IDT - Alzheimers/Dementia Lee Flashcards by Josh Miller

What is defined as a deficiency in cognitive function relating to memory, reasoning, planning, attention, language and executive function, and visuospatial perception?

Cognitive Impairment

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What is it called when there is a drop from prior levels of cognitive function, and when is it most commonly see?

Mild Cognitive Impairment, common with age progression

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Mild Cognitive impairment plus a loss in the ability to care for one’s self is called?

Dementia

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What are some daily living activities often impaired in Dementia?

Eating
Bathing
Grooming
Toileting
Transferring
Cooking

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What is the difference between MCI and Dementia?

Detailed history of levels of function prior to impairment

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Number of people affected with Alzheimers Disease?
Mortality?
Annual US cost?

5 million Americans
1 in 3 seniors dies w/ Alzheimers or Dementia
6th leading cause of death
Costs 236 billion annually

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What Genetic Markers are commonly seen in Alzheimers/Dementia?

APOE-e4 (increases risk)
APP
PSEN-1&2
Family history of CVD

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What activities help increase and maintain cognitive reserve?

Education

Social Engagement

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What is the most common form of Dementia?

Alzheimers (60-80%)

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What is the effect of normal aging on # of neurons?

Preserved

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What is the effect of normal aging on brain mass?

Preserved

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What is the effect of normal aging on number/speed of Synaptic connections?

Lost

Lose both speed and linkage

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What is the effect of normal aging on the storage of memories?

Slowed, not impaired

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What is the effect of normal aging on the retrieval of memories?

Preserved, yet slower recall

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What is the effect of normal aging on thinking/reasoning?

Slowed, but not impaired

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What region of the brain is earliest affected due to dementia? What processes are affected?

Hippocampus (affects memory creation/recall and language

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What is the effect of dementia on the size of ventricles and sulci?

Enlargement

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What is the timeline for cholinergic neuron loss due to dementia?

(Early)
Memory
Language
Reasoning/Understanding
Disinhibition of behavior (Later)

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The formation of what cellular body may be responsible for increase in dementia?

Amyloid Beta Plaques (accumulate on outside of cells)

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How are Amyloid Beta plaques formed?

APP is cleaved by B-secretase, then gamma-secretase, forming the B-amyloid42 plaques due to insolubility

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What normal function should occur to create less amyloid beta plaques?

A-secretase cleavage of APP to B-amyloid40, much more soluble

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What is the function of Hyperphosphorylated Tau protein?

Responsible for stabilization of microtubules, which transport molecules and nutrients within the cell, axon, dendrites

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What is the Cholinergic Hypothesis?

Hypothesis for Alzheimers which states Loss of cholinergic neurons is responsible for AD, now considered a downstream event.

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What is the impaired glucose transport Hypothesis?

Novel hypothesis for AD, that a disruption of energy formation in brain leads to oxidative stress, free radical formation, inflammation, and neuronal death, decreasing cognitive function.

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What is the "bottom line" about the cause of AD?

Multifactorial disease with no single cause and no single cure.

What is the relationship between appearance of plaques and AD Dementia

Positive, approximately a 10 year delay between pathology and symptoms.

What is the prevalence/start time of Early onset AD?

5% of all AD patients Symptoms start <65yo Can start in 30s (Genetics is stronger)

What is MMSE score of 30-26?

Preclinical | No symptoms, only possible biomarker changes

What is MMSE score of 22-26?

A drop in cognitive function, can be due to normal aging, no functional changes yet

What is MMSE score <22?

Dementia due to AD based on clinical symptoms, functional impairments have occurred

Mild AD primarily is expressed as?

Problems with Memory - finding right word/name - forgetting material just read - losing/misplacing things - problems organizing/planning

Moderate AD primarily expressed as?

More problematic - forgetfulness of personal history (address, phone #) - trouble with bladder - personality/behavioral changes

Severed AD primarily expressed as?

Late Stage Require full time care Loss of awareness Changes in physical abilities

approximately 10-20% of all dementias, caused by cerebrovascular infarcts or narrowing of the arteries that is progressive.

Vascular Dementia,

Symptoms of Vascular Dementia

Depend on where infarcts are, may include urinary incontinence and frequent falls. Symptom progression is stepwise.

Vascular Dementia vs Alzheimer's Slope

Alzheimers - Steady decline Vascular - Step decline (Possible combination)

Lewbody Dementia Symptoms

``` Inattention Executive Dysfunction Visuaspatial impairment Visual Hallucinations (common) Memory Loss (less common) ```

What is Picks Disease?

Frontotemporal dementia, makes up 2% of dementias Social behavior and personality changes (grumpy old people) Do well on cognitive testing, memory and executive function

Treatment options for AD and Dementia

Cholinesterase Inhibitors | NMDA antagonist

Types of Cholinesterase Inhibitors

Donepezil Galantamine Rivastigmine Tacrine (not marketed)

NMDA antagonist for AD

Memantine

ChE inhibitors Mechanism

Increase ACh in synaptic cleft, to help with loss of cholinergic neurons

What is the length of efficacy of cholinesterase inhibitors

About 6 months of delayed symptoms

Adverse effects of ChE inhibitors

``` Cholinergic Side Effects GI: Nausea, Vomiting Diarrhea Anorexia, weight loss Bradycardia Muscle Tremor/Weakness Insomnia ```

Memantine for treatment of AD

Not useful as Monotherapy | effective in combination with ChE inhibitor

What are the four current targets for Drug Research in AD?

Tau Protein Insulin Inflammation B-A Cascade

What is the difference between Delirium and Dementia?

Delirium is an acute disease that fluctuates throughout the day but does not progress further and may also have some precipitating factors.

What percentage of hospitalized older adults experience delirium?

30%

What percentage of older adults are hospitalized for a hip fracture or injurious fall?

50%

What percentage of delirium in older hospitalized patients is missed?

70%

What percentage of older adults w/ delirium in hospitals have symptoms over 6 months?

30%

What is the average length of hospital stay for adults with delirium and what is the estimated cost of delirium to the US?

8 days, approximately $150 million

D.E.L.I.R.I.U.M

``` Dementia Electrolytes levels Lungs (liver, heart, kidney) Infection Rx Injury, pain, stress Unfamiliar scenery Metabolic ```

What are common precipitating factors for postoperative delirium?

``` Confusion New Environment Pain or Discomfort Depression Sleep disruption ```

What are some strategies to prevent delirium?

``` Cogntitive Stimulation Quiet Time Sleep Hygiene Orientation Protocols Prevent Hypoxemia Mobilization Avoid Restraints Hydration Glasses/Hearing Aids Manage Pain ```

What Tests can be used to screen for Delirium?

CAM DSM-4 (recommended frequently, up to daily, it is based on recent history)

What percentage of psychiatric consults with older adults are diagnosed with delirium?

40%

Hypoactive vs Hyperactive Delirium

Hypoactive - say yes, sedated, peaceful, "model patient" | Hyperactive - Agitation, aggression, pull out IV lines

When do you treat for delirium?

Only when they might cause harm to self or others | NEVER "just in case"

Psychiatric symptoms of dementia?

``` Agitation Aggression Delusions Hallucinations Wandering Depression Sleep Disturbances ```