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Geriatrics > Lecture 8: Dementia, Delirium, and Depression > Flashcards

Lecture 8: Dementia, Delirium, and Depression Flashcards

1
Q

What happens to our glial cell count and size as we age normally?

A

Both increase as part of the normal aging process.

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2
Q

What are the common aging changes in the nervous system?

A
  1. Decreased # of neurons, increased size and # of neuroglial cells.
  2. Decline in nerves and nerve fibers
  3. Atrophy of the brain and increase in dead space
  4. Thickened leptomeninges in spinal cord
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3
Q

What are the 3 functions of a glial cell?

A
  • Provide insulation
  • Remove pathogens
  • Supply nutrients
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4
Q

What are the 4 types of glial cells?

A
  • Ependymal cells
  • Astrocytes
  • Microglial cells
  • Oligodendrocytes
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5
Q

What is Alzheimer’s?

A

Malfunctioning DNA Damage Response (DDR)

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6
Q

What are the two types of cerebral atrophy?

A
  • Generalized
  • Focal
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7
Q

What are the two primary symptoms of dementia?

A
  1. Progressive impairment of memory and intellectual function
  2. Memory, orientation, abstraction, ability to learn, and executive functions may be affected.
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8
Q

What is expressive aphasia? Receptive?

A
  • Expressive: odd choice of words, partial speech, incomplete sentences.
  • Receptive aphasia: impaired comprehension
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9
Q

What are the two leptomeninges?

A
  1. Arachnoid mater
  2. Pia mater

Both become thickened

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10
Q

What makes up the brachial plexus?

A

C5-T1

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11
Q

What should not be affected in the normal aging process when it comes to memory?

A

Mild memory impairment, but no functional impairment. Their 3-word recall should still remain intact.

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12
Q

How should we obtain history to verify cognitive impairment?

A
  • History from patient
  • Verified by reliable source
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13
Q

What is apraxia?

A

Not able to perform previously learned motor skills.

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14
Q

What common medication classes can affect cognitive function?

A
  • BZDs
  • Anticholinergics
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15
Q

What diagnostics are appropriate for evaluating cognitive impairment?

A
  • B12
  • TSH
  • LFTs
  • RPR (syphilis)
  • antibodies
  • LP
  • Noncon MRI/CT Brain
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16
Q

What characterizes mild cognitive impairment (MCI)?

A
  • Trouble remembering names, appts, etc
  • Age-related neurodegeneration
  • Difficulty solving complex problems
  • Abnormal memory but no functional impairment
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17
Q

What organ system should we focus risk factor modification on to prevent mild cognitive impairment?

A

Vascular risk factors

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18
Q

What are the 4 types that fall under dementia?

A
  1. Alzheimer’s
  2. Vascular
  3. Lewy body
  4. Frontotemporal
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19
Q

Define dementia

A

Various conditions in which there are deficits in multiple areas of cognitive function, resulting in impairment of daily function.

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20
Q

After 60, how does the prevalence of dementia trend?

A

Doubles every 5 years

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21
Q

Where does damage initially occur in Alzheimer’s?

A

Hippocampus, specifically entorhinal cortex.

Memory formation

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22
Q

What are the two types of cerebral cortex lesion?

A
  • Amyloid plaques
  • Neurofibrillary tangles

Both appear more frequently in Alzheimer’s

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23
Q

What do neurofibrillary tangles do to neurons?

A

Prevent neurons from communicating

Tangled up communications

Neurofibrillary tangles come from tau proteins, which are normally adhered to microtubules.

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24
Q

What do amyloid plaques come from?

A

Amyloid precursor protein and beta amyloid protein (BAP is the sticky fragment of APP)

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25
Q

What do beta amyloid plaques do in Alzheimer’s?

A

Prevent dendrites from communicating with each other.

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26
Q

What are the risk factors for Alzheimer’s?

A
  • Age
  • Female
  • Apo e4 on chromosome 19
  • Hx of head trauma
  • Lower educational level
  • Vascular disease
  • DM
  • Down syndrome
  • FMhx
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27
Q

What is the classic triad of Alzheimer’s?

A
  1. Difficulty learning and recalling information
  2. Visuospatial problems
  3. Language impairment
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28
Q

How are Alzheimer’s symptoms usually first seen?

A

Family and friends usually notice first.

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29
Q

What characterizes severe Alzheimer’s?

A
  • Loss of self
  • Completely dependent on others for care
30
Q

What is delirium?

A

Acute loss of cognitive functioning

31
Q

How is Alzheimer’s diagnosed?

A

Clinically, with evidence of cognitive dysfunction, by ruling out any other cause of dementia.

32
Q

What are the acetylcholinesterase inhibitors used to treat Alzheimer’s?

A
  • Donepezil
  • Galantamine
  • Rivastigmine
33
Q

What are the MC SE of cholinesterase inhibitors?

A
  • Nausea
  • Anorexia
  • Sleep disturbance
  • Diarrhea
  • Take with food!!
34
Q

What is the purpose of NMDA receptor antagonists?

A
  1. Reduce destruction of cholinergic neurons
  2. May inhibit beta-amyloid production

Memantine

35
Q

What are the MC SE of NMDA receptor antagonists?

A
  • Dizziness
  • Headache
  • Confusion
  • Constipation
36
Q

When is referral to a geriatric psychiatrist warranted for Alzheimer’s?

A

Lack of symptom control

37
Q

What does advanced Alzheimer’s lead to?

A
  • Poor nutritional intake
  • Urinary incontinence
  • Skin breakdown
  • Infections
38
Q

What is vascular dementia?

A
  • Gradual or acute onset of cognitive dysfunction with clinical or radiographic evidence of cerebrovascular disease.
  • Micro-ischemic changes

Generally no focal deficits

39
Q

What is the clinical presentation of vascular dementia?

A
  • Mild memory impairment
  • Difficulty in timed and executive functions (1 minute semantic test)
  • Behavioral and psychological symptoms
  • Depression that is severe

Mainly emotionally based.

40
Q

What imaging modality would help diagnose vascular dementia?

A

MRI showing white matter lesions

41
Q

What are the vascular risk factors for vascular dementia?

A
  • HTN
  • Smoking
  • DM
  • Statins
  • Antiplatelets
42
Q

What are Lewy bodies?

A

Alpha-synuclein deposits found in presynaptic terminals

43
Q

When do lewy bodies tend to occur?

A

75yo with a male preference

44
Q

What are the core features of dementia with lewy bodies?

A
  1. Insidious onset of fluctuating cognitive impairment
  2. Memory not as affected
  3. Visuospatial, problem solving, and processing speed severly impaired early
  4. Spontaneous parkisonism HALLMARK SIGN
  5. Visual hallucinations
  6. Delusional misidentification

Lewey loses muscular control

45
Q

What is parkinsonism?

A
  • Bradykinesia
  • Bilateral limb rigidity
  • Flat affect
  • Postural instability
  • Gait changes

Tremor and response to levodopa are rare if with dementia.

46
Q

What medication class is dementia with lewy bodies highly susceptible to?

A

Antipsychotics

47
Q

What does MRI typically show for dementia with lewy bodies?

A
  • Greater atrophy of the medial temporal lobe (Alzheimer’s)
  • Hippocampus atrophy (Alzheimer’s)
  • Basal ganglia and dorsal midbrain atrophy
48
Q

How is lewy body dementia diagnosed?

A

McKeith criteria

49
Q

What are the 4 essential core clinical features of dementia with lewy bodies?

A
  1. Fluctuating cognition with pronounced variations in attention and alertness
  2. Recurrent visual hallucinations
  3. REM sleep disorder
  4. 1+ features of spontaneous parkisonism
50
Q

How are most dementia with lewy bodies diagnoses made?

A

Autopsy

51
Q

What MRI changes are most characteristic of dementia with lewy bodies?

A

Cortical atrophy

52
Q

What does a SPECT scan usually show for dementia with lewy bodies?

A

Reduction in dopamine uptake and perfusion.

53
Q

What treatments are used for dementia with lewy bodies?

A
  • Cholinesterase inhibitors
  • Memantine (maybe)
  • Atypical antipsychotics for severe psychosis
  • SSRIs
  • Melatonin
  • Carbidopa-levodopa (For parkinsonism)
  • Fludrocortisone (for orthostatic hypotension)
54
Q

What are the risk factors for higher mortality in dementia with lewy bodies?

A
  • Older age
  • Hallucinations
  • Greater degrees of fluctuation
  • Neuroleptic sensitivity
55
Q

How do MMSE scores decrease annually in dementia with lewy bodies?

A

4-5 points

56
Q

What is the MCC of early-onset dementia ?

A

Frontotemporal dementia

57
Q

What are the variants of frontotemporal dementia?

A
  • Behavioral variants
  • Semantic variants with primary progressive aphasia
  • Non-fluent/agrammatic with primary progressive aphasia
58
Q

What characterizes behavioral variant frontotemporal dementia?

A
  • Changes in personality
  • Apathy, disinhibition, compulsivity, loss of empathy, overeating
59
Q

What characterizes semantic primary progressive aphasia?

A

Loss of ability to decode/recalling words, object, person-specific

60
Q

What characterizes primary progressive aphasia?

Non-fluent/agrammatic

A
  • Inability to produce words, often with prominent motor speech impairment
  • Affects Broca’s area
61
Q

What is normal pressure hydrocephalus?

A

Accumulation of CSF leading to enlargement of ventricles and compression of local structures

62
Q

What characterizes normal pressure hydrocephalus?

A
  • Abnormal gait
  • Urinary incontinence
  • Dementia

Gait improves once intervention occurs.

63
Q

How do we manage hydrocephalus?

A
  1. MC: ventriculoperitoneal shunting
  2. Ventriculoatrial shunting
64
Q

What is the hallmark sign of Normal pressure hydrocephalus on MRI?

A

Ventriculomegaly

65
Q

What is a good prognostic sign for normal pressure hydrocephalus?

A

Improvement of gait post LP

66
Q

What is the greatest predisposing risk factor for delirium?

A

Preexisting cognitive impairment

67
Q

How does delirium typically present?

A
  • Acute onset
  • Attention deficit
  • Fluctuating symptoms
  • Cognitive impairments
68
Q

What are the 3 concurrent approaches to managing delirium?

A
  1. Identification and treatment for underlying cause
  2. Eradication or minimizing contributing factors
  3. Manage delirium symptoms
69
Q

When are meds recommend in treating delirium?

A
  • Only for severely agitated individuals who are safety concerns
  • Avoid sedation of patient
70
Q

Generally, what is the prognosis for delirium?

A

Good, becaue it is fully reversible.

71
Q

What are the risk factors for delirium?

A
  • Cognitive impairment
  • Immobilization
  • Psychoactive medications
  • Sleep deprivation
  • Vision impairment
  • Hearing impairment
  • Dehydration

Geriatrics (14 decks)

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