Gérontopsychiatrie Flashcards
what are the 3 elements of the biological diagnosis of alzheimers disease
ATN
amyloid beta deposition
pathological Tau
Neurodegeneration
*premature to use in general medical practice
should you use amyloid or tau imaging to assess people without memory decline
no, not outside research setting (as presence of these factors is of uncertain significance)
what imaging technique is recommended to investigate VASCULAR cognitive impairment
MRI > CT
what tools are recommended for the diagnosis of vascular mild cognitive impairment and vascular dementia
use of STANDARDIZED criteria
i.e one of:
Vascular Behavioural and Cognitive Disorders Society criteria (VAS-COG)
DSM 5
Vascular Impairment of Cognition Classification Consensus Study
or American Heart Assoc consensus statement
why should you treat HTN
treatment of HTN may reduce the risk of dementia and thus clinicians should assess, diagnose and treat HTN according to HTN Canada guidelines
which patients should be treated with antihypertensives
those with cognitive disorders in which vascular contribution is known or suspected–> if avg. diastolic is at or above 90mmHG and /or systolic at or above 140mmHG
is the use of aspirin recommended for patients with MCI or dementia who have brain imaging evidence of covert white matter lesions of presumed vascular origin without history of stroke or infarcts
no
are cholinesterase inhibitors or memantine recommended for treatment of vascular cognitive impairment
may be considered in selected patients
is cognitive screening recommended in asymptomatic patients
no
list risk factors for cognitive disorders
- late onset depressive disorder or lifetime history of MDD
- untreated sleep apnea
- hx stroke or TIA
- unstable metabolic or CV morbidity
- a recent episode of delirium
- first major psychiatric episode at an advanced age (i.e psychosis, anxiety, depression)
- recent head injury
- parkinsons disease
what rapid, objective assessments of cognitive function are recommended by the guidelines
- Memory Impairment Screen (MIS) + clock drawing test
- the Mini-Cog
- the AD8
- the four item version of the MoCA
- GP Assessment of Cognition (GPCOG)
what are the four items included on the four item MoCA
clock drawing
tap at letter A
delayed recall
orientation
why might you use the MoCA over the MMSE
more sensitive to MCI
use when MCI is suspected or when there is suspicion for cognitive impairment or concern about patients cognitive status but the MMSE score is within normal range
what is the normal range on the MMSE
24+/30
what are the more comprehensive psychometric screening tools listed in the guidelines
Modified Mini Mental State (3MS) exam
MMSE
Rowland University dementia assessment scale (RUDAS)
what is a questionnaire a caregiver or informant could fill out about dementia in a patient
AD-8
IQCODE (informant questionnaire on cognitive decline)
what tools can be used to assess BPSD in a patient if a behavioural, personality or mood change has been observed
short version of the Neuropsychiatric Inventory (NPI-Q)
Mild Behavioural Impairment Checklist (MBI-C)
(or PHQ-9 if mood change)
what are 2 tools that can be used for rapid screening of functional autonomy in suspected dementia
the Pfeffer Functional Activities Questionnaire (FAQ)
or the Disability Assessment for Dementia (DAD)
in which disorders might the DCQ be particularly helpful
behavioural variant FTD
primary progressive aphasia
alzheimers disease variants
as it is based on updated criteria for atypical syndromes like these –> MMSE, MoCA were not designed for screening for atypical syndromes and are often not sufficient to capture subtle cognitive and social cognition changes associated with atypical dementia
why is getting corroborative history essential when someone has subjective concerns about their cognition
has prognostic significance
what is recommended as one of the primary tools for tracking cognitive response and change over time
folstein’s MMSE
*has been used in several clinical trials of cholinesterase inhibitors
what is one major determinant of hospitalization or nursing home placement for patients with dementia
caregiver burnout
should be regularly assessed in followup of patients with dementia
what is a structured scale to measure caregiver burnout
Zarit Burden Interview
is MRI or CT preferred? why?
MRI–> higher sensitivity to some vascular lesions as well as for some subtypes of dementia and rarer conditions
what should you look for on CT when assessing dementia
hippocampal atrophy
should you do CT or non contrast CT when assessing dementia
non con
what type of imaging can be helpful in assessing/diagnosing cognitive imapirment linked to Lewy Body Disease
SPECT scan (where diagnosis is suspect but remains unclear)
consider PET scan first due to cost
what motor marker is suggestive of future dementia
slower gait speed
when slow gait speed + cognitive impairment the risk is higher
by how much does parkinsonism increase risk of developing dementia
up to 3x
what are two other factors associated with development of dementia
sleep disturbance
hearing impairment
–> should assess both of these in primary clinics as dementia risk factor
(insufficient evidence to support assessment of vision as dementia risk)
what diet is recommended to decrease risk of cognitive decline
mediterranean
what type of exercise interventions have been shown to improve cognitive outcomes in older adults
dance
mind body (ie yoga, qi gong)
aerobic and/or resistance exercise
how does OSA affect risk of dementia
treatment with CPAP in presence of OSA may improve cognition and decrease risk of dementia
for those on a cholinesteras inhibitor for alzheimers, parkinsons dementia, lewy body or vascular dementia for MORE THAN 12 months, when should you consider discontinuation of the medication
when:
1. there has been a CLINICALLY MEANINGFUL WORSENING of dementia as reflected by changes in cognition, functioning, global ax over the past 6 MONTHS in absence of other medical condition or enviro factors
- NO clinically meaningful benefit was observed at any time during treatment
- person has severe or end stage dementia
- development of intolerable side effects
- medication adherence is poor and precludes safe ongoing use of meds
**this is the same for deprescription of memantine in those taking for same indications
should you prescribe cholinesterase inhibitors for frontotemporal dementia or other neuro-degenerative conditions
these should be discontinued
*same for memantine
what characteristics unify those disorders listed under “neurocognitive disorders” listed in the DSM
- the primary clinical deficit is in cognitive function 2. they are acquired rather than developmental –> they represent a DECLINE in previous levels of functioning *although cognitive deficits are present in many if not all mental disorders, only disorders whose core features are cognitive are included in the NCD category
list the cognitive domains on which the criteria for the various NCDs are based
- complex attention 2. executive function 3. learning and memory 4. language 5. perceptual-motor 6. social cognition
what are the elements included in complex attention
sustained attention divided attention selective attention processing speed
define the following cognitive domain, and give an example of an assessment for: sustained attention
maintenance of attention over time, i.e pressing a button every time a tone is heard, over a period of time
define the following cognitive domain, and give an example of an assessment for: selective attention
maintenance of attention despite competing stimuli and/or distractors i.e hearing numbers and letters read out loud and asked to count only letters
define the following cognitive domain, and give an example of an assessment for: divided attention
attending to two tasks within the same time period i.e rapidly tapping while learning a story being read
define the following cognitive domain, and give an example of an assessment for: processing speed
can be quantified on any task by timing it i.e time to put together a design of blocks
describe what might be observed in a patient with MAJOR deficits in the domain of: complex attention
has increased difficulty in environments with multiple stimuli easily distracted by completing events in the environment is unable to attend unless input is restricted and simplified has difficulty holding new information in mind, such as recalling phone numbers or addresses just given or reporting what was just said is unable to perform mental calculations all thinking takes longer than usual and components to be processed must be simplified to one or a few
list the components of executive function
planning decision making working memory responding to feedback/error correction overriding habits/inhibition mental flexibility
define the following cognitive domain, and give an example of an assessment for: planning
ability to find the exit to a maze, or interpret a sequential picture or object arrangement
define the following cognitive domain, and give an example of an assessment for: decision making
performance of tasks that assess process of deciding in the face of competing alternative i.e simulated gambling
define the following cognitive domain, and give an example of an assessment for: working memory
ability to hold information for a brief period and to manipulate it i.e adding up a list of numbers or repeating a series of numbers or words backwards
define the following cognitive domain, and give an example of an assessment for: feedback/error utilization
ability to benefit from feedback to infer the rules for solving a problem
define the following cognitive domain, and give an example of an assessment for: overriding habits/inhibition
ability to choose a more complex and effortful solution to be correct (i.e looking away from direction indicated by an arrow, naming the color or words font instead of naming the word)
define the following cognitive domain, and give an example of an assessment for: mental/cognitive flexibility
ability to shift between two concepts, tasks or response rules i.e from number to letter, from verbal to key press response
define the following cognitive domain, and give an example of an assessment for: mental/cognitive flexibility
ability to shift between two concepts, tasks or response rules i.e from number to letter, from verbal to key press response
describe what might be observed in a patient with MILD deficits in the domain of: executive function
increased effort required to complete multistage projects has increased difficulty multitasking or difficulty resuming a task interrupted by a visitor or a phone call may complain of increased fatigue from the extra effort required to organize, plan and make decisions may report that large social gatherings are more taxing or less enjoyable because of increased effort required to follow shifting conversations
what are the components of learning and memory relevant to NCDs
immediate memory recent memory (including free recall, cued recall, and recognition memory) very long term memory (semantic, autobiographical, implicit learning)
define the following cognitive domain, and give an example of an assessment for: immediate memory span
ability to repeat a list of words or digits *immediate memory sometimes is subsumed under “working memory” in executive function
define the following cognitive domain, and give an example of an assessment for: recent memory
assesses the process of encoding new information (i.e word lists, diagrams) aspects of recent memory: 1. free recall 2. cued recall 3. recognition memory
how to test free recall
person asked to recall as many words, diagrams or elements of a story as possible
how to test cued recall
examiner aids recall by providing semantic cues
how to test recognition memory
examiner asks about specific items i.e was apple on the list?
describe what might be MAJOR deficits in the domain of: learning and memory
repeats self in conversation, often within the same conversation cannot keep track of short list of items when shopping or of plans for the day requires frequent reminders to orient to task at hand
which types of learning and memory are generally preserved in NCDs
except in severe forms of major NCD, semantic, autobiographical, and implicit memory are relatively preserved, compared with recent memory
what are the components of language
expressive language (naming, word finding, fluency, grammar and syntax) receptive language
define the following cognitive domain, and give an example of an assessment for: expressive language
confrontational naming (ID objects or pictures) fluency (name as many items as possible in a semantic or phonemic category)
define the following cognitive domain, and give an example of an assessment for: grammar and syntax
errors observed during naming and fluency tests are compared with norms to assess frequency of errors and compare with normal slips of the tongue
define the following cognitive domain, and give an example of an assessment for: receptive language
comprehension (word definition and object pointing tasks involving animate and inanimate stimuli)–> performance of actions based on a verbal command
what are the elements included under “perceptual motor” cognitive domain
visual perception visuoconstructional perceptual-motor praxis gnosis
how do you test visuoconstructional skills
assembly of items requiring hand eye coordination such as drawing, copying
how do you test perceptual-motor skills
integrating perception with purposeful movement–> inserting blocks into form board without visual cues
how do you test praxis
integrity of learned movements, such as ability to imitate gestures (wave goodbye) or pantomime use of objects to command (show me how you would use a hammer)
how would you test gnosis
perceptual integrity of awareness and recognition such as recognition of faces and colors
describe what might be MILD deficits in the domain of: perceptual motor
may need to rely more on maps or others for directions uses notes and follows others to get to a new place may find self lost or turned around when not concentrating on task is less precise in parking needs to expend greater effort for spatial tasks such as carpentry, knitting, sewing, assembly
describe what might be MAJOR deficits in the domain of: perceptual motor
has significant difficulties with previously familiar activities (using tools, driving motor vehicle), navigating in familiar environments often more confused at dusk, when shadows and lowering levels of light change perceptions
what are the elements of social cognition
recognition of emotions theory of mind
how do you test recognition of emotions
ID of emotions in images of faces representing a variety of both positive and negative emotions
how do you test theory of mind
ability to consider another persons mental state or experience–> story cards with questions to elicit info about the mental state of the individuals portrayed
describe what might be MILD deficits in the domain of: social cognition
has subtle changes in behaviour or attitude often described as change in personality, such as less ability to read facial expressions, decreased empathy, increased extraversion or introversion, decreased inhibition or subtle or episodic apathy or restlessness
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, social cognition) based on: 1. concern of the INDIVIDUAL, a knowledgeable INFORMANT or the CLINICIAN that there has been a SIGNIFICANT decline in the cognitive function AND 2. a SUBSTANTIAL impairment in cognitive performance, preferably documented by a standardized neuropsychological testing or, in its absence, another quantified clinical assessment
what is criterion B for major neurocognitive disorder
the cognitive deficits interfere with INDEPENDENCE in everyday activities (i.e at a minimum, requiring assistance with complex iADLs such as paying bills or managing meds)
list the etiologic specifiers listed in the DSM 5 for major/minor neurocognitive disorder
- alzheimers disease 2. frontotemporal lobar degeneration 3. lewy body disease 4. vascular disease 5. traumatic brain injury 6. substance/medication use 7. HIV infection 8. Prion disease 9. Parkinsons disease 10. Huntington’s disease 11. Another medical condition 12. Multiple etiologies 13. Unspecified
what other specifiers are present in the DSM for major /mild neurocognitive disorder
- without behavioural disturbance–> if the cognitive disturbance is not accompanied by any clinically significant behavioural disturbance 2. with behavioural disturbance–> *specify disturbance* if the cognitive disturbance is accompanied by a clinically significant behavioural disturbance (i.e psychotic symptoms, mood disturbance, agitation, apathy, or other behavioural symptoms)
define moderate major neurocognitive disorder
difficulties with basic ADLs (feeding, dressing)
define severe major neurocognitive disorder
fully dependent
what is criterion A for mild neurocognitive disorder
evidence of MODEST cognitive decline from a previous level of performance in one or more cognitive domains based on: 1. concern of the INDIVIDUAL, a knowledgeable INFORMANT or the CLINICIAN that there has been a MILD decline in the cognitive function AND 2. a MODEST impairment in cognitive performance, preferably documented by a standardized neuropsychological testing or, in its absence, another quantified clinical assessment
what is criterion B for mild neurocognitive disorder
the cognitive deficits DO NOT interfere with capacity for independence in everyday activities (i.e complex iADLs like paying bills, managing meds are preserved, but greater effort, compensatory strategies, or accommodation may be required)
in which NCDs are psychotic features common? what are common psychotic features?
alzheimers lewy body Frontotemporal lobar degeneration *paranoia and other delusions are common features and often a persecutory theme may be a prominent aspect of delusional ideation
how do you distinguish psychotic disorders with onset later in life (i.e schizophrenia) from NCDs with psychotic features
disorganized speech and behaviour seen in other psychotic disorders are not characteristic of psychosis in NCDs
how might hallucinations differ when seen in NCDs vs other disorders
visual hallucinations are more common in NCDs compared to other disorders (though hallucinations can occur in any modality)
in which NCDs are depression common early in the course of the illness
alzheimers and parkinsons
define apathy, and indicate how it might manifest in NCDs
typically characterized by diminished motivation, and reduced goal oriented behaviour accompanied by decreased emotional responsiveness may manifest early in course of NCDs when loss of motivation to pursue daily activities or hobbies may be observed
what are the DSM criteria for substance/medication induced Major or Mild NCD
A–> criteria are met for a major or mild NCD
B–> neurocognitive impairments do not occur exclusively during the course of a delirium and persist beyond the usual duration of intoxication and acute withdrawal
C–> involved substance or medication and duration and extent of use are capable of producing the neurocognitive impairment
D–> temporal course of the neurocognitive deficits is consistent with the timing of substance or medication use and abstinence (i.e deficits remain stable or improve after a period of abstinence)
E–> neurocognitive disorder not attributable to another medical condition and is not better explained by another disorder
what types of alcohol relayed NCDs are there
major NCD: nonamnestic-confabulatory type
major NCD: amnestic-confabulatory type
mild NCD
what are the 4 types of substances listed in the DSM for substance/medication induced Major or Mild NCD
alcohol
inhalant
sedative/hypnotic/anxiolytic
other or unknown
what is a specifier for substance/medication induced Major or Mild NCD
persistent–> neurocognitive impairment continues to be significant after an extended period of abstinence
what neurocognitive impairment is seen most predominantly in NCDs due to sedative/anxiolytic/hypnotic drugs/meds
greater disturbances in MEMORY than in other cognitive functions
NCD due to alcohol frequently manifests with a combination of what impairments
impairments in EXECUTIVE FUNCTIONING and MEMORY and LEARNING domains
what are the features of alcohol-induced amnestic confabulatory NCD (korsakoffs)
prominent amnesia (severe difficulty learning new information with rapid forgetting)
tendency to confabulate
*may co occur with signs of thiamine encephalopathy (wernicke’s) with associated features such as nystagmus and ataxia
what ocular abnormality is associated with wernicke’s encephalopathy
lateral gaze paralysis (ophthalmoplegia)
what are the more common neurocognitive symptoms related to methamphetamine use? what kind of overall NCD profile is seen in methamphetamine use
difficulties with learning and memory
difficulties with executive function
*most common neurocognitive profile approximates that seen in vascular NCD
is major NCD due to alcohol abuse common
no–> MAJOR NCD is rare, may result from concomitant nutritional deficits as in alcohol-induced amnestic confabulatory NCD
what are the criteria for major/mild NCD due to HIV infection
A–The criteria are met for major or mild neurocognitive disorder.
B–There is documented infection with human immunodeficiency virus (HIV).
C–The neurocognitive disorder is not better explained by non-HIV conditions, including secondary brain diseases such as progressive multifocal leukoencephalopathy or cryptococcal meningitis.
D–The neurocognitive disorder is not attributable to another medical condition and is not better explained by a mental disorder.
what pattern of NCD is seen in major/mild NCD due to HIV infection
“subcortical pattern”
–> prominently impaired EXECUTIVE FUNCTION, slowing of processing speed, problems with more demanding attentional tasks, difficulty in learning new information
–> in major NCD due to HIV, SLOWING may be prominent
major/mild NCD due to HIV infection show relatively preserved function in what cognitive areas
recall of learned information is relatively preserved
language difficulties are uncommon
what % of those infected with HIV have at least mild neurocognitive disturbance
1/3 to 1/2
*may not meet full criteria for NCD
estimated 25% meet criteria for mild NCD
estimated fewer than 5% meet criteria for major NCD
what are the criteria for major/mild NCD due to Prion disease
A–The criteria are met for major or mild neurocognitive disorder.
B–There is insidious onset, and rapid progression of impairment is common.
C–There are motor features of prion disease, such as myoclonus or ataxia, or biomarker evidence.
D–The neurocognitive disorder is not attributable to another medical condition and is not better explained by another mental disorder.
what type of onset and progression would you expect for major/mild NCD due to Prion disease
insidious onset, rapid progression of impairment (i.e progression to major NCD over as little as 6 months)
what are some motor features of prion disease
myoclonus
ataxia
what is the most common spongiform encephalopathy/prion disease
sporadic creutzfeldt-jakob disease (CJD)
how do those with CJD typically present
neurocognitive deficits
ataxia
abnormal movements–> myoclonus, chorea, dystonia
startle reflex is common
what are the characteristic biomarker features of prion disease
recognized lesions on MRI with DWI or FLAIR
tau or 14-3-3 protein in CSF
characteristic TRIPHASIC waves on EEG
(family history or genetic testing for rare familial forms)
what would be seen on EEG in prion diseases
characteristic triphasic waves
what proteins would be seen in CSF in prion diseases
tau or 14-3-3 protein
what are prodromal symptoms of prion disease
fatigue, anxiety, problems with appetite or sleeping, difficulties with concentration
what is the most sensitive diagnostic test for prion diseases currently
MRI with DWI–> see multifocal gray matter hyper-intensities in subcortical and cortical regions
what is the expected onset and progression of major/mild NCD due to parkinsons disease
insidious onset
GRADULE progression of impairment
list features that are frequently present in the context of major/mild NCD due to parkinsons disease
apathy
depressed mood
anxious mood
hallucinations
delusions
personality changes
REM sleep behaviour disorder
excessive daytime sleepiness
what % of those with parkinsons disease will develop a major NCD sometime in the course of their illness
75%
what type of neuroimaging may be helpful to distinguish lewy body vs non-lewy body dementias
dopatmine transporter scans i.e DaT scans or structural neuroimaging scans
how do you distinguish between the two lewy body dementias (parkinsons and dementia with lewy bodies)
onset and timing–> for parkinsons, motor and other symptoms must have been present for about a year before onset of cognitive symptoms
for dementia with lewy bodies, cognitive symptoms begin at the same time or shortly before motor symptoms
what are the early cognitive changes seen in huntingtons disease
executive function (rather than learning and memory)
often precede the emergence of the typical motor abnormalities of huntingtons disease
what are the typical motor abnormalities of huntingtons disease
bradykinesia and chorea
what is the genetic abnormality responsible for huntingtons disease
CAG trinucleotide repeat expansion in the HTT gene on chromosome 4
*fully penetrant, autosomal dominant (repeat length of 36 or more is invariably associated with huntingtons disease)
what psychiatric symptoms may be associated with huntingtons disease
depression
irritability
anxiety
obsessive-compulsive symptoms
apathy
psychosis–more rare
what is the average age at diagnosis of huntingtons disease
40
what is the median survival after motor symptom diagnosis of huntingtons disease
about 15 years
*psychiatric and cognitive symptoms of huntingtons disease can predate motor symptoms by as much as 15 years
define traumatic brain injury
“brain trauma”–>an impact to the head or other mechanisms of rapid movement or displacement of the brain within the skull, with one or more of the following:
loss of consciousness
posttraumatic amnesia
disorientation and confusion
neurological signs (i.e neuroimaging demonstrates injury; a new onset of seizures; a marked worsening of preexisting seizure disorders; visual field cuts; anosmia; hemiparesis)
criterion C for M/M NCD due to TBI
the NCD presents immediately after the occurrence of the TBI or immediately after recovery of consciousness and persists past the acute post injury period
what is the cognitive presentation of M/M NCD due to TBI
variable
commonly see difficulties in the domains of:
- -complex attention
- -executive ability
- -learning
- -memory
- -slowing speed of info processing
- -disturbances in social cognition
*in more severe TBI, there may be additional neurocognitive deficits like aphasia, neglect, or constructional dyspraxia
what are some other categories of symptoms that may be associated with M/M NCD due to TBI
disturbances in emotional function
personality changes
physical disturbances
neurological symptoms and signs
orthopedic injuries
what deficits in emotional function may be present in those with M/M NCD due to TBI
irritability
easy frustration
tension
anxiety
affective lability
what personality changes may accompany M/M NCD due to TBI
disinhibition
apathy
suspiciousness
aggression
what physical disturbances may accompany M/M NCD due to TBI
headache
fatigue
sleep disorders
vertigo, dizziness
tinnitus or hyperacuity
photosensitivity
anosmia
reduced tolerance to psychotropic medications
what are the three injury characteristics taken into consideration when judging the severity of a TBI
loss of consciousness (length of time)
posttraumatic amnesia (length of time)
disorientation and confusion at initial assessment (GCS)
list the characteristics of a mild TBI
loss of consciousness less than 30 min
posttraumatic amnesia less than 24 hours
GCS 13-15 at initial assessment (not below 13 at 30 min)
list the characteristics of moderate TBI
loss of consciousness 30 min-24 hours
posttraumatic amnesia 24 hours - 7 days
GCS 9-12 at initial assessment
list the characteristics of severe TBI
loss of consciousness over 24 hours
posttraumatic amnesia more than 7 days
GCS 3-8 at initial assessment
what are factors that affect course of recovery from TBI
course of recovery is variable
depends on:
- -specifics of injury
- -age
- -prior history of brain damage
- -hx of substance use
what is the usual recovery course in the case of mild or moderate TBI
typical course is that of complete or substantial improvement in associated neurocognitive, neurological and psychiatric symptoms and signs
how quickly do neurocognitive symptoms associated with mild TBI tend to resolve
within days to weeks after the injury
complete resolution typical by 3 months
*other symptoms that co occur with the neuro symptoms, like photosensitivity, headache, irritability, fatigue, sleep disturbance) tend to also resolve in the WEEKS following mild TBI
moderate and severe TBI increases risk for which disorders
depression
aggression
possible NCDs like alzheimers
how might persisting-TBI related impairment present in a child
delays in reaching milestones
worse academic performance
impaired social development
what might you see on CT scan in the setting of TBI
petechial hemorrhages
SAH
contusion
what might people notice functionally in the case of MILD NCD due to TBI
reduced cognitive efficiency
difficulty concentrating
lessened ability to perform usual activities
what might people notice functionally in the case of MAJOR NCD due to TBI
may have difficulty with independent living and self care
may have prominent neuromotor features like:
- -severe incoordination
- -ataxia
- -motor slowing
