Geriatrics: depression, delirium, dementia Flashcards
most common type of dementia?
alzheimers
how do most people die from alzheimer’s?
aspiration pneumonia: unable to swallow
define dementia
An acquired syndrome of decline in memory and other cognitive functions sufficient to affect daily life in an ALERT patient
5 risk factors for alzheimers
Age Family history Head injury Fewer years of education Female sex
what part of the brain gets attacked (and shut down) first in Alzheimer’s dz
hippocampus
what is “mild cognitive impairment” ?
Memory problem without deficits in other domains
No functional impairment
alzheimer’s Dz: onset, progression
Onset: gradual
Progression: gradual, over 8–10 yr on average
alzheimer’s Dz: cognitive and motor symptoms
Cognitive symptoms: primarily memory
Motor symptoms: rare early, apraxia later
alzheimer’s Dz: lab tests and imaging
Lab tests: normal
Imaging: possible global atrophy, small hippocampal volumes
alz. DSM IV
Development of cognitive deficits manifested by:
Impaired memory and
Aphasia, apraxia, agnosia, disturbed executive function
apraxia: what is it?
- An inability to execute learned purposeful movements despite having the desire and physical capacity
- Acquired disorder of motor planning
- All of the muscles work but the region of the brain that plans and coordinates the movement of the muscles is impacted
Agnosia: what is it? where are the lesions?
The inability to recognize common objects, people, sounds, and places
Lesions on the parietal or temporal lobe
Semantic information and language
what is semantic memory?
long term memory or concepts not drawn from personal experience ( Letters, what is a cat…)
vascular dementia DSM IV
same as alzheimers but there are…
-Focal neurologic symptoms/signs or evidence of cerebrovascular disease
3 stages of progressive AD
mild, moderate and severe impairment
Vascular dementia: onset + progression
Onset: may be SUDDEN/ STEPWISE
Progression: stepwise with further ischemia
vascular dementia: cognitive and motor symptoms
Cognitive symptoms: depend on anatomy of ischemia
Motor symptoms: correlates with ischemia
vascular dementia: labs + imaging
Lab tests: normal
Imaging: cortical or subcortical changes on MRI
Lewy Body Dementia: cognitive + motor symptoms
and what is the major key for this Dx
Cognitive symptoms: memory, visuospatial, hallucinations, fluctuations
Motor symptoms: parkinsonism
key difference: *EARLY hallucinations
Lewy Body Dementia: labs + imaging
Lab tests: normal
Imaging: possible global atrophy
Fronto-temporal dementia and Lewy Body Dementia: onset + progression
Onset: gradual
Progression: gradual but faster than AD
fronto-temporal dementia: cognitive + motor symptoms
Cognitive symptoms: executive: disinhibition, apathy, behavior changes
Motor symptoms: none
fronto-temporal dementia: labs + imaging
Lab tests: normal
Imaging: atrophy in frontal and temporal lobes
aggitation may be a sign of ____ in someone with dementia
depression
primary goal of alzheimers txt
To enhance quality of life and maximize functional performance by improving cognition, mood, and behavior
non-pharm txt of alzheimer’s dz (kinds weeds)
Cognitive enhancement Individual and group therapy Regular appointments Communication with family, caregivers Environmental modification Attention to safety
- routines are importmant!
pharm txt for alzheimer’s dz (kinda weeds)
Cholinesterase inhibitors: ***donepezil (Aricept)
+/- Memantine
(anti-chol may lower HR)
maybe: anti-depressants, pyschoactive meds
symptom mgmt for alzheimers Dz
Sundowning Psychoses (delusions, hallucinations) Sleep disturbances Aggression, agitation Hypersexuality
what is “sundowning”
the closer to evening, the more agitated and confused the AD pt gets
(dont know why this happens)
anti-pyschotic meds for alzheimer’s pts can cause what? how do we avoid this?
DEATH
start low, go slow!
what are the distinguishing signs of delirium (from dementia)?
Acute onset, Cognitive fluctuations over hours or days
Impaired consciousness and attention
Altered sleep cycles
*can be under-alert or hyper-alert
delirium DSM IV (3)
- Disturbance of consciousness with reduced ability to focus, sustain, or shift attention
- Change in cognition /perceptual disturbance
- Development over a short time (hours to days) and fluctuation during the day
4 forms of delirium
- Hyperactive or agitated delirium = 25% of all cases
- Mixed
- Hypoactive delirium = ≥50% of all cases, but less recognized and appropriately treated
- Additional features include emotional lability, psychosis, hallucinations
predisposing factors for delirium (kinda weeds)
Advanced age, dementia male Functional impairment in ADLs Medical comorbidity History of alcohol abuse Sensory impairment (↓ vision, ↓ hearing)
how to prevent post-op delirium (3)
Limit sedation
Provide adequate analgesia
Transfuse high-risk patients
3 ways to avoid complications of delirium
Remove indwelling devices ASAP
Prevent or treat constipation and urinary retention
Encourage proper sleep hygiene, avoid sedatives
what 4 things are shared in dementia and depression
Impaired concentration
Lack of motivation, loss of interest, apathy
Psychomotor retardation
Sleep disturbance
what 4 things differentiates depression from dementia
Demonstrate ↓ motivation during cognitive testing
Express cognitive complaints that exceed measured deficits
Maintain language and motor skills
minor depression vs major depression vs bipolar in older people, what is common/uncommon?
minor: common
major: uncommon
bipolar: incidence declines with age
major depression DSM IV: gateway symptoms?
Gateway symptoms (must have 1)
- Depressed mood
- Loss of interest or pleasure (anhedonia)
depression : onset, cognitive deficit shown?, responses?
Sudden onset. Exposes cognitive deficit. Often responds “I don’t know.” Variability in cognitive ability. Inconsistent effort.
dementia : onset, cognitive deficit shown?, responses?
Gradual onset. Conceals deficit. Tries to answers questions. Stable or declining ability. Consistent effort.
how is bereavement different from depression ?
Most disturbing symptoms resolve in 2 months
Not associated with marked functional impairment
3 steps in treating depression: acute, continues, prophylaxis/maintenance
Acute — reverse current episode Continuation — prevent a relapse Continue for 6 months Prophylaxis or maintenance — prevent future recurrence Continue for 3 years or longer
pharm txt for depression?
primary: SSRIs (celexa, zoloft)
when would you use ECT for depression? (3)
- major depression & mania; response rates exceed 70% in older adults
- pts at serious risk for suicide, life-threatening poor intake of food
- psychotic depression in older pts
