lecture 7: dementia and movenet disorders Flashcards
what is delirium
actue confusion state
what is the progressive loss of cognitive functions which interfere with work or usual social activities
dementia
what is an onset over a short period of time (typically over hours ) , worse at nights and has associated features of
– Disrupted sleep wake cycle
– Disorganized thinking
– Inattention
– Drowsiness
– Restlessness/agitation/combativeness – Delusions
– Hallucinations
delirium
is delirium or dementia common in the hospital
delirium
what drugs can causes ddelirum
-anticholinergic
-benzo
-opiates
-steroids
what is the treatment for delirium
-eliminate the cause
- frequent re orientation with white boards w th days date and schedule
- out of bed during the day w blinds open
-reduce noise at night
An 83-year-old man was evaluated for 2 years of progressive cognitive decline. He reported increasing problems remembering the names of distant acquaintances, thinking of words, and learning to use new devices. He started keeping a detailed to-do list and daily calendar because he had missed several medical appointments. His wife agreed that he had become more forgetful in the previous 2 years and commented that he now repeated himself in daily conversations. He remained active in local community organizations and was fully independent with all instrumental activities of daily living. His medical history was notable for well-controlled hypertension. He had been taking diphenhydramine at bedtime for many years for insomnia
would u think dementia ??
no just normla aging
• Decrease in attention span and ability to learn new information with age.
• Mild and do not affect normal IADLs
what does this describe
normla aging
Dementia?
A 73-year-old woman presented for evaluation of 3 years of progressive memory loss. Her husband reported that she frequently misplaced personal items, forgot passwords, and repeated the same questions. She had trouble locating her car in the parking lot and had been late paying bills. She had difficulty completing tasks and recently seemed overwhelmed when trying to plan travel for a vacation. She had shown less interest in previous hobbies but did not report low mood. She denied motor problems or disruption of sleep. Her husband had taken over managing finances and bill paying and had to remind her to take her medications. She was otherwise independent with day-to-day function
yes bc decline in PLOF
what is dementia based on
history and mental status exam
dementia is characterized by the presence of at 2 least of the following
-impaired learn and short term memory
- impaired handing complex task
- imparied reasoning ability
-impaired spatial ability and orientation
-impaired language
dementia is Based on history and mental status exam, dementia characterized by presence of at least 2 of following:
– Impaired learning and short-term memory
– Impaired handling of complex tasks
– Impaired reasoning ability (abstract thinking)
– Impaired spatial ability and orientation (constructional ability and agnosia)
– Impaired language (aphasia’
what lobes are these in
- Impaired learning and short-term memory (TEMP)
– Impaired handling of complex tasks (FRONT)
– Impaired reasoning ability (abstract thinking) (FRONT)
– Impaired spatial ability and orientation (PART)(constructional ability and agnosia)
– Impaired language (aphasia(TEMP/PAR)
does dementia have a decline from PLLOF
yes
• Alzheimerdisease
• DementiawithLewy
Bodies
• Frontotemoral Dementia
• Vascular dementia
• Parkinsondisease
with dementia
• Progressive supranuclear palsy
• Huntington disease
• Alcohol related dementia
• Chronic traumatic encephalopathy
• Medication side effects
• Prion disease
• HIV
these are all causes of what
dementia
• Medication side effects
• Poor sleep - ? Sleep study
• Hypothyroidism, B12 deficiency, Thiamine deficiency
• Neurosyphilis, other infections
• Autoimmune encephalitis
• Normal pressure hydrocephalus
these are reversible casues of waht
dementia
what will be the different on a image of a normla pressure hydrocephalaus vs atrophy
hydro will just be big ventricles and atrophy will be big ventricles but also atrophy of the brain
what is the triad of normal pressure hydrocephalus’s
-memory problems
-gait problems - magnetic major problme
- incontinence
what is the dx and rx for a normal pressure hydrocephalus
dx: large volume lumbar puncture
rx: VP shunt
what is the rx and dx for normal pressure hydrocephalus
rx:VP shunt
dx: large volume lumbar puncture
what is the bed side exam that is for dementia is assess cognitive and ask what is the year , season , date , time , country , to count back wards.. etc
mini mental status exam
what is a bed side exam for dementia that tells you what u are testing and is more common but harder then the others
montreal cognitive assessment (MOCA(
what is a bed side exam for dementia that tells the patients a story and they have to memorize some of it
SLUMS exam slu.edu
what cognitive domains does the clock drawing test
visuospatial , executive , attention , memory
what is the 3 hour cognitive testing that test visual perceptual spatial functional and executive functioning and is the best fore dementia it just takes the longest
neuropsychological testing for dementia
– Copy various geometric designs
– Identify faces
– Calculations
– Left right discrimination
this is apart of what functioning for the neuropsychological testing
visual perceptual spatial functioning
– Naming fluency
– Alternate numbers and letters in order – Stroop test
– Repeat series of hand gestures
these are for what functions for the neuropsychological testing
executive functioning
what is considered Pre-dementia/prodromaldementia
mild cognitive impairment (MCI)
what for MCI predictors of more rapid progressions
medial temporal lobe atrophy on MRI and hypo metabolic pattern on FDG-PET
what is progressive cognitive , functional and behavioral deficits
alzheimer’s disease
what lobes does alzheimer’s disease hit first
temporial (fisrt) and parietal lobe
Temporal Lobe: This lobe, which houses the hippocampus, is crucial for memory and learning. Alzheimer’s disease often begins here
if a patients initially presents with short term memory loss , work finding difficulties , mild executive dysfunction and mild visuospatial deficits what are u thinking
AD
if a pateints Initially has short term memory loss, word finding difficulties, mild executive dysfunction, mild visuospatial deficits, then Later has All aspects of memory become impaired, fluctuating behavioral changes, disturbed sleep and appetite, hallucinations
what are u think
AD
what is the end stage of AD
mute , aspiration risk , bed bound and incontinent
what is the most common neuro degenerative disorder
AD
what is the 6th most common causes of death in the USA
AD
what age is mostly affected by AD
75-84
what are teh 4 risk factors for AD
-fam history and genetics
-lower education
-gender (being a women)
-head trauma
for the gene ApoE ε4 the ______ carriers have 50% risk for developing AD in mid 60’s and _____ carried have 50% risk of AD in mid to late 70’s
homozygous
heterozygous
Hypertension Elevated BMI Smoking
Cholesterol
Diabetes mellitus
Hyperhomocysteinemia Metabolic syndrome
Physical inactivity
Obstructive Sleep apnea
these are all ___ risk factors from AD
modifiable
what is the pathology for AD
-brain atrophy with neuron loss
- neuro fibrillar triangles tau protein
-senile plaques amyloid beta protein
-cerebrovascualr amyloid
where does AD start and end in the brain
hippocampus/temporal lobes
partietal
frontal
global
• Global dysfucntion
• Visuospatial function, calculations, orientation in space
-Memory impairment and naming/language
• Later in disease course executive dysfunction
put these in order of pattern of AD
• Memory impairment and naming/language
• Visuospatial function, calculations, orientation in space
• Later in disease course executive dysfunction
• Global dysfunction
what do the labs rule out for AD
reversible causes of dementia
what are the biomarkers of CSF for AD
amyloid beta (more pathology) and tau (more clinical S&S)
what imaging for u get for AD
mri
what is the second most common type of dementia
vascular dementia
– Step-wise progression (have normal mem then have stroke then mem is bad then have stroke again)
– Asymmetric focal weakness
what kind of dementia is this (type of vascular dementia)
multi infarct dementia
Diffuse white matter disease, subcortical leucoencephalopathy, Binswanger disease.. what is this
a type of vascular dementia and is a chronic progressive and diffuse global impairment
what vascular dementia has attention and concentration deficit with psychomotor slowing
subcortical
pertaining to the MOCA what is the difference between AD and VD ? what will be the problems with AD and VD
AD will have problems in the visuospatial and delayed recall section
VD will have problems int he attention area
– HIV, tests for syphilis
– thyroid, liver function tests
– Kidney function
– B12, folate
these are all a search for a reversible cause for what
dementia
what are the 3 different AD imaging
-MRI
-FDG-PET
- amyloid PET
for a amyloid PET can a patient still have amyloid deposition w no symptoms of dementia
yes
what is AD diagnosed based on
amyloid deposition in the brain
___ deficiency results from degeneration of the nucleus basalis of meynert
cholinergic deficiency
Donepezil (Aricept)
Galantamine (Razadyne)
Rivastigmine (Exelon
these are exmaple of what inhibitory and whar does it help w
cholinesrterase and helps memory for AD
what is a NMDA partial antagonist
memantine (namenda)
what 2 medications are used to clear out amyloid for AD
lecanemad and aducanumad-avwa (aduhelm)
what is an IV medications given every 2 weeks to treat amyloid for AD but is very exopensive
lecanemab
67 year-old man brought by wife for evaluation of “memory loss”
Forgets where he puts things and has other problems with attention
No longer draws or engages in conversation the way he used to.
Will sit in front of TV and sleep for hours or just stare into space for a while
Sometimes appears confused and sometimes seems to do well. Worse at night than during day
At night wife notes he acts out his dreams (like he’s part of a parade….)
Sometimestalksaboutanimalsrunningaroundthat are not in the house but not bothered by it
• Exam–maskedfacesandstoopedposturewithen bloc turning. No tremor; +postural instability and axial rigidity.
what can we suspect
lewy body dementia
how would u describe lewy body dementia
-more attention and visual spatial problems
-not that much of a memory problems
-hallucinations start early
**-acts out dreams
what lobes does lewy body disease attack rather then dementia
partietal and occipital lobe not temporal lobe
for the MOCA exam where will someone with lewy body diease have problems
-visuospatial/executive
-attention
what is rivastigmine used for in lewy body disease treatment
reduce hallucinations and fluctuation
what does Levodopa-carbidopa treat in LBD
motor symptoms of parkinsonism
haldol avoided can results in what for LBD
clinical deterioration and increased risk for death
what are frontal release signs
reflexes that babies have and come back w dementia
what is the 2nd most common causes of early onset dementia
frontotemporal lobe degeneration
what age group does Frontotemporal Lobe Degeneration attack
45-64 yo
Behavioral variant (bvFTD) is a subtype of what
Frontotemporal Lobe Degeneration
– Behavioral variant (bvFTD)
– Primary progressive aphasia
– FTD associated with motor neuron disease
these are all subtypes of what
Frontotemporal Lobe Degeneration
if a patient appears too hones t, flippant , arrogant , aggressively egotistically anf a show off… he thinks that nothing is wrong w him , his memory is okay and he has frontal release signs what can we suspect
Frontotemporal Lobe Degeneration
what is the pathology for Behavioral variant (bvFTD)
atrophy in frontal and temporal lobes
what are the 2 main medications for Behavioral variant (bvFTD)
anitdepressents and antipsychotics
a MOVEMENT DISORDER is a Neurological syndromes in which there is either an excess of movement or a paucity of voluntary and automatic movement, unrelated to ____ or ____. Generally due to pathology in the ____ ___.
weakness or spasticity
basal ganglia
what is the pyramidal system
primary sensoruimotor cortex (frontal partietal) thru the internal capsule , BS , meduallry pyramids , CST to the anterior horn cells of the spinal cord
what is the extra pyramidal system
fine tuning of motor control
composed of BS (putamen , GP and caudate) , substantial nigra , red uncles and sub thalamic nucleus
what is hyperkinesia
excessive movement
what is dyskinesia
abnormal movement
what is hypokinesia
decreased amplitude of movemtn
what is bradykinesia
slowness of movement
what is akinesia
loss of movement
what is a Rhythmic oscillatory movement around an axis
tremor
what is ongoing random involuntary movements incorporated
chorea
what is athletosis
prevents stable posture
what is ballism
more violent movement at a joint
what is Involuntary sustained or intermittent contractions cause twisting/repetitive movements or abnormal postures
dystonia
what is Involuntary sustained or intermittent contractions cause twisting/repetitive movements or abnormal postures
dystonia
what are repeated non-rhythmic brief shock-like jerks
myoclonus
what is a movement with an urge that is relieved with the movement
tic
what are repetitive simple movements that can be suppressed
stereotypy
what movements disorder is considered hypokinetic(not enough movement)
parkinsonism
• Tremor
• Chorea
• Ballism
• Dystonia
• Dyskinesia • Myoclonus • Tics
• Stereotypies
what classification would these movemtn disorders be
hyperkinetic (too much movement)
– Drugs- neuroleptics
– Post-encephalitic
– Toxins- manganese, carbon monoxide, MPTP – Vascular
– Brain tumor
– Head trauma
these are considered ____ parkinsonism
secondary
what is a tremor
rhythmic oscillation of a body part
what is the difference between a resting tremor , postural tremor and intention tremor
resting - seen w body part at rest
postural- revealed by extending a limb against gravity
intention tremor - moving limb to and from a target
what is the difference between essential tremor and parkinson’s disease tremor ?
Location
position
direction
frequency
amplitude
-location
E: bilateral (hands , leg ,head ,voice , tongue )
P: unilateral (hands , legs and chin)
-position
E: action , posture
P: rest
-direction
E: flexion and extension
P: pronation and supination
-frequency
E: fast
P:slow
amplitude
the same anxiety makes it worse
how is the handwriting different for people with parkinson’s and essential tremor
for parkinson’s its smaller and essential it is bigger
• Frequency5-8Hz(fast)
• Slow progression
• Usually no other neurologic deficits
• Hands>head>speech,chin,tongue,trunk,legs
what tremor is this
essential
what is the treatment from essential tremors
– primidone (antiepileptic)
– propranolol (Beta-blocker)
– topirimate- an antiepileptic
what disease is A progressive, neurodegenerative disorder with loss of dopaminergic cells within the substantia nigra
parkinson’s disease
what is the second more common neurodenerative disease
parkinson’s disease (the first is AD)
what are PD sytmoms
-masked face
-reduce arm swing
-rest tremor
-slightly flexed hip
- shuffling short stepped gait
-flexed elbows and writs
-rigitidity
-stooped posture
what is the rest tremor features of parkinson’s
distal extremities and limp , “pill rolling”, stops with action of the limb
what feature does this describe for parkinson’s x increased resistance to passive movement, equal in all directions, “cog-wheeling and velocity independent
rigidity
what feature of parkinson’s does this describe Masked facies, decreased blink, soft speech, loss of inflection, micrographia, drooling, shuffling gait
bradykinesia
Loss of postural reflexes: _____
* Freezing: motor blocks, start-hesitation difficulty moving through doorways/ hallways
* Flexed posture of trunk, neck, and limbs
these are features of what diease
retropulsion
parkinson’s
what parkinson’s drug has the ability to replace brain dopamine
levodopa
(sinemet , parcopa , stalevo)
what parkinson’s drug stimulates dopamine receptors
dopamine agonists
(requip , mirapex, apokyn (injectable), neupro (patch)
what parkinson’s drug prevents the breakdown of levodopa only in advanced PD -only; in combo with levodopa
COMT inhibitor (contain , tasmar)
what parkinson’s drug prevents the break down of levodopa
MAO inhibitor (Selegiline (Zelapar) Rasagiline (Azilect
what parkinson’s drug works the best for TREMOR
Anticholinergics ( Artane, Cogentin, Benadryl)
what is peak dose dyskinesias for PD
to much dopamine leads to to much moments
how do u know if a patients has dystonia from PD
bc their foot will turn in
what is camp decorum for PD
slumped and hunched over
what is camptocormina for PD
forward flexion/ slumped over
what neurosurgical treatment for PD improves
contralateral tremor, rigidity, not bradykinesia.
thalamotomy
what are the 2 things that are overactive in PD
subthalamic nucleus and globes pallidus
what neurosurgical treatment of PD Improves tremor, bradykinesia, and rigidity on side opposite the lesion
pallidotomy
what is via high frequency electrodes implanted in VIM nucleus of the thalamus, STN, or GPi and is used for PD
deep brain stimulation
what is a atypical parkinsonism disorder and has the inability to look up or down , has axial rigidity and early falls
professice supranuclear palsy
what is a atypical parkinsonism disorder and has alien limb/apraxia movement
corticobasal degeneration
what is an atypical parkinsonism disorder that has orthostatic hypotension and hypereflexia
multi system atrophy
IF a patient presents with prominent freezing , gait disturbance and postural instability in the context of relatively normla upper extremity what condition would u say this pateint has
vascular parkinsonism (lower body parkinsonism)
How will be MRI present with vascular parkinsonism
extensive subcortical white matter ischemia disease
• Akathisia • Athetosis • Ballism
• Chorea
• Dysmetria
• Dystonia
• Hemifacial spasm
• Myoclonus
• Paroxysmal dyskinesias
• Restless legs syndrome
‘• Rigidity
• Stereotypy
• Tics
• Tremor
are they hyperkinesias or hypokinesias
hyper
what are the drug induced tremor from rest tremor (and PD)
-dopamine blocking (antipsychotics)
-metoclopramide
-despakote
-lithium
-calcium channel blockers
*first 2 were in red on slide)
• Beta agonists
• Caffiene
• Nicotine
• Thyroxine
• Cocaine
• Lithium
• Tricyclic antidepressants
these all cause what kind of tremor
postural/kinetic
what disease is
-AUTOSOMAL DOMIANTLY INHERITED
- has to do with chromosome 4
-mean age of onset is 35-42
-average time to death is 17 years
- mean neuronal loss is in the caudate and putamen
huntington disease
huntington disease is an ____ ____ inherited diease and has main neuronal loss in the ___ and ____
autsomal dominately
caudate and putamen
what are the symptoms assoscuted with huntington’s disease
personality changes , dementia , CHOREA AND ATHETOSIS
if you see think or think chorea what disease can u suspect
huntingtons disease
what is chorea
rapid, jerky, irregular movements of the extremitie
what is Athetosis
slow, nearly continuous writhing movements of the distal extremities
what is the mainstay of treatment for CHOREA
Tetrabenazine
what is Tetrabenazine
main treatments for chorea
what is a treatable disease of COPPER METABOLISM , can ppresent with tremor and is an AUTOSOMAL RECESSIVE condition and is typically in younger people (20-30)
wilson’s disease
wilson’s disease is a treatable disease of ___ metabolism and can present w tremor … it is an ___ ____ condition
copper
autosomal recessive
what are the symptoms of wilson’s diease
behavioral or personality change, dysarthria, ataxia, and abnormal movements (chorea, athetosis, tremor, or rigidity)
*in the slide ataxia and abnormal movements was bolded)
what diease has the treatment chelation with D-penicillamine
wilson’s
what is the treatment of wilson’s disease
chelation with D-penicillamine
____ os Sustained or intermittent contractions that cause abnormal often repetitive movements, postures, or both
dystopia
dystonia is initiated or worsened by ___ movement
voluntary
what can relieve dystonia? anf what is it called
gentle touch to affected area called sensory tricks
what is focal dystonias invovled in and whoa re they usually developed in
head , neck or limb mms and usually developed in adults
what kind of dystonia is most commonly seen in CHILDERN
generalized
what is the treatment for dystonia
botulinum toxin injections, PT to prevent contractures, encourage search for sensory trick
what is writers cramp
sustained contraction only when writing
• Brief, sudden, rapid, intermittent movements or sounds
• Can be repetitive and stereotyped
• May be volitionally suppressed to some extent
• Typically associated with preceding sensory phenomena
• Can change over time
what kind of disorder is this
tic
what kind of disorder is tourette syndrome
genetic disorder ; autosomal dominant
what does the dx require for tourette syndrome
- > 1 motor tic
- 1 vocal tic
- fluctuating course
- present > 1 yr
if a patient presents with a. genetic disorder that is autosomal dominant … has > 1 motor tic , 1 vocal tic , fluctuating course , presents for > 1 year and is 15 years old what can we think they have
tourette’s syndrome
If someone has NEUROLOGICAL SYMPTOMS (such as limb weakness, numbness, shaking or blackouts) which are REAL (and not imagined ) caused by a PROBLEM with the FUNCTIONING of the nervous system and is not due to damage or structural disease of the nervous system and causes difficulty what can we suspect the pateitns has
functional neurological disorder
what are 6 things that would make it an epileptic seizure
• Open eyes
• Hypoventilation
• Lack of memory
• 1-2 minutes
• GTC or tonic
• Sudden onset
if someone’s has
• Closed eyes
• Ictal hyperventilation
• Memory of attack when GTC • Long duration
• Prolonged motionlessness
• Ictal weeping
• Gradual onset
what kind of seizure is this
Psychogenic Non-Epileptic (PNES)
what is hoover sign used for
weakness
*have patient life tone leg up and put ur hand underneath their heel and wait to see if they try to dig their heel into ur hand to help lift the opposite leg up)
what will a pateitns MRI pressent with if they have functional weakness and sensory disturbance
contralateral hypoperfusion of thalamus and caudate
