Exam 1 Cognitive Disorders Flashcards
Gradual onset and progression, aphasia, amnesia, apraxia, agnosia, executive dysfunction, visuospatial impairment, concreteness, indifference, preserved motor function
Alzheimers disease
Gradual onset and progression, aphasia, apraxia, agnosia, executive dysfunction, relative retention of memory and visuospatial skills until later stages, personality changes, disinhibition, apathy, atypical depression, preserved motor function
Frontotemporal dementia ie Picks disease
Abrupt onset, stepwise progression, fluctuating course, preservation of personality, emotional incontincenc, depression, focal neurologic s/sx, vascular risk factors
Vascular Dementia aka multi-infarct dementia
Gradual onset and progression, aphasia, amnesia, apraxia, agnosia, fluctuating severity, suddon onset parkinson’s features and visual hallucinations, fluctuating cognitive function
Lewy Body dementia
Cortical and subcortical feautres, psychomotor retardation, apathy, inattention, poor memory, ataxia, gait disturbance (falls), urinary incontinence
NPH
- Falls, urinary incontinence, signs neuro-cognitive decline
What is delirium
Acute, rapidly progressive change in cognition characterized by inattention and disturbance of consciousness in which dx fluctuate over 24 hrs
AKA encephalopathy or acute confusional state
What are risks for developing delirium
Cognitive impairment 70+ yo Poor functional status hearing/visual impairment dehydration, sleep deprivation, infection Metabolic derangment, polypharmacy
DSM-IV criteria for Delirium includes what?
- Altered level of arousal
- Memory Impairment
- Disorientation
- Perceptual Disturbance
- Language disturbance/incoherent speech
What types of Delirium are possible
Hyperactive (41%)
Hypoactive (11%)
Mixed Disorder (48%)
Describe Hyperactive delirium
comprises 41% of delirium cases
- hallucinations
- delusions
- agitation
- combativeness
- Incoherent, rambling speech
- disturbed sleep/wake cycle
- hypersensitivity to light/sound
Describe Hypoactive delirium
comprises 11% of delirium cases, subtle, often overlooked, misdx
- inattention, sedation, depressed, withdrawn, loss of appetite, flat affect
Besides delirium, what other potential ddx are there?
a) Delirium secondary to: medical condition, substance abuse/withdrawal
b) Substance intoxication
c) substance withdrawl
d) dementia
e) Psych disorder (psychotic disorder, schizophrenia, mood disorder with psychotic feature
f) malingering/factitious disorder
Important factors in the assessment of delirium include
Primary Survery
- Good H&P (med/nursing records, medication hx, outside informant)
- MSE
Secondary Survey**
Thorough Med workup
What is often helpful vs not always necessary in assessment of delirium
Often helpful: Hx, PE, MSE, CBC, Metab panel, UA, EKG, CXR
Sometimes: EEG (diffuse slowing), CT, Cultures without known cause, LP
Components of the MMSE include
Orientation to time and place Recall Registration Attention and Calculation Language Repetition Complex commands
27-30 = no cognitive impairment 21-26 = mild cog impairment 11-20 = moderate cog impairment <10 = severe
what is the primary principle of delirium tx
treat underlying medical cause* maintain stability avoid use of restraints ID and eliminate offending meds educate family and caregivers
what are non-pharmacologic tx options for delirium
replace hearing aids/glasses
- private room
- around the clock attendant/sitter
- calm and reassuring behavior
- reorienting devices
- re-establish sleep/wake cycle
- educate family
- expedite return to familiar environment
when should you treat someone with delirium
- Severe agitation
- Combative behavior
- Behavior that severely interferes with care
*agitation, combative, interfering = treat
what should you be aware of with the delirium pharmacologic tx
BLACK BOX warning for sudden cardiac death
List the various antipsychotic meds
Haloperidol (trad'l) IV/IM/PO Zyprexa (IM/PO/SL) Seroquel (PO) Risperdal (PO) BZ
Haloperidol: use, side effects
- traditional antipsychotic
- available IV/IM/PO
- EPS likely - treat with Cogentin (Benztropine), an anticholinergic to reduce EPS PD like sx
- prolonged QTI –> torsades, sudden cardiac death
What are the second generation antipsychotics
Zyprexa (IM/PO/SL) Seroquel (PO) Risperdal (PO) *fewer EPS (bc antichol activity) *less likely to prolong QTI
what is the perspective on pharm tx of delirium with antipsychotics?
no other good alternative
- use for appropriate reasons
- get baseline EKG, start low and go slow, monitor electrolytes and correct, monitor BP/orthostatics
- educate family and get informed consent
Besides antipsychotics, what medication class can be used to treat delirium
BZ
SE of BZ
deleterious cognitive SE - avoid at all costs; can worsen depression, cause delirium
- over Rx
what are BZ indicated for
alcohol/drug delirium
Diazepam and Lorazepam
*side note, according to pharm: treat alcoholic seziures with Lorazepam and Phenytoin, prevent with Diazepam and Chlordiazepoxide
what are different forms of delirium/ special considerations to be aware of
postop delirium
sundowning
alcohol withdrawal/DT
what is sundowning
delirium precipitated by hospitalization, sensory deprivation or medications
*worse at night
How is alcohol related to delirium
alcohol withdrawal –> DT (delirium tremens)
- MEDICAL EMERG
- signs DTs are extreme autonomic hyperactivity with delirium
- later signs = confusion, psychosis, agitation, seizures
- mainly seen in heavy, chronic drinkers, pt with prior detox, seizures or DT
what is dementia
chronic progressive decline of memory impairment and 1+:
a) aphasia (absence speech - understanding or expression)
b) apraxia (absent learned motor skills)
c) agnosia (absence of sensory understanding or recognition)
d) disturbance in executive functioning
deficits severe enough to cause functional impairment
Delirium NOT PRESENT
Irreversible
What are causes of dementia
a) Alzheimers disease (AD) 50%
b) Vascular dementia (25%)
c) Neurodegen process: (Lewybody, PD dementia, frontotemporal/picks dz)
e) secondary to medical condition (huntingtons, TBI, infecitons, anoxia, Creutzfeldt-Jakob, HIV, MS)
*with or w/o behavioral disturbance
AD (alzheimers dementia) - when and how does it develop, findings?
Typically after 50 yo; under 65 = early onset
- slow progression, lose 3 pt/yr on MMSE
- higher rates in pt with repeated head trauma or Downs
- familial role
findings: myoclonus and gait disorder late findings
CT/MRI/Histo
what are sx of Parkinson’s Dementia (neurodegenerative dementia), how freq is it, and what makes it worse
20-60% Parkinson’s pt dev PD
- tremor, rigidity, bradykinesia, postural instability, micrographia, slow mvmt, cogwheel rigidity
- exacerbated by depression
What is dementia with Lewy Body sx? cause?
Neurodegenerative dementia *protein deposits in brain
Parkinson’s features and visual hallucinations
What is Pick’s disease (frontotemporal) characterized by
Neurodegenerative dementia –> change in personality/behavioral disinhibition
*prominent primitive reflexes on exam
What are the characteristics of Vascular dementia and how is it dx?
aka multi-infarct dementia
- vascular risk factors
- neuro deficit from previous CVA usually
- imaging to dx (MRI)
What is Creutzfeldt Jakob dz triad
- dementia
- involuntary mvmt
- periodic EEG activity (diffuse slowing pattern)
What are the characteristics of Creutzfeldt-Jakob dz? who does it affect and how? cause? tx?
Triad of dementia, involuntary mvmt and periodic EEG activity
- typ 40-60 yo
- prions: transmisison via corneal transplant, CSF
- rapid (wk-mth) fatal
- no tx
what are characteristic brain pathologies associated with Creutzfeldt Jakob dx
brain shrinkage and deterioration (rapid), spongiform pathology of brain
components of Huntington’s dementia
AD gene
onset 30-40
choreiform mvmt
Boxcar ventricles on imaging
Features of HIV dementia include? cause?
direct result of HIV (can isolate in CSF)
= forgetfulness, slowness, poor problem solving/concentration, apathy, delirium, tremor ataxia
*remember to look for infectious causes
reversible dementias include
NPH (norm pressure hydrocephalus) B12 deficiency Hypothyroidism Depression Syphilis
what is mild cognitive impairment? characteristics? risk?
"pre-dementia" Characterized by: 1. Memory complaints (subj) 2. mild Memory impairment (obj) 3. preserved cognitive function and intact ADL's
*increase risk of ALL types of dementia
how to diagnose dementia?
H&P*** clinical! postmortem pathology only definitive test
- lab eval
- neuro imaging
- cognitive testing (neuropsych testing, MMSE, Kokman) “cerebral atrophy”
H&P for dementia…
best way to dx
- use outside informants
- often only way to differentiate bw diff types of dementai
Lewy body, AD, vascular, Picks, creutzfeldt-jakob
H&P: lewy body
fluctuations in cognitive function, sudden onset parkinsonian features, visual hallucinations
H&P AD (alzheimers dementia)
progressive decline
H&P: Vascular dementia
signs previous stroke/risk factors
H&P: Picks dz
Progressive nonfluent aphasia, Behavioral disinhibition (frontotemporal neurodeg)
H&P: creutzfeldt jakob
rapid/progressive, involuntary mvmts (not unlike Tardive dyskinesia)
*fatal
what lab eval should be ordered for dementia dx?
*draw to r/o other/reversible causes
CBC/CMP, TSH, B12, folate, homocysteine, SED rate, HIV, RPR (syphilis)
CSF eval
is neuroimaging for dementia recommended?
controversial
“cerebral atrophy” questionable clinical sig
AAN rec structural neuroimaging with either noncontrast head CT or MRI in routine intiial eval of all pt with dementia (r/o reversible cause)
Neuropsych testing, main sig test for us to know?
MMSE
*neuropsych testing wide range of specificity and sensitivity
what are components of neuropsych testing
Attention Orientation Executive functioning Memory (short and long) Intelligence Language Problem solving
A.O.E.M.I.L.P. is neuropsych testing for me
*best when performed on increased risk population
mgmt of dementia includes
treat cognitive sx
behavior mgmt
education/caregiver support
prevention (avoid excess BZ)
Pharmacologic mgmt of Dementia includes
Cholinesterase inhibitors:
- Donepezil (Aricept)
- Rivastigmine (Exelon)
- Galantamine (Razadyne)
NMDA antagonists
1. Memantien (Namenda)
Indications for prescribing cholinesterase inhibitors for dementia mgmt
off label use:
- prevention in mild uncharacterized cognitive impairment
- Lewy body neurodegenerative dementia
- multi-infarct vascular dementia
*besides LB and vascular, no other dementia supports cholinesterase inhibitor use
Dementia mgmt supplements/other tx includes
May have benefit:
*Vit E, Selegiline, fish oil, ginkgo biloba
Little evidence: Vit B, hormone replacement, NSAIDS, coconut oil
how can you prevent dementia
no modifiable risk factor known (except avoid BZ, educate pt)
Promising: cognitive training, exercise
Ntr: Mediterranean diet, Omega 3, veggies
Dementia vs delirium
Dementia: memory impairment, progressive insidious onset
Delirium: memory impairment, disturbance of consciousness, acute onset, fluctuation during 24 hr, attention deficit
What are amnestic disorders
impaired ability/inability to learn new info, recall
causes marked impair in social or occupational functioning
*must not occur in setting of delirium/dementia
Associated features of amnestic disorders include
confusion, disorientation, confabulation (make up details), rarely disoriented to self, lack insight to memory deficits, apathy
Causes of amnesia..
head injury, alcohol, BZ, sedative (ambien, lunesta), postictal, ECT, focal tumors or infarct, infections (HSV encephalitis), cerebral anoxia (carbon monoxide poisoning), postconcussive, transient global amnesia
Define transient global amnesia
abrupt loss of the ability to recall events or to remember new info lasting 6-24 hr
*memory usually returns EXCEPT for gap
what are the alcohol amnestic disorders
wernickes encephalopathy and Korsakoffs syndrome
Features of Wernickes encephalopathy include
thiamine deficiency
TRIAD: ophthalmoplegia, ataxia, nystagmus
ACUTE!!! = wernicke
Features of Korsakoffs syndrome
really progression or second stage of Wernicke Korsakoff Syndrome
- chronic
- further thiamine def usually associated with prolonged alcohol abuse
- irreversible
- psychosis can be present aka Korsakoffs psychosis
How do you treat amnestic disorders
mainly supportive
remove offending agent
alcohol detox/rehab
supportive psychotherapy, pharmacotherapy
