Dimentia and Delerium Flashcards
What is dementia?
DSM 5 criteria for Dementia Dx
Dementia is a term used to describe a cluster of sx including:
-forgetfulness (progressive), difficulty doing familiar tasks, confusion, poor judgement, decline in intellectual functioning
DSM5:
- significant cognitive impairment in at least one of the following cognitive domains:
- learning and memory
- language
- executive function
- complex attention
- perceptual-motor function
- social cognition
- cognitive deficits must interfere with independence in everyday activities/social/occupational impairment
Causes of Dementia
- alzheimers (70%)
- vascular dementia (strokes and TIA)
- parkinsons
- frontotemporal dementia
- Normal-pressure hydrocephalus
- dementia w/ Lewy Bodies
- delirium/depression
What are some modifiable causes of dementia?
- medications (anticholinergics)
- alcohol
- metabolic (B12, thyroid, hyponatremia, hypercalcemia, hepatic and renal dysfunction)
- depression
- CNS neoplasms chronic subdural hematoma
- NPH
Alzheimers Dz:
- what?
- what are the most common early and late stage signs?
What: progressive neurologic disorder that results in memory loss, personality changes, global cognitive dysfunction, and functional impairments.
Loss of short term memory is most prominent early.
In the late stages of dz pts are totally dependent on others for ADLS.
Alzheimers
- Dx
- clinical dx
- symptoms & behaviors
Dx of exclusion
Clinical Dx:
-Hx, mental status eval, depression screening, PE, neuroimaging, CBC, CMP, B12, TSH
Symptoms and Behaviors:
- short term memory loss
- long term memory loss (late)
- poor judgement
- disorientation/inability to adapt to new environments
- personality changes
- communication disorders
- demanding and repetitive behaviors
- behavior changes; aggression. delusions, hallucinations
Alzheimers Assessment:
-what does this consist of?
- Mini mental status exam
- Draw clock face w/ the time.
- 3 item recall
- neuro exam (focality, grasp, apraxia, cogwheeling, eye movements)
Mini Mental Status Exam
-describe scores of 20-26, 10-20, less than 10
-what MMSE score is suggestive of dementia?
20-26: mild functional dependence
10-20: moderate, more immediate dependence
less than 10: severe, total dependence
MMSE score of 24/30 is suggestive of dementia
What are the 3 neuropathological hallmarks of Alzheimers dz?
- amyloid rich senile plaques
- neurofibrillary tangles
- neuronal degeneration
Describe the 7 stages of Alzheimers
Stage 1: free of symptoms, pathology has begun
Stage 2: normal aged forgetfulness, greater than 65yrs most likely, believe they can no longer recall names
Stage 3: mild cognitive impairment, deficits are subtle but are noted by persons who are in close contact (e.g repeated questions, job performance may decline)
Stage 4: Mild Alzheimers Dz, pt has decreased ability to manage instrumental activities of daily life. (manage finances, prepare meals for guests) Stage lasts 2 years
Stage 5: Moderate Alzheimers Dz,deficits in basic activities of daily life (e.g choose proper clothing to wear for the weather conditions,wearing same clothes everyday). Cannot recall such major events of their current lives (e.g current president, their current address, names of schools they attended for many years) Lasts 1.5years
Stage 6: Moderately Severe Alzheimers dz; basic activities of daily life become compromised (e.g not able to maintain living at home, cannot put their own clothing on properly) Stage lasts 2.5years
Stage 7: Severe Alzheimers Dz; all intelligible speech is essentially lost, ambulatory ability is lost, lose ability to smile, and ability to hold their head up independently. Re-emergence of so-called infantile or primitive reflexes
Alzheimers Dz:
- most frequent cause of death?
- pts in 7th stage are more vulnerable to what causes of mortality?
- most common cause of death is aspiration pneumonia
- Pts in 7th stage appear more vulnerable to all common causes of mortality including sstroke, heart disease, cancer
Alzheimers Dz:
- Tx general
- Tx: medications
- -cholinesterase inhibitors & SE
- -NMDA receptor agonists & SE
- -Selegiline
- -Vit E
- -Antidepressant
- -antipsychotics
- -antiepileptics
-there is no cure
Cholinesterase inhibitors:
slow the breakdown of ach. may slow progression of sx.
*Examples:
-Donepezil: only tx approved by FDA for all stages of alzheimers dz
- Rivastigmine: approved for use in mild-moderate alzheimers dementia; skin patch, capsules, liquid
- Galantamine/Razadyne: approved mild-moderate, CI in renal/hepatic impairment
SE of all cholinesterase inhib: D/V/N, fatigue, insomnia, weight loss.
NMDA receptor antagonist:
-Memantine; regulates the activity of glutamate, brain cells in people wiith alzheimers release too much glutamate. moderate to severe
SE: dizziness, confusion, hallucinations
Selegiline: prevents breakdown of dopamine
Antidepressant:
-Zoloft, Paxil, Celexa (SSRI)
Anti-psychotics: hallucinations, delusions, aggression
- abilify, zyprexa, seroquel, risperdal, geodon
- these may increase risk of death
Anti-eleptics:
-dedakote and gabapentin
What drugs should be avoided in patients with dementia?
Benzodiazepines, antihistamines, anticholinergics
*may actually worsen symptoms
Vascular Dementia:
- how does one acquire this?
- criteria for vascular dimentia
onset of cognitive deficits associated with CVA, abrupt onset of symptoms followed by stepwise deterioration.
Criteria for VD:
- Cerebrovascular dz evident on hx, examination, or imaging in addition to:
- -onset of dimentia within 3mo
- -abrupt fluctuating or stepwise progression in dementia
Frontotemporal Dementia
- what is this?
- whats one subtype? characteristic of pathology?
- age at onset
-What: focal atrophy of the frontal and temporal lobes in the absence of alzheimers pathology
Picks dz is a subtype of FTD.
Pathology: pick bodies
Age: 35-75yrs
Frontotemporal Lobe Dementia:
- core features
- supportive features
Core:
- insidious onset and gradual progression
- early decline in social conduct
- early impairment of personal conduct
- early loss of insight
- emotional blunting
Supportive:
- behavior disorder (hygeine, dietary changes, perseverative behavior=wont let stuff go)
- speech and language
- akinesis, restlessness, rigidity, tremor, labile BP
Normal pressure hydrocephalus:
- what is this?
- Triad of sx
- dx
- tx
What: condition of pathologically enlarged ventricular size with normal opening pressures on LP.
Traid:
- wacky (dementia)
- wobbly (gait)
- wet (urinary incontinence)
dx:
- MRI
- miller fisher test: objective gait assessment before and after remove of 30cc of CSF
Tx:
ventriculoperitoneal shunt
Dementia w/ Lewy Bodies
-most commonly associated with what other disorder?
- sx
- Core features for clinical diagnosis
Parkinsonism
Sx:
- delirium, visual hallucinations, parkinsonism
- syncope. falls, sleep disorders, depression, transient loss of consciousness*
features for clinical dx:
- progressive cognitive decline of sufficient magnitude to interfere with normal social or occupational function.
- 2 of the following:
- -fluctuating cognition w/ variation in attention and alertness
- -recurrent visual hallucinations
- -spontaneous motor features of parkinsonsim
Parkinsons Dz Dementia
-when does the dementia hit?
-dementia usually occurs in the last half of the clinical course of PD
Progressive Supranuclear palsy
- aka
- mimics which disease?
- characteristics
aka: Steele Richardson Olszewski syndrome
mimics PD in early phases
Characteristics: restricted up down eye movement, postural instability (stand straight or even tilt their heads backwards & tend to fall backwards.
Creutzfeldt Jacob Dz
- aka
- caused by?
- characterized by?
aka: mad cow dz
caused by: prion, contracted from consuming material from animals (cows)
Characterized by: dementia with rapid onset and deterioration, motor deficits, seizures
What are some other infections that may cause dementia?
- neurosyphillis
- HIV dementia
Delerium:
- what is this?
- 4 major causes
- risks
What; sudden and significant decline in mental functioning, reduced ability to focus, sustain, and shift attention
4 major causes:
- underlying medical condition (hypoglycemia)
- substance intoxication
- substance withdrawl
- combination of any or all of these.
Risk:
- elderly, greater than 80yrs
- hx of dementia
- post cardiac surgery
- burns
- drug withdrawl
- AIDS
Delerium:
-clinical features
Clinical features:
-Prodrome: restlessness. anxiety, sleep disturbance
- fluctuating course; develops over short period, sx fluctuate
- attention deficit: easily distracted
- arousal/psychomotor disturbance: hyperactive, hypoactive, or mixed
- impaired cognition: memory deficits, language disturbance, disorganized thinking, disorientation
SLeep-wake disturbance: fragmented or reversed normal cycle
Altered perceptions: illusions, hallucinations, delusions
Affective Disturbances: anxiety, fear, depression, irritability, apathy, euphoria, lability
Delerium:
- duration
- What is I watch death?
Duration:
-sx resolve in 10-12days may last up to 2 mo, dependent upon the underlying problem and management.
I WATCH DEATH = causes of delerium.
- infections (meningitis, urosepsis)
- withdrawl
- acute metabolic (liver/renal failure)
- Trauma
- CNS pathology (seiz, stroke, tumor)
- Hypoxia
- Deficiencies (thiamin, B12)
- endocrinopathies
- acute vascular (hypertensive; MI)
- toxins or drugs
- heavy metals (lead)
