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Neuromuscular management > Lecture 10 Dementia > Flashcards

Lecture 10 Dementia Flashcards

1
Q

What is Delirium?

A

Acute confusional state

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2
Q

what is Dementia?

A

Progressive loss of cognitive functions which interfere with work or usual social activities

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3
Q
  • 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?

A

Delirium

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4
Q

Delirium: onset over _____ period of time

A

Short

over hours

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5
Q

Is delirium better or worse at night?

A

Worse at night

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6
Q

What are some associated features of Delirium?

A
  • Disrupted sleep wake cycle
  • Disorganized thinking
  • Inattention
  • Drowsiness
  • Restlessness/ agitation/ combativeness
  • Delusions
  • Hallucinations
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7
Q

What is the most common thing that happens in neuro inpatient?

A

Delirium

occur in 15-50% of inpatients

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8
Q

What are some options for treating Delirium?

A
  • eliminate underlying cause
  • frequent re-orientation
  • Out of bed during day, blinds open, no naps
  • Reduce noise at night minimize interruptions
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9
Q
A
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9
Q
  • 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?

A

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
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10
Q
  • 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?

A

Yes

  • Progressive memory loss
  • Difficulty completing tasks
  • Less interest in previous hobbies but did not report low mood
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11
Q

How can we define dementia? (4 criteria)

A

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

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12
Q

Which cortical lobe does Learning and short term memory?

A

Temporal Lobe

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13
Q

Which cortical lobe does handling of complex tasks?

A

Frontal Lobe

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14
Q

Which cortical lobe does reasoning ability (abstract thinking)?

A

Frontal

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15
Q

Which cortical lobe does spatial ability and orientation (constructional ability and agnosia)?

A

Parietal

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16
Q

Which lobe does language (aphasia)?

A

Temporoparietal Lobe

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17
Q

Dementia is not “more difficult,” its ____ ____ ___.

A

Can’t do it

Note: you have to have been able to do it before, for you to not have it anymore

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18
Q

What are (7) reversable causes of Dementia?

A
  1. Depression
  2. Med side effects
  3. Poor sleep -?
  4. Hypothyroidism, B12 deficiency, Thiamine deficiency
  5. Neurosyphilis, other infections
  6. Autoimmune encephalitis
  7. Normal pressure hydrocephalus
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19
Q

Is this atrophy or normal pressure hydrocephalus?

A

Normal pressure hydrocephalus

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20
Q

Is this atrophy or normal pressure hydrocephalus?

A

Atrophy

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21
Q

What is the triad of Normal Pressure Hydrocephalus?

A
  1. Memory problems
  2. Gait problems - magnetic
  3. Incontinence
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22
Q

How do we dx NPH?

NPH = normal pressure hydrocephalus

A

Large volume lumbar puncture

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23
Q

What test is this?

A

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

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24
Q

What test is this?

A

MOCA
Montreal Cognitive Assessment

Items include:
* Visuospatial/Executive
* Naming
* Memory
* Attention
* Language
* Abstraction
* Delayed Recall
* Orientation

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25
Q

Which (MMSE or MOCA) is harder for illiterate/lower education levels?

A

MOCA

but this is the norm for education levels aka most “normal” educated people should be at this level

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26
Q

What test is this?

A

SLUMS

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27
Q
A
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28
Q

The Clock Drawing tests for which cognitive domains?

A
  • Visuospatial
  • Executive
  • Attention
  • Memory
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29
Q

What is the best way to evaluate for dementia? Name a test.

A

Neuropsychological testing

  • 3 hours of cognitive testing
  • Visual-Perceptual-Spatial Functioning
  • Executive Functioning
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30
Q

What is Mild Cognitive Impairment?

A
  • pre-dementia/prodromal dementia
  • Impairment in 1 or > domain in absence of dementia or impairment in ADLs
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31
Q
  • 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?

A

No, this is Alzheimer’s Disease

because it includes Cognitive, Functional, and Behavioral deficits

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32
Q

What is Alzheimer’s Disease?

A

Progressive Cognitive, Functional, Behavioral deficits

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33
Q

What does AD look like initially?

AD = Alzheimer’s Disease

A
  • Short term memory loss
  • word finding difficulties
  • mild executive dysfunction
  • mild visuospatial deficits
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34
Q

What does AD look like later?

A
  • All aspects of memory are impaired
  • fluctuating behavioral changes
  • disturbed sleep and appetite
  • hallucinations
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35
Q

What does end stage AD look like?

A
  • Mute
  • aspiration risk
  • bed bound
  • incontinent
  • complications: bed sores, DVT, infections, aspiration pneumonia, malnutrition
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36
Q

What is the most common neurodegenerative disorder?

A

Alzheimer’s Disease

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37
Q

What are common risk factors for AD?

A
  • family history & genetics (ApoE E4 gene)
  • Lower education?
  • gender (women)
  • Head trauma

education & multi-language is protective for AD

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38
Q

What are modifiable risk factors for AD?

A
  • HTN
  • elevated BMI
  • smoking
  • cholesterol
  • Diabetes mellitus
  • hyperhomocysteinemia
  • Metabolic syndrome
  • Physical inactivity
  • Obstructive sleep apnea
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39
Q

What are some things we see in AD pathology?

A
  • Brain atrophy with neuron loss
  • Neurofibrillary tangles - tau protein
  • Senile plaques (abnormal nerve processes, glial processes, central amyloid core) amyloid beta protein
  • Cerebrovascular amyloid
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40
Q

What pattern does AD follow?

A
  1. Hippocampus/temporal lobes
  2. Parietal
  3. Frontal
  4. Global
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41
Q

Pattern of AD

  1. Hippocampus/temporal lobe deficits –>
  2. Parietal lobe deficits –>
  3. Frontal lobe deficits –>
  4. Global deficits –>
A
  1. Memory impairment and naming/language
  2. Visuospatial function, calculations, orientation in space
  3. Later in disease course - executive dysfunction
  4. Global dysfunction
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42
Q

What kind of testing do we do for AD?

A
  • 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)
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43
Q

What are the 2 main types of Vascular Dementia?

A
  • Multi-infarct dementia
  • Diffuse white matter disease, subcortical leucoencephalopathy, Binswanger disease
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44
Q

What is multi-infarct Dementia?

A
  • step-wise progression
  • asymmetric focal weakness
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45
Q

What is Diffuse white matter disease, subcortical leucoencephalopathy, Binswanger disease?

A
  • Chronic progressive
  • diffuse global impairment
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46
Q

How does subcortical (vascular dementia) present?

A
  • attention and concentration deficit with psychomotor slowing
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47
Q

On the MOCA, AD will struggle more with ________ and ______

A

Visuospatial and Delayed Recall

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48
Q

On the MOCA, VD will struggle with ____, ____, and _____

A

Visuospatial, Attention, and Delayed Recall

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49
Q

In your lab eval for dementia, you want to search for _____ _____.

A

Reversible causes:

  • HIV
  • thyroid, liver function
  • kidney function
  • B12, folate
  • ANA
  • paraneoplastic antibodies
  • heavy metal screen
  • thiamine levels
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50
Q

what is the main goal of treatment for AD?

A

Slow progression & maintain current level of function for longer

51
Q

When treating AD pharmaceutically, we are focusing on …

A

the cholinergic deficiency which results from degeneration of the Nucleus Basalis of Meynert

52
Q

Name 3 cholinesterase inhibitors

A
  1. Donepezil
  2. Galantamine
  3. Rivastigmine
53
Q

What is Aducanumab?

A

new drug, Monoclonal antibodies that clear out amyloid in the brain

  • NO CLINICAL DIFFERENCE
  • significant side effect: causes bleeding in the brain
54
Q

What is Lecanemab?

A

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
55
Q

AD management looks like…

A
  • supervision needed
  • caregivers trained in dealing with aggression –> caregiver burden
  • quiet, familiar environment
  • depression should be treated
  • behavioral disturbances/hallucinations are common
56
Q
  • 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?

A

PD+: Lewy Body Dementia

aka no amyloid

57
Q

With Lewy Body Dementia, we have 2 or more of:

A
  • Fluctuations
  • Recurrent visual hallucinations
  • Spontaneous parkinsonism
  • REM sleep behavior disorder (acting out their dreams)
58
Q

_____ ______ _______ develops before Parkinsonism or within one year of onset of Parkinsonism

A

Lewy Body Disorder

59
Q

Severe neuroleptic sensitivity is a suggestive feature of what?

A

Lewy Body Disorder

60
Q

On the MOCA, Lewy Body Disease struggle with _____ and ____.

A
  • Visuospatial/Executive
  • Attention

aka Parietal & Occipital lobes NOT TEMPORAL.

61
Q

Compared with AD, Lewy body disease has fewer _____ issues.

A

Memory

62
Q

With LBD, Rivastigmine helps with what?

LBD = lewy body disease

A
  • reducing hallucinations and fluctuation
63
Q

With LBD, Levodopa-carbidopa helps with what?

A

To treat motor symptoms of parkinsonism

64
Q
  • 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?

A

Frontotemporal Lobe Degeneration (FTD)

65
Q

T/F: we typically see Frontotemporal dementia in 45-65 year olds.

A

TRUE

FTD is 2nd most common cause of EARLY-onset dementia

66
Q

If patients with AD are able to recognize their deficits causing them to socially “shrink,” patients with FTD _________________.

A

Don’t feel like anything is wrong with them

note this difference

67
Q

What are the subtypes of FTD?

A
  • behavioral variant (bvFTD)
  • primary progressive aphasia
  • FTD associated with motor neuron disease
68
Q

Is there amyloid with bvFTD?

A

No

pathology with atrophy in frontal & temporal lobes
* protein inclusions of tau, TDP-43, ubiquitin

69
Q

What are some gradual behavior changes we see with FTD?

A
  • disinhibition
  • loss of empathy
  • apathy
  • hyperorality
  • perseverative or compulsive behaviors
  • newfound artistic talent - uninhibition
70
Q

What are ways to treat bvFTD?

A
  • antidepressants
  • antipsychotics
  • cholinesterase inhibitors
  • nonpharma: safety, driving, behavior mod, caregiver support
71
Q

Movement disorders are generally due to pathology in where?

A

Basal ganglia

72
Q

What is a movement disorder?

A

Neuro syndromes in which there is an excess of movement or a paucity of voluntary and autonomatic movement, unrelated to weakness or spasticity

73
Q

What does the pyramidal system include?

A

Primary sensorimotor cortex through internal capsule, brainstem, medullary pyramids, CS tracts, anterior horn cells of SC

74
Q

What makes up the extrapyramidal system?

A
  • Basal ganglia (putamen, globus pallidus, caudate)
  • substantia nigra
  • red nucleus
  • subthalamic nucleus
75
Q

What is excessive movement called?

A

Hyperkinesia

76
Q

What is abnormal movement called?

A

Dyskinesia

77
Q

What is decreased amplitude of movement called?

A

Hypokinesia

78
Q

What is slowness of movement called?

A

Bradykinesia

79
Q

What is loss of movement called?

A

Akinesia

80
Q

What is rhythmic oscillatory movement around an axis?

A

Tremor

81
Q

What is ongoing random involuntary movements incorporated?

A

Chorea

82
Q

What is involuntary sustained or intermittent contractions that cause twisting/repetitive movements or abnormal postures?

A

Dystonia

83
Q

What are repeated non-rhythmic brief shock-like jerks?

A

Myoclonus

84
Q

What is postural tremor vs. intention tremor?

A

Postural tremor: revealed by extending a limb against gravity

Intention tremor: evident by moving a limb to and from a target

84
Q

What is movement with an urge that is suppressed with the movement?

A

Tic

85
Q

Essential Tremor is during _____

PD tremor is during _____

PD = Parkinson’s Disease

A
  • Essential tremor: action, posture
  • PD: rest > posture (re-emergence)
86
Q

Is essential tremor or PD faster?

A

Essential tremor is faster

87
Q

Direction of tremor:

Essential tremor vs PD

A

Essential tremor: flex/extend
PD: sup/pron

88
Q

Handwriting with:

Essential Tremor vs. PD

A

Essential Tremor: gets bigger

PD: gets smaller

89
Q

Essential tremor: half of patients have ______ history and it is a ____ progression

A

Family history

Slow progression

usually no other neuro deficits

90
Q

Essential tremor attacks ___ > _____ > _____

A

Hands > head > speech

91
Q

Pharma treatment for Essential Tremor includes

A
  • primidone
  • propranolol
  • topirimate
92
Q

What is a progressive, neurodegenerative disorder with loss of dopaminergic cells within substantia nigra?

A

Parkinson’s Disease (PD)

93
Q

PD symptoms?

A
94
Q

What are features of PD rest tremor? (what part of body does it affect? during rest or action?)

A
  • distal extremities and lips
  • “pill-rolling”
  • stops with action of the limb
95
Q

What does rigidity of PD look like?

A
  • Increased resistance to passive movement
  • equal in all directions
  • “cog-wheeling”
96
Q

What does bradykinesia in PD look like?

A
  • masked facies
  • decreased blink
  • soft speech
  • loss of inflection
  • micrographia
  • drooling
  • shuffling gait
97
Q

What does loss of postural reflexes look like in PD?

A

Retropulsion

a disorder of locomotion that causes a person to lean backward and lose their balance

98
Q

What does freezing look like in PD?

A
  • Motor blocks
  • start-hesitation
  • difficulty moving through doorways/halls
99
Q

With parkinson’s we see _____ posture of trunk, neck, limbs

A

Flexed

100
Q

Off state of PD is ____
ON state of PD is ____

A

Off: freezing (not on medications)

On: on medication, normal, looks a lot better

101
Q

What are indications for Levodopa (main drug for PD)?

A
  • treats any motor symptoms of PD - early or late
  • replaces brain dopamine
102
Q

What drug do you add to Levodopa to make it last longer?

A

COMT inhibitor

  • prevents breakdown of Levodopa
  • advanced PD - only in combo with Levodopa
103
Q

What is Peak Dose Dyskinesias with PD?

A

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

104
Q

Who is Deep Brain Stimulation for?

A

Advanced PD patients

105
Q

What is Deep Brain stimulation?

A

Implant high frequency electrodes in VIM nucleus of thalamus, Sub thalamic nucleus, or GPi

106
Q

What does a Thalamotomy do?

A

improves CL tremor, rigidity (not bradykinesia)

Note: in contrast to palliotomy that improves bradykinesa

107
Q

What does a Pallidotomy do? when is it indicated?

A

improves tremor, bradykinesia, and rigidity on CL side of lesion

indicated: when STN and GPi are overactive in PD

108
Q

What are 4 atypical parkinsonism disorders?

A
  1. Lewy body
  2. progressive supranuclear palsy (PSP)
  3. corticobasal denegeration (CBD)
  4. multisystem atrophy (MSA)
109
Q

What does progressive supranuclear palsy present with?

A
  • inability to look up or down (supranuclear)
  • axial rigidity
  • early falls (because you can’t look up or down at feel = fall)
110
Q

What does Corticobasal degeneration present with?

A

Alien limb/apraxia

111
Q

What does multisystem atrophy look like?

A

Orthostatic hypotension
Hypereflexia

112
Q

What 2-3cognitive domains do each of these affect on the MOCA:

Alzheimer’s

Lewy body

Vascular

A

Alzheimer’s- visuospatial/executive + short term memory

Lewybody- attention + visuospatial/executive

Vascular dementia- short term memory + attention + visuospatial/executive

113
Q

What kind of dementia is associated with Parkinsons?

A

Lewy body

114
Q

how does vascular/lower body parkinsonism present

A

freezing. gait disturbances, normal upper extremity

115
Q

Parkinsons patients have what kind of tremor?

A

resting tremor

116
Q

How is huntington disease inhereted?

what chromosome

A

Autosomal dominant

chromosome 4

note: mean onset 35-42, avg time till death 17 years

117
Q

what structures does huntington disease primarily affect

A

neuron loss in caudate and putamen

118
Q

What are the symptoms of huntingtons

A

Personality changes, dementia

CHOREA- rapid jerky movements of extremities that can be incorporated into regular movement

ATHETOSIS- slow continous writing movements of LE

119
Q

what medication treats huntington

A

tetrabenazine, depletes dopamine

120
Q

Wilsons disease is due to a disorder of __________ metabolism

A

copper

caused ataxia, chorea, abonromal movements

can be mistaken for huntington but it’s more rare

121
Q

What is dystonia

A

sustained contractions that cause abnormal repetitive movements

initiated or worsened by voluntary movement

sensory tricks can relieve dystonia

122
Q

What are tic disorders

A

repetitive stereotyped movements that change overtime

urge or desire is relieved when they do it

123
Q

How do you classify a patient as having tourette syndrome

A

1+ motor tic

1 vocal tic

fluctuating course

over 1 year

onset before 21

124
Q

what is the main thing to know about functional neurological disorders

A

they are real neurological dysfunctions, not caused by damage

they improve w/ distraction

can treat with PT!

Neuromuscular management (19 decks)

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