Lecture 10 Dementia Flashcards
What is Delirium?
Acute confusional state
what is Dementia?
Progressive loss of cognitive functions which interfere with work or usual social activities
- Pt presents to ED with 2 days of confusion.
- No PMHx.
- Febrile.
- UTI on lab work
- That night would not stay in bed, accused nurses of trying to kill him
Is this delirium or dementia?
Delirium
Delirium: onset over _____ period of time
Short
over hours
Is delirium better or worse at night?
Worse at night
What are some associated features of Delirium?
- Disrupted sleep wake cycle
- Disorganized thinking
- Inattention
- Drowsiness
- Restlessness/ agitation/ combativeness
- Delusions
- Hallucinations
What is the most common thing that happens in neuro inpatient?
Delirium
occur in 15-50% of inpatients
What are some options for treating Delirium?
- eliminate underlying cause
- frequent re-orientation
- Out of bed during day, blinds open, no naps
- Reduce noise at night minimize interruptions
- Pt presents with 2 years of progressive cognitive decline
- increasing problems remembering names of distant acquaintances
- started keeping detailed to-do list because he missed several appointments
- wife comments he has become more forgetful in previous 2 years
- he remains active in local community organizations
- fully independent with all IADLs
- PMHx: well controlled HTN
- takes meds for insomnia
Is this dementia?
No; He has normal ADLs/work life
This is normal aging
- decrease in attention span, ability to learn new information with age
- mild and do not affect normal IADLs
- Pt presents with 3 years of progressive memory loss
- Husband reports she frequently misplaces personal items, forgets passwords, repeats questions
- Trouble with locating car in parking lot, tardiness with paying bills
- Difficulty completing tasks
- Less interest in previous hobbies but did not report low mood
- Husband has taken over with finances and paying bills and has to remind her of medications
Is this dementia?
Yes
- Progressive memory loss
- Difficulty completing tasks
- Less interest in previous hobbies but did not report low mood
How can we define dementia? (4 criteria)
A. Presence of at least 2 of the following
- Impaired learning and short term memory
- Impaired handling of complex tasks
- Imapired reasoning ability (abstract thinking)
- Impaired spatial ability and orientation (constructional ability and agnosia)
- Impaired language (aphasia)
B. Significant impairment in social and occupational functioning due to impairments from A
C. Decline from PLOF
D. Not d/t delirium or major psychiatric illness
Which cortical lobe does Learning and short term memory?
Temporal Lobe
Which cortical lobe does handling of complex tasks?
Frontal Lobe
Which cortical lobe does reasoning ability (abstract thinking)?
Frontal
Which cortical lobe does spatial ability and orientation (constructional ability and agnosia)?
Parietal
Which lobe does language (aphasia)?
Temporoparietal Lobe
Dementia is not “more difficult,” its ____ ____ ___.
Can’t do it
Note: you have to have been able to do it before, for you to not have it anymore
What are (7) reversable causes of Dementia?
- Depression
- Med side effects
- Poor sleep -?
- Hypothyroidism, B12 deficiency, Thiamine deficiency
- Neurosyphilis, other infections
- Autoimmune encephalitis
- Normal pressure hydrocephalus
Is this atrophy or normal pressure hydrocephalus?
Normal pressure hydrocephalus
Is this atrophy or normal pressure hydrocephalus?
Atrophy
What is the triad of Normal Pressure Hydrocephalus?
- Memory problems
- Gait problems - magnetic
- Incontinence
How do we dx NPH?
NPH = normal pressure hydrocephalus
Large volume lumbar puncture
What test is this?
MMSE
Mini Mental Status Exam
Items include
* orientation of time and place
* repeat 3 object names
* count backwards from 100 by sevens
* remember 3 object names
* name 2 simple objects
* repeat phrases
* fold paper in half
* read what this says
* make up a sentence about anything
* copy this picture
What test is this?
MOCA
Montreal Cognitive Assessment
Items include:
* Visuospatial/Executive
* Naming
* Memory
* Attention
* Language
* Abstraction
* Delayed Recall
* Orientation
Which (MMSE or MOCA) is harder for illiterate/lower education levels?
MOCA
but this is the norm for education levels aka most “normal” educated people should be at this level
What test is this?
SLUMS
The Clock Drawing tests for which cognitive domains?
- Visuospatial
- Executive
- Attention
- Memory
What is the best way to evaluate for dementia? Name a test.
Neuropsychological testing
- 3 hours of cognitive testing
- Visual-Perceptual-Spatial Functioning
- Executive Functioning
What is Mild Cognitive Impairment?
- pre-dementia/prodromal dementia
- Impairment in 1 or > domain in absence of dementia or impairment in ADLs
- Pt presents with 3 years of progressive memory loss
- Husband reports she frequently misplaces personal items, forgets passwords, repeats questions
- Trouble with locating car in parking lot, tardiness with paying bills
- Difficulty completing tasks
- Less interest in previous hobbies but did not report low mood
- Husband has taken over with finances and paying bills and has to remind her of medications
Is this MCI?
No, this is Alzheimer’s Disease
because it includes Cognitive, Functional, and Behavioral deficits
What is Alzheimer’s Disease?
Progressive Cognitive, Functional, Behavioral deficits
What does AD look like initially?
AD = Alzheimer’s Disease
- Short term memory loss
- word finding difficulties
- mild executive dysfunction
- mild visuospatial deficits
What does AD look like later?
- All aspects of memory are impaired
- fluctuating behavioral changes
- disturbed sleep and appetite
- hallucinations
What does end stage AD look like?
- Mute
- aspiration risk
- bed bound
- incontinent
- complications: bed sores, DVT, infections, aspiration pneumonia, malnutrition
What is the most common neurodegenerative disorder?
Alzheimer’s Disease
What are common risk factors for AD?
- family history & genetics (ApoE E4 gene)
- Lower education?
- gender (women)
- Head trauma
education & multi-language is protective for AD
What are modifiable risk factors for AD?
- HTN
- elevated BMI
- smoking
- cholesterol
- Diabetes mellitus
- hyperhomocysteinemia
- Metabolic syndrome
- Physical inactivity
- Obstructive sleep apnea
What are some things we see in AD pathology?
- Brain atrophy with neuron loss
- Neurofibrillary tangles - tau protein
- Senile plaques (abnormal nerve processes, glial processes, central amyloid core) amyloid beta protein
- Cerebrovascular amyloid
What pattern does AD follow?
- Hippocampus/temporal lobes
- Parietal
- Frontal
- Global
Pattern of AD
- Hippocampus/temporal lobe deficits –>
- Parietal lobe deficits –>
- Frontal lobe deficits –>
- Global deficits –>
- Memory impairment and naming/language
- Visuospatial function, calculations, orientation in space
- Later in disease course - executive dysfunction
- Global dysfunction
What kind of testing do we do for AD?
- Labs: to rule reversible causes of dementia (rule out B12 deficiency)
- Neuropsychological testing
- CSF: biomarkers: amyloid, tau
-
Imaging: MRI brain, exclude structrual or reversible causes
- cortical atrophy is common (temporal/parietal lobes)
What are the 2 main types of Vascular Dementia?
- Multi-infarct dementia
- Diffuse white matter disease, subcortical leucoencephalopathy, Binswanger disease
What is multi-infarct Dementia?
- step-wise progression
- asymmetric focal weakness
What is Diffuse white matter disease, subcortical leucoencephalopathy, Binswanger disease?
- Chronic progressive
- diffuse global impairment
How does subcortical (vascular dementia) present?
- attention and concentration deficit with psychomotor slowing
On the MOCA, AD will struggle more with ________ and ______
Visuospatial and Delayed Recall
On the MOCA, VD will struggle with ____, ____, and _____
Visuospatial, Attention, and Delayed Recall
In your lab eval for dementia, you want to search for _____ _____.
Reversible causes:
- HIV
- thyroid, liver function
- kidney function
- B12, folate
- ANA
- paraneoplastic antibodies
- heavy metal screen
- thiamine levels
what is the main goal of treatment for AD?
Slow progression & maintain current level of function for longer
When treating AD pharmaceutically, we are focusing on …
the cholinergic deficiency which results from degeneration of the Nucleus Basalis of Meynert
Name 3 cholinesterase inhibitors
- Donepezil
- Galantamine
- Rivastigmine
What is Aducanumab?
new drug, Monoclonal antibodies that clear out amyloid in the brain
- NO CLINICAL DIFFERENCE
- significant side effect: causes bleeding in the brain
What is Lecanemab?
Drug that showed clinical improvement
- early stage Alzheimer slowed cognitive decline by 27% over 18 months on clinical dementia rating scale sum of boxes score
- IV medication
- $26,500/year - only in big research centers
AD management looks like…
- supervision needed
- caregivers trained in dealing with aggression –> caregiver burden
- quiet, familiar environment
- depression should be treated
- behavioral disturbances/hallucinations are common
- Pt presents with memory loss
- Forgets where he puts things and has other problems with attention
- Sometimes appears confused and sometimes seems to do well
- Worse at night than day
- At night, wife notes he acts out his dreams
- Sometimes talks about animals running around that are not in the house, but not bothered
- Exam showed: masked faces, stopped posture with en bloc turning. No tremor
- Impaired executive function, attention, visuospatial function, phonemic fluency
What are we thinking this patient has?
PD+: Lewy Body Dementia
aka no amyloid
- Fluctuations
- Recurrent visual hallucinations
- Spontaneous parkinsonism
- REM sleep behavior disorder (acting out their dreams)
_____ ______ _______ develops before Parkinsonism or within one year of onset of Parkinsonism
Lewy Body Disorder
Severe neuroleptic sensitivity is a suggestive feature of what?
Lewy Body Disorder
On the MOCA, Lewy Body Disease struggle with _____ and ____.
- Visuospatial/Executive
- Attention
aka Parietal & Occipital lobes NOT TEMPORAL.
Compared with AD, Lewy body disease has fewer _____ issues.
Memory
With LBD, Rivastigmine helps with what?
LBD = lewy body disease
- reducing hallucinations and fluctuation
With LBD, Levodopa-carbidopa helps with what?
To treat motor symptoms of parkinsonism
- Pt presents with wife with cc of “my husband is crazy”
- “Too honest, flippant, arrogant, aggressively egotistically, show-off”
- not interested in grandchildren anymore, credit cards suspended after spending spree
- 50 lb weight gain d/t profound love affair with chocolate
- hoarding behavior
- speech becoming emptier in meaning
- disregard of persla hygeine
- memory ok
What are we thinking this patient has?
Frontotemporal Lobe Degeneration (FTD)
T/F: we typically see Frontotemporal dementia in 45-65 year olds.
TRUE
FTD is 2nd most common cause of EARLY-onset dementia
If patients with AD are able to recognize their deficits causing them to socially “shrink,” patients with FTD _________________.
Don’t feel like anything is wrong with them
note this difference
What are the subtypes of FTD?
- behavioral variant (bvFTD)
- primary progressive aphasia
- FTD associated with motor neuron disease
Is there amyloid with bvFTD?
No
pathology with atrophy in frontal & temporal lobes
* protein inclusions of tau, TDP-43, ubiquitin
What are some gradual behavior changes we see with FTD?
- disinhibition
- loss of empathy
- apathy
- hyperorality
- perseverative or compulsive behaviors
- newfound artistic talent - uninhibition
What are ways to treat bvFTD?
- antidepressants
- antipsychotics
- cholinesterase inhibitors
- nonpharma: safety, driving, behavior mod, caregiver support
Movement disorders are generally due to pathology in where?
Basal ganglia
What is a movement disorder?
Neuro syndromes in which there is an excess of movement or a paucity of voluntary and autonomatic movement, unrelated to weakness or spasticity
What does the pyramidal system include?
Primary sensorimotor cortex through internal capsule, brainstem, medullary pyramids, CS tracts, anterior horn cells of SC
What makes up the extrapyramidal system?
- Basal ganglia (putamen, globus pallidus, caudate)
- substantia nigra
- red nucleus
- subthalamic nucleus
What is excessive movement called?
Hyperkinesia
What is abnormal movement called?
Dyskinesia
What is decreased amplitude of movement called?
Hypokinesia
What is slowness of movement called?
Bradykinesia
What is loss of movement called?
Akinesia
What is rhythmic oscillatory movement around an axis?
Tremor
What is ongoing random involuntary movements incorporated?
Chorea
What is involuntary sustained or intermittent contractions that cause twisting/repetitive movements or abnormal postures?
Dystonia
What are repeated non-rhythmic brief shock-like jerks?
Myoclonus
What is postural tremor vs. intention tremor?
Postural tremor: revealed by extending a limb against gravity
Intention tremor: evident by moving a limb to and from a target
What is movement with an urge that is suppressed with the movement?
Tic
Essential Tremor is during _____
PD tremor is during _____
PD = Parkinson’s Disease
- Essential tremor: action, posture
- PD: rest > posture (re-emergence)
Is essential tremor or PD faster?
Essential tremor is faster
Direction of tremor:
Essential tremor vs PD
Essential tremor: flex/extend
PD: sup/pron
Handwriting with:
Essential Tremor vs. PD
Essential Tremor: gets bigger
PD: gets smaller
Essential tremor: half of patients have ______ history and it is a ____ progression
Family history
Slow progression
usually no other neuro deficits
Essential tremor attacks ___ > _____ > _____
Hands > head > speech
Pharma treatment for Essential Tremor includes
- primidone
- propranolol
- topirimate
What is a progressive, neurodegenerative disorder with loss of dopaminergic cells within substantia nigra?
Parkinson’s Disease (PD)
PD symptoms?
What are features of PD rest tremor? (what part of body does it affect? during rest or action?)
- distal extremities and lips
- “pill-rolling”
- stops with action of the limb
What does rigidity of PD look like?
- Increased resistance to passive movement
- equal in all directions
- “cog-wheeling”
What does bradykinesia in PD look like?
- masked facies
- decreased blink
- soft speech
- loss of inflection
- micrographia
- drooling
- shuffling gait
What does loss of postural reflexes look like in PD?
Retropulsion
a disorder of locomotion that causes a person to lean backward and lose their balance
What does freezing look like in PD?
- Motor blocks
- start-hesitation
- difficulty moving through doorways/halls
With parkinson’s we see _____ posture of trunk, neck, limbs
Flexed
Off state of PD is ____
ON state of PD is ____
Off: freezing (not on medications)
On: on medication, normal, looks a lot better
What are indications for Levodopa (main drug for PD)?
- treats any motor symptoms of PD - early or late
- replaces brain dopamine
What drug do you add to Levodopa to make it last longer?
COMT inhibitor
- prevents breakdown of Levodopa
- advanced PD - only in combo with Levodopa
What is Peak Dose Dyskinesias with PD?
chorea-type movement AKA too much dopamine,
but sometimes we prefer that over not enough cuz at least they’re not freezing and we can do things with them but they may feel like their tremor is worse
Who is Deep Brain Stimulation for?
Advanced PD patients
What is Deep Brain stimulation?
Implant high frequency electrodes in VIM nucleus of thalamus, Sub thalamic nucleus, or GPi
What does a Thalamotomy do?
improves CL tremor, rigidity (not bradykinesia)
Note: in contrast to palliotomy that improves bradykinesa
What does a Pallidotomy do? when is it indicated?
improves tremor, bradykinesia, and rigidity on CL side of lesion
indicated: when STN and GPi are overactive in PD
What are 4 atypical parkinsonism disorders?
- Lewy body
- progressive supranuclear palsy (PSP)
- corticobasal denegeration (CBD)
- multisystem atrophy (MSA)
What does progressive supranuclear palsy present with?
- inability to look up or down (supranuclear)
- axial rigidity
- early falls (because you can’t look up or down at feel = fall)
What does Corticobasal degeneration present with?
Alien limb/apraxia
What does multisystem atrophy look like?
Orthostatic hypotension
Hypereflexia
What 2-3cognitive domains do each of these affect on the MOCA:
Alzheimer’s
Lewy body
Vascular
Alzheimer’s- visuospatial/executive + short term memory
Lewybody- attention + visuospatial/executive
Vascular dementia- short term memory + attention + visuospatial/executive
What kind of dementia is associated with Parkinsons?
Lewy body
how does vascular/lower body parkinsonism present
freezing. gait disturbances, normal upper extremity
Parkinsons patients have what kind of tremor?
resting tremor
How is huntington disease inhereted?
what chromosome
Autosomal dominant
chromosome 4
note: mean onset 35-42, avg time till death 17 years
what structures does huntington disease primarily affect
neuron loss in caudate and putamen
What are the symptoms of huntingtons
Personality changes, dementia
CHOREA- rapid jerky movements of extremities that can be incorporated into regular movement
ATHETOSIS- slow continous writing movements of LE
what medication treats huntington
tetrabenazine, depletes dopamine
Wilsons disease is due to a disorder of __________ metabolism
copper
caused ataxia, chorea, abonromal movements
can be mistaken for huntington but it’s more rare
What is dystonia
sustained contractions that cause abnormal repetitive movements
initiated or worsened by voluntary movement
sensory tricks can relieve dystonia
What are tic disorders
repetitive stereotyped movements that change overtime
urge or desire is relieved when they do it
How do you classify a patient as having tourette syndrome
1+ motor tic
1 vocal tic
fluctuating course
over 1 year
onset before 21
what is the main thing to know about functional neurological disorders
they are real neurological dysfunctions, not caused by damage
they improve w/ distraction
can treat with PT!
