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PSYCH ROTATION > First Aid: Cognitive Disorders > Flashcards

First Aid: Cognitive Disorders Flashcards

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1
Q

List the 3 main categories of cognitive disorders.

A
  • Dementia
  • Delirium
  • Amnestic disorders
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2
Q

List the 3 main categories of cognitive disorders.

A
  • Dementia
  • Delirium
  • Amnestic disorders
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3
Q

What is a perfect score on an MMSE?

A

30

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4
Q

What is considered dysfunction on an MMSE?

A
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5
Q

Impairment of memory and other cognitive functions without alteration in the level of consciousness.

A

Dementia

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6
Q

What percentage of people >80 yo have a severe form of dementia?

A

20%

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7
Q

What percentage of demented patients get delusions and hallucinations?

A

30%

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8
Q

What percentage of demented patients have affective symptoms (depression and anxiety)?

A

40-50%

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9
Q

What are the 3 most common causes of dementia?

A
  • Alzheimer’s disease (50-60%)
  • Vascular dementia (10-20%)
  • Major depression (pseudodementia)
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10
Q

What percent of demented patients have a treatable and potentially reversible condition?

A

15%

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11
Q

What is the minimum workup to exclude reversible causes of dementia? (6)

A
  • CBC
  • Electrolytes
  • TFTs
  • VDRL/RPR
  • B12 and folate
  • Brain CT or MRI
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12
Q

Dementia with stepwise increase in severity + focal neurological signs

A

Multi-infarct dementia

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13
Q

How do you diagnose multi-infarct dementia?

A

CT/MRI

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14
Q

Dementia with cogwheel rigidity + resting tremor

A

Lewy Body Dementia/ Parkinson’s Disease

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15
Q

How do you diagnose Lewy Body Dementia/ Parkinson’s Disease?

A

clinical

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16
Q

Dementia with ataxia + urinary incontinence + dilated cerebral ventricles

A

Normal pressure hydrocephalus

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17
Q

How do you diagnose normal pressure hydrocephalus?

A

CT/MRI

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18
Q

Dementia with obesity + coarse hair + constipation + cold intolerance

A

Hypothyroidism

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19
Q

How do you diagnose hypothyroidism?

A

T4, TSH

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20
Q

Dementia with diminished position/vibration sense + megaloblasts on the CBC

A

Vitamin B12 deficiency

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21
Q

Dementia + tremor + abnormal liver enzymes + Kayser-Fleischer rings

A

Wilson’s disease

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22
Q

How do you diagnose Wilson’s disease?

A

Ceruloplasmin

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23
Q

Dementia + diminished position and vibration sense + Argyll-Roberston pupils

A

Neurosyphilis

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24
Q

What are Argyll-Robertson pupils?

A

pupils that accommodate and constrict but do not react to light

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25
Q

How do you diagnose neurosyphilis?

A

CSF FTA-ABS or CSF VDRL

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26
Q

What is the hallmark of delirium?

A

waxing and waning of consciousness

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27
Q

What are the 2 types of delirium?

A

Quiet

Agitated

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28
Q

What is used to diagnose delirium?

A
  • Memorial Delirium Assessment Scale

- CAM

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29
Q

What is the treatment for delirium?

A
  • Rule out life-threatening causes
  • Treat reversible causes
  • Antipsychotics: Quetiapine or Haloperidol PO/IM (not IV unless connected to heart monitor as TdP may occur)
  • Avoid napping
  • Keep lights on, shades open during day
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30
Q

What are the negatives of using benzodiazepines on a patient with delirium?

A
  • Can cause paradoxical disinhibition
  • Respiratory depression
  • Increased risk of falls
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31
Q

What is the differential for delirium?

A

AEIOU TIPS

  • Alcohol
  • Electrolytes
  • Iatrogenic
  • Oxygen hypoxia
  • Uremia/hepatic encephalopathy
  • Trauma
  • Infection
  • Poisons
  • Seizure (post-ictal)
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32
Q

How long does delirium last?

A

3 days to 2 weeks

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33
Q

Orientation is impaired in delirium or dementia?

A

both! (dementia patients can sometimes remain oriented)

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34
Q

What type of memory is impaired in delirium?

A

immediate and recent memory

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35
Q

What type of memory is impaired in dementia?

A

Recent and remote memory

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36
Q

Hallucinations more commonly occur in delirium or dementia?

A

delirium (usually visual)

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37
Q

Symptoms are worse at night in delirium or dementia?

A

delirium

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38
Q

EEG changes (fast waves or generalized slowing) is seen in delirium or dementia?

A

delirium

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39
Q

What is the most common dementia? What percent?

A

Alzheimers (80% of all dementias)

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40
Q

What is the incidence of Alzheimer’s disease in people > 85?

A

25%

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41
Q

What gender more commonly gets Alzheimer’s?

A

women > men

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42
Q

What is the average life expectancy after diagnosis for an Alzheimer’s patient?

A

8 years

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43
Q

What percentage of patients with Alzheimer’s have a family history?

A

40%

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44
Q

What is the clinical hallmark of Alzheimer’s?

A

gradual progressive decline of cognitive functions, especially memory and language

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45
Q

What is the DSM-IV criteria for Alzheimer’s disease?

A

Memory impairment plus at least one of the following:

  • Aphasia
  • Apraxia
  • Agnosia
  • Diminished executive functioning
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46
Q

What is aphasia?

A

disorder of language affecting speech and understanding

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47
Q

What is apraxia?

A

inability to perform purposeful movements

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48
Q

What is agnosia?

A

inability to interpret sensations correctly

49
Q

What neurochemical changes are seen in patients with Alzheimer’s disease?

A

Decreased levels of NE (due to loss of noradrenergic neurons in the locus ceruleus of the brainstem) and of Ach (loss of cholinergic neurons in the basal nucleus of Meynert of the midbrain)

50
Q

What is the only way to definitively diagnose Alzheimer’s disease?

A

Pathological examination of the brain at biopsy showing diffuse atrophy with enlarged ventricles and flattened sulci

51
Q

What are the microscopic changes seen in the brain of an Alzheimer’s patient?

A
  • Senile plaques
  • Neurofibrillary tangles (dysfunctional ER within neurons)
  • Neuronal and synaptic loss
52
Q

What are senile plaques composed of?

A

amyloid protein

53
Q

What are neurofibrillary tangles composed of?

A

Tau proteins

54
Q

In what other settings do you see senile plaques and neurofibrillary tangles?

A
  • Down’s syndrome

- Normal aging

55
Q

What 2 classes of drugs are used to treat Alzheimer’s disease?

A
  • NMDA receptor antagonist

- Cholinesterase inhibitors

56
Q

What is the NMDA receptor agonist used to treat Alzheimer’s disease?

A

Memantine

57
Q

What are the cholinesterase inhibitors to help slow progression of Alzheimer’s disease?

A

Tacrine (Cognex)
Donepezil (Aricept)
Rivastigmine (Exelon)

58
Q

What percentage of patients experience a transient improvement in symptoms on cholinesterase inhibitors?

A

25%

59
Q

What is the cause of vascular dementia?

A

Microvascular disease in the brain that produces multiple small infarcts (substantial infarct burden builds up before dementia develops)

60
Q

What is the disease manifestations of vascular dementia?

A

same as Alzheimer’s

61
Q

How might you differentiate between vascular dementia and Alzheimer’s disease?

A
  • Vascular dementia has a stepwise loss of function as the microinfarcts build up
  • Focal neurological symptoms (hyperreflexia or paresthesias)
  • More abrupt onset
  • Greater preservation of personality
62
Q

What is mild cognitive impairment (MCI)?

A

normal daily function but abnormal memory for age (most progress to Alzheimer’s disease)

63
Q

How do you diagnose vascular dementia?

A

MRI

64
Q

Which cause of dementia has personality and behavioral changes that are more prominent early in disease (compared with Alzheimer’s disease)?

A

Pick’s Disease (Frontotemporal Dementia)

65
Q

What is the gross pathology of a brain with Pick’s disease?

A

atrophy of frontotemporal lobes

66
Q

What is the microscopic pathology of Pick’s disease?

A

Intraneuronal inclusion bodies (not necessary for diagnosis)

67
Q

How long after diagnosis do patients with Huntington’s Disease live?

A

around 15

68
Q

When is the onset of HD?

A

35-50 yo

69
Q

What are the hallmarks of HD?

A
  • Progressive dementia
  • Bizarre choreiform movements
  • Muscular hypertonicity
  • Depression and psychosis are very common
70
Q

What is the cause of HD?

A

trinucleotide repeat on short arm of chromosome 4

71
Q

What part of the brain is affected in HD?

A

Basal ganglia

72
Q

How can you diagnose HD?

A
  • MRI (caudate atrophy; some cortical atrophy)

- Genetic testing

73
Q

List the cortical dementias.

A

Alzheimer’s
Pick’s
CJD

74
Q

List the subcortical Dementias

A

Huntington’s
Parkinson’s
NPH
Multi-infarct dementia

75
Q

Which type of dementia has a decline in intellectual functioning?

A

Cortical

76
Q

Which type of dementia have more prominent affective and movement symptoms?

A

Subcortical

77
Q

What part of the brain is affected in Parkinson’s disease?

A

Prominent neuronal loss in the substantia nigra

78
Q

What is the normal role of the substantia nigra?

A

provides dopamine to the basal ganglia

79
Q

What percentage of patient with Parkinson’s disease develop dementia?

A

around 30%

80
Q

What are the clinical manifestations of Parkinson’s disease?

A
  • Bradykinesia
  • Cogwheel rigidity
  • Resting tremor (pill-rolling)
  • Mask-like facial expression
  • Shuffling gait
  • Dysarthria (abnormal speech)
81
Q

What percent of patients with PD have depression?

A

50%

82
Q

What causes PD?

A
  • Idiopathic
  • Traumatic
  • Drug- or toxin- induced
  • Encephalitic
  • Familial (rare)
83
Q

What are the treatment options for PD?

A
  • Replace DA
  • Stimulate DA receptors
  • Inhibit DA breakdown
  • Anticholinergics
84
Q

What is levodopa?

A

Chemical that can cross BBB and is degraded to DA by dopadecarboxylase

85
Q

What is carbidopa?

A

peripheral dopadecarboxylase inhibitor that prevents levodopa conversion to DA before it can reach the brain

86
Q

What is the role of amantadine in PD?

A

emancipates DA

87
Q

What is the role of anticholinergics in PD?

A

helps relieve tremor

88
Q

What is an example of a DA agonist used in PD?

A

bromocriptine

89
Q

What is selegiline and why is it used in PD?

A

MAO-B inhibitor that inhibits breakdown of DA

90
Q

What are the treatment options for PD patients no longer responsive to pharmacotherapy?

A

Thalamotomy
Pallidotomy
(surgery)

91
Q

WHat is the name of the rapidly progressive, degenerative disease of the CNS caused by a prion.

A

Creutzfeldt-Jakob Disease

92
Q

What type of transplant is associated with CJD?

A

corneal

93
Q

What are the hallmark features of CJD?

A
  • Rapidly progressive dementia 6-12 months after onset of symptoms
  • > 90% have myoclonus
  • Extrapyramidal signs, ataxia, and LMN signs are also common
94
Q

What is the typical length of time between exposure and disease onset with CJD?

A

long latency period

95
Q

What are prions?

A

proteinaceous infectious particles that are normally expressed by healthy neurons in the brain

96
Q

What pathological changes are seen in CJD?

A

spongiform changes of cerebral cortex
neuronal loss
hypertrophy of glial cells

97
Q

What does an EEG show in CJD?

A

periodic sharp waves/spikes

98
Q

What is needed for a definitive diagnosis of CJD?

A

pathological demonstration of spongiform changes of brain tissue

99
Q

What s/s point you toward CJD?

A

Presence of both rapidly progressive dementia and EEG changes + at least 2 of the following features:

  • Myoclonus
  • Cortical blindness
  • Ataxia, pyramidal signs, extrapyramidal signs
  • Muscle atrophy
  • Mutism
100
Q

What reversible form of dementia has large ventricles with increased CSF pressure?

A

Normal pressure hydrocephalus

101
Q

What is the classic triad for normal pressure hydrocephalus?

A
  • Wobbly (gait disturbance)
  • Wet (urinary incontinence)
  • Wild (dementia with mild and insidious onset)
102
Q

How do you treat normal pressure hydrocephalus?

A

Relieve increased pressure with a shunt

103
Q

What is an acute disorder of cognition related to impairment of cerebral metabolism?

A

delirium

104
Q

List some causes of delirium.

A 
I'M DELIRIOUS
Impaired delivery (of substrates to brain)
Metabolic
Drugs
Endocrinopathy
Liver disease
Infrastructure (structural disease of neurons)
Renal failure
Infection
Oxygen 
UTI
Sensory deprivation
105
Q

Delirium + hemiparesis or other focal neuro signs/symtpoms

A

CVA or Mass Lesion

106
Q

How do you diagnose CVA or mass lesion?

A

Brain CT/MRI

107
Q

Delirium + elevated BP + papilledema

A

Hypertensive encephalopathy

108
Q

How do you diagnose hypertensive encephalopathy?

A

Brain CT/MRI

109
Q

Delirium + dilated pupils + tachycardia

A

Drug intoxication

110
Q

Delirium + fever + nuchal rigidity + photophobia

A

Meningitis

111
Q

How do you diagnose meningitis?

A

lumbar puncture

112
Q

Delirium + tachycardia + tremor + thyromegaly

A

Thyrotoxicosis

113
Q

How do you diagnose thyrotoxicosis?

A

T4, TSH

114
Q

What is the work-up for treating delirious patinets?

A

FEUD

  • Fluids/nutrition
  • Environment
  • Underlying cause
  • Drug withdrawal
115
Q

What drug should be avoided in delirious patients due to likelihood to exacerbate delirium?

A

benzodiazepines

116
Q

Which disorder ALWAYS occur secondary to an underlying medical condition and cause impairment of memory without other cognitive problems or altered consciousness?

A

amnestic disorders

117
Q

What are some causes of amnestic disorders?

A
  • Hypoglycemia
  • Systemic illness (thiamine deficiency)
  • Hypoxia
  • Head trauma
  • Brain tumor
  • CVA
  • Seizures
  • MS
  • Herpes simplex encephalitis
  • Substance use
118
Q

Which causes of amnestic disorders lead to a transient illness with full recovery?

A
  • Seizures

- Medication induced

119
Q

Which causes of amnestic disorder can possibly lead to permanent impairment?

A

Hypoxia
Head trauma
Herpes simplex encephalitis
CVA

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