

stepwise or fluctuant course common

rapid decrease and have a new baseline

22
Q

Vascular dementia- subcortical presentation

A

gait dysfunction
personality & mood changes
urinary frequency , urgency
cognitive dysfunction

gradual or stepwise

23
Q

Vascular dementia dx

A

neurologic and cardio vascular exam + exam

imaging (MRI)- shows presence of infarcts

24
Q

Vascular dementia- tx

A

Risk factor management

  • antihypertensives
  • diabetes management
  • statin therapy
  • antiplatelet agents

Acetylcholinesterase inhibitors

  • donepezil
  • galantamine
  • rivastigmine (Alzheimer meds)

NMDA antagonists
- memantine

Calcium channel blockers

25
Vascular dementia prognosis
have severe cardiovascular disease- - stroke - MI
26
Lewy body dementia (LBD or DLB)
neurodegenerative disease characterized by dementia with or preceding parkinsonian symptoms - hallucinations - cognition and/or alertness - dysautonomia - disordered sleep 2nd most common type of degenerative dementia after Alzheimer's
27
Lewy body dementia- epidemiology
lack of caffeine use | sporadic with discordance among monozygotic twins
28
Lewy body dementia- pathophysiology
Lewy bodies (neuronal inclusions) in cerebral cortex, deep in the cortical layers throughout the brain Also unbalance of ACTH and dopamine and serotonin transmission
29
Lewy body dementia- clinical features
Cognitive dysfunction- attention, executive function, visuospatial function REM sleep disorder - vocalization - motor behaviors Neuroleptic (antipsychotics) sensitivity - irreversible parkinsonism & impaired consciousness - after taking these meds
30
Lewy body dementia- supportive
``` repeated falls syncope or transient loss of consciousness severe autonomic dysfunction delusions depression ```
31
Lewy body dementia- dx
PET- hypoperfusion of occipital region MRI- generalized atrophy and white matter changes Biopsy
32
Lewy body dementia- tx
``` Cholinesterase inhibitors (ACTH inhibitors- block breakdown) for cognitive & behavioral symptoms - Exelon- 1st line ``` Levodopa does not help like it does in Alzheimer's. High doses actually makes psychosis worst. Donepezil (aricept) - cholinesterase inhibitor - for cognitive and behavior measures Antipsychotics - avoid but if needed 2ary (ine, one) Melatonin or clonazepam - REM sleep behaviors Disabling Parkinsonism - Levodopa instead of dopamine agonist (sinemet)
33
Lewy body dementia- prognosis
Progressive Variable More rapid than Alzheimer's
34
Core clinical features of Lewy body dementia
2/3 ``` cognitive fluctuations visual hallucinations parkinsonism - bradykinesia - limb rigidity - shuffling gait - resting tumor - postural instability ``` If Parkinson's diagnosis first then dementia = Parkinson's dementia
35
Pseudodementia
psychiatric illness but appear to be demented Seen in an episode of major depression
36
Pseudodementia- clinical presentation
Demented- make something up if they do not know the answer- cover up problems Depressed- "I don't know", complain about memory issues
37
Pseudodementia- tx
SSRI's (antidepressants) ECT electro compulsive therapy Do not give acetylcholinesterase inhibitors or NMDA antagonists
38
Frontotemporal dementia
umbrella term degeneration of frontal or temporal lobes of the brain characterized in changes of personality, language, and behavior
39
Frontotemporal dementia- epidemiology
common cause of early- onset dementia highly heritable
40
Frontotemporal dementia- clinical features- behavioral variant
marked by processive change in personality and behavior - most common subtype - hyperorality - compulsiveness - apathy
41
Frontotemporal dementia- clinical features- primary progressive aphasia
language impairment - word finding - usage - comprehension - sentence construction types: nonfluent variant PPA semantic variant PPA logopenic variant PPA
42
Nonfluent PPA in Frontotemporal dementia
motor speech deficit with a lot of effort needed to produce words
43
Semantic PPA in Frontotemporal dementia
cannot understand single words but fluency, repetition, and grammar is preserved word finding difficulty Mispronounce or misspell - have surface dyslexia/dysgraphia
44
Logopenic PPA in Frontotemporal dementia
Impaired single word retrieval & repetition errors in speech and naming can comprehend a single word speech is "empty" tell a story but no details- vague
45
Frontotemporal dementia- motor syndromes
Upper motor neuron signs - hyperreflexia, spasticity, Babinski's Lower motor neuron signs - weakness, muscle atrophy, fasciculations Corticobasal syndrome - alien limb syndrome, dystonia Supranuclear palsy In general: NS in terms of MSK system is also being affected
46
Frontotemporal dementia- dx
Functional imaging | - hypoperfusion or hypometabolism
47
Frontotemporal dementia- tx
SSRI trial - paroxetine (axil) Atypical (2nd) antipsychotic - seroquel Cholinesterase inhibitors
48
Frontotemporal dementia- prognosis
worst than Alzheimer's- especially those with motor neuron disease
49
HIV associated dementia (HAD) & Signs and Symptoms
subcortical dysfunctional - attention- concentration - memory - behavior and mood changes - impaired psychomotor speed and precision - judgement intact subacute onset- wax and wane
50
HIV associated dementia (HAD)- imaging
cerebral atrophy | affects- basal ganglia and white matter
51
HIV associated dementia (HAD)- tx
antiretroviral therapy- one that penetrates CNS well

Clin med exam 2 (12 decks)

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