Neuro chapter 11 Major Neurocognitive disorder Flashcards
Major Neurocognitive Disorder (formerly dementia)
Description
- Dementia is a collection of symptoms that can be caused by a number of disorders that affect the brain.
Major neurocognitive disorder diagnosis requires…
… 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
Cognitive deficits must be…
severe enough to interfere with independence in everyday activities of daily living.
Dementia may occur with or without behavioral disturbances; these disturbances may be unsafe or disruptive:
- wandering
- restlessness
- agitation
- aggression
- sleep/wake cycle disturbances
- apathy
- difficulty concentrating
- delusions
- hallucinations
Dementia
Etiology - can be caused by a number of disorders:
- 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
Alzheimer’s type:
accounts for 60-80% of dementia cases and is the leading cause of dementia worldwide.
Vascular type:
20-30% of dementia cases, and its incidence increases linearly with age.
Lewy body disease type
10-25% of dementia cases
Frontotemporal lobar degeneration (FTD)
10-15% of dementia cases. Among patients younger than 65, FTD accounts for 20-50% of dementia cases.
Alzheimer’s type
Risk Factors
Age
Family history
Genetics
Vascular type
Risk Factors
Advanced age history of heart attack, stroke or ministroke atherosclerosis HLD HTN Diabetes smoking obesity A-fib
Lewy Body disease
Risk Factors
older than 60
more common in men
family history of Lewy body disease
Frontotemporal lobar degeneration
Risk Factors
Family history of dementia
Assessment Findings
History
- 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
Assessment findings
Physical Exam
- head-to-toe exam: may identify comorbid conditions that contribute to cognitive dysfunction (hypothyroidism, postural hypotension, COPD, etc.)
Assessment findings
Cognitive Exam:
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.
Mini-Mental Status Examination
- measures cognition; highly validated but limited in ability to measure executive functions and memory impairment
Frontal assessment batttery is good complement to this test
Neurological testing
helpful in developing differential diagnosis list and ruling out etiologies that may contribute to dementia.
Differential Diagnosis
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
Diagnostic studies
CBC CMP UA LFT Thyroid panel B12 and folate syphilis serology CT and/or MRI
Dementia
Prevention
- CV lifestyle modifications may limit the incidence of vascular disease.
Dementia
Nonpharmacologic management
- 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
Dementia
Pharmacologic management
- treatment is specific to etiology
- treatment of behavioral disturbances
Dementia
Consultation / referral
- consult with neurology for new onset dementia
- consult psychiatry for behavioral disturbances secondary to dementia.
