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
- uOttawa
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
- uOttawa
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.
- uOttawa
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)
uOttawa
What triad of symptoms is common in Dementia with Lewy-bodies?
Fluctuating attention
Visual hallucinations
Parkinsonism
uOttawa
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
uOttawa
Which antidepressants has shown some efficacy in treating frontotemporal dementia based on 2 small RCTs?
Trazodone: especially irritability
uOttawa
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
uOttawa
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%
uOttawa
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
uOttawa
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
uOttawa
Which of the following drugs can cause hypothyroidism?
a. Lithium
b. Lithium and Interferon
c. Lithium and Amiodarone
d. Lithium, Interferon and Amiodarone
d. Lithium, Interferon and Amiodarone
Note: Amiodarone can also cause hyperthyroid.
Also chemo drugs can cause hypothyroidism.
Important medical causes include postpartum hypothyroidism, Cancer, and post surgical or postinfectious states.
uOttawa
What are the medical and psychiatric sx’s of hyperparathyroidism/hypercalcemia?
Medical: ‘Bones, Stones, Groans, and Psychic Moans’
Psychiatric:
mild = anxiety, depression, cog. dysfunction
severe = lethary, confusion
rare = mania, delirium
uOttawa
What are the medical and psychiatric sx’s of adrenal insufficiency?
Medical: hyperpigmentation, hypoglycemia, GI sx, N/V, weight loss, fatigue, hypotension, low sodium, high K
Psychiatric: depression, anorexia, cognitive impairment. In severe may have psychosis in 20-40% or delirium.
uOttawa
What are the medical and psychiatric sx’s of Cushing’s Syndrome?
Medical: truncal obesity, HTN, hirsutism, proximal weakness
Psychiatric: agitated depression, irritability, anxiety, lability, mild paranoia, cognitive impairment. Atypical depression common. Psychosis or mania possible.
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You are on call in the ER. Your pt has a racing heart, is sweating, he has a headache, and is visibly anxious. His general lab work-up for depression and anxiety is normal. For the past few months he has developed sudden unexpected panic attacks. He has been stressed with a new publication coming out and was recently diagnosed with HTN.
- What medical condition are you concerned about?
- What is the common triad of sx’s for that condition?
- What lab test would you order?
- Pheochromocytoma
- Headacke, sweating, tachycardia
- plasma metanephrines
Note: also +/- HTN, panic attacks (40% have panic disorder. May have palpitations, tremors, nausea, spells.
uOttawa
What is the etiology and medical sx’s of Wilson’s Disease?
- disorder of copper transport. Autosomal recessive.
- Get copper excess with low ceruloplasmin
- Acute liver injury - Cu released in blood causes hemolytic anemia
- Chronic - brain accumulation leads to psych sx’s
- Medical: Kayser Fleischer rings, abd pain, jaundice, UGI bleed, organomegaly, peripheral stigmata of cirrhosis, hepatic encephalopathy, dysarthria, dystonia, tremor, parkinsonism, choreoathetoid.
uOttawa
What psychiatric symptoms are ass’d with Wilson’s Disease?
- Depression in the most frequent.
- personality change, irritability, mood lability, BAD, psychosis, catatonia.
- common presentation is teens/20s with movement disorder, personality changes.
- Labs: LFT (AST>ALT by at least 2), cbc, serum ceruloplasmin (low), serum copper (low), high CSF copper, ocular slit-lamp, 24hr urinary copper (high).
- Tx: chelating agents.
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What are 4 psychiatric meds that should not be used in patients with liver impairment?
- Duloxetine
- Asenapine
- Valproic acid
- Clozapine
uOttawa
What does a B12 deficiency and a Folate deficiency presentation look like in a patient?
B12 deficiency: lemon-coloured skin from jaundice and anemia, mentally sluggish, shiny tongue (atrophic glossitis), broad based gait, vibration and position sense lost.
Folate deficiency: sx’s related to anemia
- both may have megaloblastic anemia, depression, irritability, mood lability, apathy, memory loss, dementia, psychosis, delirium.
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Which of the following changes in endocrine function occurs in elderly patients?
a. basal ADH levels are normal to increased.
b. basal corticotropin levels are decreased.
c. aldosterone levels are increased.
d. growth hormone levels continue to rise and peak at age 70.
e. thyroid function declines significantly leading to an increased risk of hypothyroidism.
a. basal antidiuretic hormone (ADH) levels are normal to increased.
- may lead to increased risk of hyponatremia.
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Depression in the elderly; first-onset depression occurring after age 60 (late onset) makes up about ___ % of all episodes in older adults.
50%
- simllar length of untreated episodes in all ages = 9 months.
- tendency for more melancholic, psychotic, and psychomotor features.
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What do we know about suicide risk in the elderly?
- suicide rates among older adults have decreased over the past several decades.
- still remain disproportionally high
- less likely than younger adults to endorse SI or make attempts yet have substantially higher rates of completed suicide.
- rate of attempts to completions is 4:1 (compared to 200:1 in adolescents)
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Recent data suggests that patients with late-onset schizophrenia, in comparison with early-onset patients, have a lower prevalence of:
a. the paranoid subtype
b. persecutary delusions
c. organized delusions
d. auditory hallucinations
e. negative symptoms
e. negative symptoms
- general trend is for improvement in positive symptoms
- in chronically institutionalized individuals, higher levels of negative symptoms.
uOttawa
What is unique in the presentation of late onset schizophrenia?
- more women present with late onset (q. estrogen playing a protective role but trials with HRT not promising).
- more paranoid subtype (75% vs. 50%)
- less negative symptoms and executive dysfunction
- higher premorbid function including successful marriage and occupational histories
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How is VLOSLP different from ‘true’ schizophrenia?
- lower genetic load
- less evidence of childhood maladjustment
- relative lack of thought disorder and negative sx’s
- greater risk of TD
- appears to be neurodegenerative rather than a neurodevelopment disorder ass’d with focal white matter abnormalities.
- presents more commonly in immigrant populations; psychosocial factors may play a role
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What are the 3 most common psychotic symptoms in Alzheimer’s Disease?
- persecutory delusions (36%); misidentification of caregivers, delusions of theft
- visual hallucinations (18.7%)
- auditory hallucinations (9.2%)
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Personality Disorders in the elderly: which is false?
a. the prevalence of PD in older persons is generally twice the rate of PD in younger persons in the gen pop
b. the single most common comorbid axis I condition in seniors with PD is depression.
c. the prevalence of PD in selected output or input samples of older persons can be as high as 25-65%.
d. the prevalence of PD in the gen pop is est. at 10-15% of all ages.
e. the prevalence of PD in psychiatric settings is usually 3 to 4 x higher than in the community.
a. PD’s appear to be less prevalent in the elderly population overall.
- prevalence of 5-10% of community dwelling elderly population.
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Depressed elderly pts with comorbid anxiety, in contrast to depressed elderly individuals without anxiety, usually have:
a. lower risk of suicide
b. reduced response rate to tx
c. shorter time to achieve a response to tx
d. fewer somatic sx’s
e. less suicidal ideation
c.
- they have longer time to response to tx of depressive sx’s
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Extensive research has shown that marked changes in sleep and circadian rhythms accompany aging. Which of the following is an example of the changes that will occur with aging?
a. nocturnal sleep time increases
b. time in stages 3 and 4 sleep increases
c. nocturnal wake time increases
d. the amplitude of the sleep-wake cycle increases
e. older adults tend to awaken at a later phase
c. nocturnal wake time increases
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True or False? The presence of dementia appears to decrease the pain threshold.
False. Dementia increases the pain threshold.
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Which 3 antidepressants are favoured in the elderly and why?
- citalopram, escitalopram, sertraline
- favorable pharmacokinetic proflies
- lower potential for clinically significant drug interactions
- data suggesting their superiority in terms of cognitive improvement.
- beware of SIADH, increased risk of bleeding, bradycardia, increased risk of #’s through direct effects on bone metabolism.
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Treatment of psychotic disorder: in a consensus survey of 48 American experts on the tx of older adults with late-life schizophrenia, the first-line medication tx recommendation was
a. aripiprazole
b. clozapine
c. olanzapine
d. quetiapine
e. risperidone
e. Risperidone
- 1.25-3.3/day for schizophrenia
- 0.75 - 2.5 mg/day in delusional disorder
uOttawa
86 yr old man, with a history of a. fib and diabetes, who had the sudden onset of fluent, nonsensical speech, impaired repetition, and impaired comprehension. Naming was impaired.
a. Wernicke’s aphasia
b. Broca’s aphasia
c. Anomic aphasia
d. Global aphasia
e. Transcortical sensory aphasia
a. Wernicke’s aphasia
- fluent
- impaired repetition
- impaired comphrehension
- impaired naming
- left hemisphere
- posterior
- cortical
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Which is false in regards to lesion localization in post-stroke depression:
a. laterality: right > left
b. proximity to frontal pole: anterior lesions more severe
c. subcortical gradient: basal ganglia > thalamus
a. laterality: left > right
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What common personality changes are seen following traumatic brain injury?
- disinhibition (social, sexual, spending)
- labile affect (overreactive, excessive)
- aggressiveness
- apathy
- combination
- irritability/agitation: easily frustrated, difficulty modulating angry responses, verbal at times physical aggression.
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What are 4 risk factors for depression in Parkinson’s Disease?
- female
- past or family psychiatric history
- early onset
- cognitive impairment
Note: major depression 5-20%; minor or subsyndromal depression 10-30%.
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What are some cognitive and emotional symptoms of Huntington’s Disease?
Cognitive: executive dysfuntion, perseveration, learning and memory deficits, dementia
Emotional: depression (50%); suicidal thoughts (18%), suicide attempt (10%). Common = anxiety, irritability, obsessive-compulsive sx’s, apathy, hypo sexuality.
Rare = psychosis, hypersexuality.
uOttawa
What is the prevalence of MS in MS clinics vs. community samples?
- lifetime prevalence in pts attending MS clinics approaches 50%.
- 12 month prevalence in community based samples
26%.
Note: suicide risk is 7.5x the gen pop. At risk include males, < 30 yrs old, first 5 years of illness.
uOttawa
How does memory impairment differ between normal aging and Alzheimer’s Disease?
Normal aging = retrieveal deficit-type
AD = amnestic type
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What do we know about the role of APOE4 in late-onset Alzheimer’s Disease?
- gene on chromosome 19 (3 alleles = E2, E3, E4)
- Allele E4 = 20% of population; E4/E4 leads to 50% risk of AD in age 60s; E4 hetorogenous leads to 50% risk of AD in 70s.
- APOE4 screening NOT recommended due to low sensitivity/specificity and low +ve and -ve predictive values.
uOttawa
What 3 pathologic findings occur in the brains of patients with Alzheimer’s Disease?
- Senile plaques
- amyloid: beta-secretase; to gamma-secretase; toxic effect initiates pathophysiologic cascade. - Neurofibrillary tangles
- displays a gradually spreading distribution (Braak stage) that correlates with cognitive decline. Also seen in normals, but confined to medial temporal lobe - Amyloid angiopathy
- can lead to lobar hemorrhages
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Why does the basal forebrain play an important role in Alzheimer’s Disease?
The basal forebrain is a collection of structures located rostrally and ventrally to the striatum. It is considered to be the major cholinergic output of the central nervous system (CNS). It includes a group of structures that lie near the bottom of the front of the brain, including the nucleus accumbens, nucleus basalis, diagonal band of Broca, substantia innominata, and medial septal nuclei. These structures are important in the production of acetylcholine, which is then distributed widely throughout the brain.
AD = loss of cholinergic neurons in the basal forebrain.
Wikipedia/uOttawa
What is the more typical progression of the following when present in Alzheimer’s Disease?
a. Mood changes, behaviour changes, cog. impairment.
b. Cognitive impairment, mood changes, behaviour changes.
c. Functional impairment, behaviour changes, cog. impairment.
d. Functional impairment, mood changes, cognitive impairment.
e. Mood changes, cognitive impairment, behaviour changes.
b. Cognitive impairment, mood changes, behaviour changes.
uOttawa
http://www.alz.org/alzheimers_disease_stages_of_alzheimers.asp
Which of the following is or are characteristic features of behavioural-varieant FTD?
a. Early loss of memory
b. Early loss of insight
c. Early decline in social interpersonal conduct
d. All of the above
e. B and C
e. B and C
BVFTD = relative sparing of memory and visuospatial functions
uOttawa
http://www.theaftd.org/wp-content/uploads/2009/02/Table-3-International-consensus-criteria-for-behavioural-variant-FTD.pdf
Which of the following is or are characteristic features of Lewy Body Dementia?
a. Fluctuating attention
b. visual hallucinations
c. REM sleep behaviour disorder
d. All of the abvev
e. A and B
d. all of the above
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How does CJD manifest as compared to other dementias due to medical conditions?
- rapidly progressive decline
- Myoclonus in 90%
- periodically sharp- and slow-wave complexes on EEG
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What is the triad of sx’s for NPH?
- cognitive decline
- incontinence
- gait
uOttawa
Cognitive decline with bradykinesia and truncal rigidity early in the course, with absent vertical eye movement suggests what disorder?
Progressive Supranuclear Palsy
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What is true of biomarkers in Alzheimer’s Disease?
a. There are no biomarkers that predict progression to AD
b. The use of biomarkers is only recommended for research
c. The use of biomarkers has just been recommended in clinical practice
d. The use of biomarkers is only useful to select the most appropriate cognitive enhancer
b. The use of biomarkers is only recommended for research
uOttawa
_____ % of older adults with dementia have co-morbid depression.
25%
Vascular dementia and DLB > Alzheimer’s
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