LECTURE 7: DEMENTIA Flashcards
most common neurological medical condition in the hospital
deliriium
(15-50% of inpatients, 80% elderly in ICU)
-older pts: one organ
-younger: multi organ
how to treat delirium
-eliminate underlying cause
-re-orient (write day/schedule)
-no naps, out of bed in day
-good sleep
dementia characterized by presence of at least 2 of the following:
A. impaired:
1. learning/short term memory (temporal)
2. handle complex tasks (frontal)
3. reasoning/abstract thinking (frontal)
4. spatial ability (parietal)
5. language/aphasia (temporal/parietal)
B. significant impairment in social/work
C. decline from PLOF
D. no diff dx (delirium or depression) -hard to diagnose in hospital
what are differential dx of dementia that are REVERSIBLE?
- depression
- medication side effects
- poor sleep
- hypothyroidism
- neurosyphilis
- autoimmune encephalitis
- normal pressure hydrocephalus
difference between normal pressure hydrocephalus and atrophy on brain scan
-NPH:large ventricles
Atrophy: large sulci, shrinking
evaluation of dementia
history: what is impaired?
-onset
-time course: why did they stop working?
-progression
-education level
-Observation (behavior? grooming?)
-Mental Status Exam
-Neuro exam: hearing loss? involuntary mvmts?
lab tests, imaging
delirium looks like…
acute (hours)
fluctuates (worse at night)
-disrupted sleep wake
-disorganized thinking
-inattention
-drowsiness
-restlessness/agitation/combativeness
-deluisions
-hallucinations
what is normal aging?
decrease in attention and ability to learn new information
does not affect IADLs
in dementia, there are typically two lobes involved. List impairments/lobes
- learning/short term memory: temporal
- complex tasks: frontal
- reasoning: frontal
- spatial ability/orientation: parietal
- language/aphasia: parietal and temporal
these things should impair work/social function, decline PLOF
What are causes of dementia?
- alzheimers
- lewy body
- frontotemporal
- vascular dementia
- parkinsons
- progressive supranuclear palsy
- huntington’s
- alcohol related dementia
- chronic traumatic encephalopathy
10: med side effects
11: prion disease
12: HIV
What is NPH? (normal pressure hydrocephalus)
CSF build up in ventricles!
- memory problems
- magnetic gait
- incontinence
how do you diagnose NPH?
DX: gait test, pull lots of CSF out with LP, then gait test again. If it gets better, treat!
how do you treat NPH?
VP shunt to pull CSF
gait gets treated but memory doesn’t get better much
MMSE tests…
mini mental status exam
total 30
*doesn’t test all lobes
MOCA
tests all lobes
1. visuospatial/executive
2. naming animals
3. memory
4. attention
5. language
6. abstraction (banana-orange-fruit)
7. delayed recall
8. orientation
SLUMS exam
test for dementia
clock drawing tests what domains?
visuospatial
executive
attention
memory
test for dementia
neuropsychological testing includes what?
visual-perceptual-spatial functioning
1. copy geom designs
2. identify faces
3. calculations
4. left right discrimination
EXECUTIVE FUNCTIONING:
1. naming fluency
2. alternate numbers and letters in order
3. stroop test (words/colors)
4. repeated hand gestures
what are two predictors of rapid progression of MCI to dementia?
- medial temporal lobe atrophy in MRI
- hypometabolic pattern on FDG-PET
MCI is defined as
impairment in 1 or more domain but no dementia or no impairment of ADLs
*also known as pre or prodromal dementia
12-18% of people over 60 years old have
MCI
____% of people with MCI per year transition to dementia
8-15%
most effective tx for dementia/MCI
exercise!
early alzheimers looks like
-short term memory loss
-word finding difficulties
-mild executive dysfunction
-mild visuospatial deficits
later alzheimers looks like
-all memory impaired
-behavioral changes
-sleep/eating disturbed
-hallucinations
end stage alzheimers looks like
mute, aspiration risk, ned bound, incontinence
*risk of bed sores, infection, DVT, pneumonia, malnutrition
what is the most common neurodegenerative disorder and 6th common cause of death in US?
ALZHEIMERS
*90% is sporatic
*70% of dementia cases
risk factors for alzheimers
- head trauma
- women
- lower education
- ApoE e4 gene
- other genes: presenilin 1 and 2, APP gene
what are modifiable risk factors for alzheimers?
HTN, cholesterol
DM, high BMI
smoking
metSyn
inactive
obstructive sleep apnea
hyperhomocysteinemia
pathology of alzheimers/how to diagnose?
- tau (neurofibrillary tangles)
- amyloid beta (senile plaques)
- cerebrovascular amyloid
atrophy with neuron loss!
what are the 2 CSF biomarkers for alzheimers?
- amyloid beta, tau
On the MOCA, person with alzheimers looks like ____vs vascular dementia
difference: attention!
both: problems with visual/spatial, delayed recall
vascular dementia 2 types
- multi-infarct
- SUBCORTICAL diffuse white matter disease/subcort leucoencephalopathy, binswanger disease
subcortical dementia presents with
ATTENTION
concentration deficits
psychomotor slowing
what to lab test to diff dx dementia/reversible causes
– HIV, tests for syphilis
– thyroid, liver function tests
– Kidney function
– B12, folate
– ANA (test for lupus), rheumatoid factor
– paraneoplastic antibodies (not routine) – Heavy metal screen (not routine)
– Thiamine levels (not routine)
what 3 imaging do they do for alzheimers?
- MRI
- FDG-PET
- Amyloid PET
what medications are given to treat cholinergic deficiency in Alzheimers?
Cholinesterase inhibitors
1. Donepezil (Aricept)
2. Galantamine (Razadyne)
3. Rivastigmine (Exelon)
NMDA partial antagonist for Alzheimers
Memantine (Namenda)
what medication approved in 2023 can slow cognitive decline by 27% over 18 months in EARLY STAGE ALZEIMERS?
Lecanemab: IV medication every 2 weeks
how to best manage alzheimers
- caregiver/supervision
- quiet, familiar environment
- treat depression
4.behavior/hallucinations: give benzos or antipsych
Lewy Body Dementia presents with
- attention
- executive function
- visuospatial
(less memory)
+
2 or more of - fluctuations
- visual hallucinations
- spontaneous
- parkinsonism
- REM sleep behavior disorder
2 parts of brain affected by lewy body
visuospatial/executive: parietal and occipital
attention: parietal
*PARIETAL AND OCCIPITAL
2nd most common cause of alzheimers
frontotemporal lobe dementia
frontotemporal lobe dementia symptoms
low attention, perseveration, flirty
-frontal release signs
-hyperreflexia
-no weakness
-memory is fine
types of FTD
- behavioral variant
- primary prog aphasia
- FTD associated with motor neuron disease
what does the brain of someone with bvFTD look like?
atrophy in frontal, temporal lobes
proteins: tau, TDP-43, ubiquitin
behavioral changes in FTD
- disinhibition
- no empathy
- apathy
- hyperorality (oral)
- perseverative/compulsive
what is athetosis
writhing movmenets preventing stable posture
what is ballism
violent mvmt at joint
what is dystonia
contractions causing twisting/abnormal postures
myoclonus
repeated non-rhythmic brief shock like JERKS
what is sterotypy
repetitive simple movements, can be suppressed
