Neuro chapter 11 Major Neurocognitive disorder

Question 1

Major Neurocognitive Disorder (formerly dementia)

Description

Answer 1

• Dementia is a collection of symptoms that can be caused by a number of disorders that affect the brain.

Question 2

Major neurocognitive disorder diagnosis requires…

Answer 2

… a cognitive decline from a previous level of functioning in one or more domains:

• complex attention
• executive function
• learning memory
• language
• perceptual motor
• social cognition

Question 3

Cognitive deficits must be…

Answer 3

severe enough to interfere with independence in everyday activities of daily living.

Question 4

Dementia may occur with or without behavioral disturbances; these disturbances may be unsafe or disruptive:

Answer 4

• wandering
• restlessness
• agitation
• aggression
• sleep/wake cycle disturbances
• apathy
• difficulty concentrating
• delusions
• hallucinations

Question 5

Dementia

Etiology - can be caused by a number of disorders:

Answer 5

• Alzheimer’s disease
• vascular disease
• frontotemporal lobar degeneration
• lewy body disease
• traumatic brain injury
• substance / medication abuse
• HIV infection
• Prion disease
• Parkinson’s disease
• Huntington’s disease
• Another medical condition
• multiple etiologies

Question 6

Alzheimer’s type:

Answer 6

accounts for 60-80% of dementia cases and is the leading cause of dementia worldwide.

Question 7

Vascular type:

Answer 7

20-30% of dementia cases, and its incidence increases linearly with age.

Question 8

Lewy body disease type

Answer 8

10-25% of dementia cases

Question 9

Frontotemporal lobar degeneration (FTD)

Answer 9

10-15% of dementia cases. Among patients younger than 65, FTD accounts for 20-50% of dementia cases.

Question 10

Alzheimer’s type

Risk Factors

Answer 10

Age
Family history
Genetics

Question 11

Vascular type

Risk Factors

Answer 11

Advanced age
history of heart attack, stroke or ministroke
atherosclerosis
HLD
HTN
Diabetes
smoking
obesity
A-fib

Question 12

Lewy Body disease

Risk Factors

Answer 12

older than 60
more common in men
family history of Lewy body disease

Question 13

Frontotemporal lobar degeneration

Risk Factors

Answer 13

Family history of dementia

Question 14

Assessment Findings

History

Answer 14

• Collateral information is essential, they may lack the insight for acknowledgement of symptoms.
• focus should be on cognitive complaints and functional concerns, psychiatric and behavioral changes

Question 15

Assessment findings

Physical Exam

Answer 15

• head-to-toe exam: may identify comorbid conditions that contribute to cognitive dysfunction (hypothyroidism, postural hypotension, COPD, etc.)

Question 16

Assessment findings

Cognitive Exam:

Answer 16

used to develop differential list, and to rate severity of dementia symptoms

• Mini mental status examination
• montreal cognitive assessment
• short portable mental status assessment
• frontal assessment battery
• consider neuropsychological testing - in patients with worrisome history but score well on cognitive exams; when malingering is suspected; and to distinguish depression from neurocognitive disease.

Question 17

Mini-Mental Status Examination

Answer 17

• measures cognition; highly validated but limited in ability to measure executive functions and memory impairment
  Frontal assessment batttery is good complement to this test

Question 18

Neurological testing

Answer 18

helpful in developing differential diagnosis list and ruling out etiologies that may contribute to dementia.

Question 19

Differential Diagnosis

Answer 19

Alzheimer's disease
vascular disease
frontotemporal lobar degeneration
lewy body disease
TBI
Substance/medication
HIV
Prion disease
Parkinson's disease
delerium
hypothyroidism
B12 deficiency
Folate deficiency
brain neoplasm
metabolic abnormalities
infection
anemia
various neuro conditions

Question 20

Diagnostic studies

Answer 20

CBC
CMP
UA
LFT
Thyroid panel
B12 and folate
syphilis serology
CT and/or MRI

Question 21

Dementia

Prevention

Answer 21

• CV lifestyle modifications may limit the incidence of vascular disease.

Question 22

Dementia

Nonpharmacologic management

Answer 22

• supportive care
• structure to minimize behavioral disturbances: maintain familiar, routine, low stress encirons.
• offer frequent meals and fluids to maintain nutritional status and hydration
• use verbal and nonverbal forms of communication to ensure processing of messages
• keep communication simple and direct.
• reminiscent therapy.
• fall precautions: avoid loose rugs, nonskid bath mats, low chairs, utilize railings
• secure environment to minimize getting lost
• utilize respite services for caregivers to prevent burnout
• discuss advance directives early
• facilitate communication between providers
• utilize support groups

Question 23

Dementia

Pharmacologic management

Answer 23

• treatment is specific to etiology

- treatment of behavioral disturbances

Question 24

Dementia

Consultation / referral

Answer 24

• consult with neurology for new onset dementia

- consult psychiatry for behavioral disturbances secondary to dementia.

Question 25

Dementia

Follow-up

Answer 25

• patient, and need dependent
• involve caregivers when possible
• when treating behavioral disturbances, follow-up should occur within 2 weeks because psychotropic medications can result in side effects that could impair the patient.
• once behavioral disturbances treated, follow-up within 3 months.
  ~ once behavioral disturbances have been absent for 6 months, gradual dose reductions should be pursued every 3 months, to ensure the patient is on the smallest dosage needed.
  ~ behavioral disturbances change as dementia progresses, thus the need for regular follow-up

Question 26

Dementia

Expected Course

Answer 26

• expected course of dementia is disease-specific

- refer to the etiology of dementia for details.

Question 27

Dementia

Possible Complications

Answer 27

• polypharmacy
• caregiver burnout
• family conflict over care decisions
• malnutrition
• risk for injury
• abuse