Geriatrics, Neurocognitive Disorders & C/L Flashcards
In Mild Cognitive Impairment;
- What % per year converts to dementia?
- What % per year revert to normal?
5-10% per year convert to dementia
25-30% per year revert to normal
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Of the 4 main types of dementia; which 2 are primarily Cortical and which 2 are primarily Subcoritical?
Cortical = Alzheimer's & Behaviour-variant FTD Subcortical = PDD/DLB & Vascular
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What is the typical age of onset for Frontotemporal lobar degeneration?
EARLY onset: ages 45-65 (range 21-85). Tends to effect people in the prime of life.
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What is the primary neurotransmitter deficit in frontotemporal dementia?
Post-synaptic serotonin deficit
(also moderate evidence for dopaminergic deficit; cholinergic system is relatively spared)
- Tauopathies and Tardopathies
FTLD with ubiquitin- and TAR-DNA binding protein-43-positive inclusions (FTLD-U/TDP-43), FTLD with motor neuron disease, and frontotemporal dementia with parkinsonism linked to chromosome 17 associated with mutations in the gene encoding progranulin (FTDP-17PGRN) are considered “tardopathies.” (Boeve, 2011)
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What triad of symptoms is common in Dementia with Lewy-bodies?
Fluctuating attention
Visual hallucinations
Parkinsonism
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What triad of symptoms is common in Binswanger’s Syndrome?
Slowly progressive cognitive decline
Gait abnormalities
Early urinary incontinence
(other vascular risk factors present but no history of stroke of TIA; diffuse atrophy and confluent white matter changes help differentiate from normal pressure hydrocephalus)
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Subcortical dementia appears in what % of HIV patients?
< 10 %
(initial presentation in 20% of AIDS)
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The following side effect is more common with Donepezil than Rivastigmine or Galantamine:
a. Insomnia
b. Weight loss
c. Diarrhea
d. Vomiting
e. Fatigue
A. Insomnia
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Which antidepressants has shown some efficacy in treating frontotemporal dementia based on 2 small RCTs?
Trazodone: especially irritability
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What is first line treatment for DLB with neuropsychiatric symptoms?
Rivastigmine (exelon)
In DSM-5, list criteria a, b, and c for Delirium.
a. A disturbance in attention (i.e., reduced ability to direct, focus, sustain, and shift attention) and awareness (reduced orientation to the environment).
b. The disturbance develops over a short period of time (usually hours to days), represents a change from baseline attention and awareness, and tends to flucuate in severity during the course of a day.
c. An additional disturbance in cognition (e.g., memory deficit, disorientation, language, visuospatial ability, or perception).
DSM-5
The 3-month mortality rate of patients who have an episode of delirium is estimated to be ___?
23-33%
The 1 year mortality rate may be as high as 40-50%
K&S p323
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The major neurotransmitter hypothesized to be involved in delirium is _________, and the major neuroanatomical area is the _____________.
Acetylcholine
Reticular formation
K&S p326
True or false: Female gender is associated with higher prevalence of dementia overall, and especially Alzheimer’s disease, but this difference is largely, if not wholly, attributable to greater longevity in females.
True
DSM-5
What is criterion A for Major Neurocognitive Disorder?
Evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition) on:
- Concern of the individual, a knowledgeable informant, or the clinician that there has been a significant decline in cognitive function, and
- A substantial impairment in cognitive performance, preferably documented by standardized neuropsychological testing or, in its absence, another quantified clinical assessment.
Note: for Mild Neurocognitive Disorder insert ‘modest’ or ‘mild’ as a descriptor instead, otherwise it’s the same A criteria.
DSM-5
What are the 3 core diagnostic features and the 2 suggestive features of a Neurocognitive Disorder with Lewy Bodies?
- Core diagnostic features
- Fluctuating cognition with pronounced variations in attention and alertness.
- Recurrent visual hallucinations that are well formed and detailed.
- Spontaneous features of parkinsonism, with onset subsequent to the development of cognitive decline. - Suggestive diagnostic features:
- Meets criteria for rapid eye movement sleep behaviour disorder.
- Severe neuroleptic sensitivity
Ass’d features: falls, syncope, transient unexplained LOC, autonomic dysfunction such as orthostatic hypotension, urinary incontinence, auditory hallucinations, systematized delusions, depression. REM sleep behaviour disorder.
DSM-5
When does spontaneous parkinsonism tend to occur in Major/Mild Neurocognitive Disorder with Lewy Bodies?
“Another core feature is spontaneous parkinsonism, which must begin after the onset of cognitive decline; by convention, major cognitive deficits are observed at least 1 year before the motor symtpoms.”
DSM-5
The underlying neurodegenerative disease in NCDLB is?
“primarily a synucleinopathy due to alpha-synuclein misfolding and aggregation.”
DSM-5
The male-to-female ratio in Mild/Major Neurocognitve Disorder with Lewy Bodies is ?
1.5: 1 (male:female)
Note: onset of sx’s is typically observed from the 6th through the 9th decades of life, with most cases having their onset when affected individuals are in their mid-70’s. In most cases there is no family history.
DSM-5
In delirium what % of cases are
- hyperactive
- hypoactive
- mixed
Hyperactive 30%
Hypoactive 24%
Mixed level of activity 48%
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What is untrue of the epidemiology of delirium?
- 10-30% of medically ill hospitalized pts
- 10 to > 50% post-operative pts
- 90% Postcardiotomy pts
- 40% ICU
- 60% in nursing homes/post-acute care settings
- 80% at end of life.
70-85% of ICU pts have delirium
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Why are opioids a risk factor for delirium?
- possibly dur to an anticholinergic mechanism
- disrupt sleep patterns
- may disrupt thalamic gating function, leading to sensory overload or hyperarousal
- meperidine > morphine > dilaudid
- IV opioids worse than PO
- rotating opioids may improve pain and reduce delirium potential (ex. morphine and Fentanyl)
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Why are GABA drugs a risk factor for delirum? (e.g., Propofol; Midazolam; Lorazepam)
- interfere with physiologic sleep patterns
- Interrupts central cholinergic muscarinic transmission
- may disrupt melatonin circadian rhythm
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Are word finding difficulties more likely in dementia or delirium?
Dementia
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What is the antipsychotic of choice in delirium and what is the risk associated with it?
- Haldol (PO or IV)
- 0.25 to 0.5 mg PO od or bid to start; may require higher doses.
- do not combine with cogentin
- Risk is QTc prolongation; likely a small risk.
- Baseline EKG; caution if > 440 sec. Change med or reduce dose if QTc lengthens >25% of baseline.
- Serum Mg and K (correct abnormalities)
- alternatives with best evident: risperidone or quetiapine
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List risk factors for developing Torsades de Pointe.
Hypokalemia Hx of long QT syndrome High med doses Concomitant use of QTc prolonging medication Heart disease Female
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