Neurocognitive Disorder/Dementia Flashcards
Define neurocognitive disorder (NCD)/dementia
1) Acquired cognitive decline in at least 1 cognitive domain based on
- subjective concern of patient, informant, or clinician
- objective cognitive performance testing (MMSE, MOCA)
2) Functional impairment as difficulties in daily ADL (instrumental or basic) causing dependence
List the 6 cognitive domains in DSM-V
MALE PMS
1) Memory and Learning
2) Attention
3) Language
4) Executive Function
5) Perceptual Motor Function
6) Social Cognition
List the 5As of dementia in ICD-10
1) Amnesia (short, long, procedural)
2) Apraxia
3) Aphasia (receptive, expressive)
4) Agnosia
5) Abstract thinking impairment
Outline instrumental ADLs
1) Cooking
2) Taking public transport
3) Following directions
4) Using telephone
5) Taking medication
Outline basic ADLs
1) Urination
2) Defecation
3) Showering/Bathing
4) Feeding
Outline the NCD severity grading
Mild = difficulties w/instrumental ADLs Moderate = difficulties w/basic ADLs Severe = fully dependent on others
List the behavioural and psychological symptoms of dementia (BPSD)
Behavioural (A PASS)
- apathy, pacing, aggression, shouting, sexual disinhibition
Psychological
- psychotic: 40% delusion (theft, prosecution); 30% hallucinations (visual, auditory)
- mood: 50% depression, anxiety
List examples of symptoms of NCD
1) Retaining new information e.g. remembering recent events
2) Handling complex tasks e.g. balancing a checkbook
3) Reasoning e.g. poor coping w/unexpected events
4) Spatial ability and orientation (e.g. lost in familiar places)
5) Language (e.g. word finding)
6) Behaviour
List the reversible causes of NCD
1) B12 deficiency
2) Folate deficiency
3) Malabsorption
4) Hypothyroidism
5) Electrolytes (e.g. hyperCa, hypoNa, hyperNa)
6) Cushing syndrome
7) Addison disease
8) Subdural hematoma
9) Normal pressure hydrocephalus
10) Intracranial tumour
11) Neurosyphilis
12) HIV
13) Drugs (i.e. anticholinergics, sedatives, analgesics)
14) Wernicke encephalopathy/Korsakoff syndrome
15) Uremic encephalopathy
16) Hepatic encephalopathy
Outline the onset age for NCD; at what age is early and young?
Normal NCD >65y/o
Early NCD 40-65y/o
Young NCD
List risk factors for NCD
Metabolic syndrome
1) Diabetes mellitus
2) Hypertension
3) Hypercholesterolemia
4) Obesity
Other risk factors
5) Smoking
6) Hx myocardial infarction
List specific risk factors for Alzheimer disease
Specific risk factors for Alzheimer
1) Head injury
2) Low level education
List specific risk factors for Vascular NCD
Specific for Vascular NCD
1) Atrial fibrillation
2) Hx stroke
List the different types of NCD
1) Alzheimer NCD/ Alzheimer’s disease
2) Vascular NCD/ Vascular dementia
3) Frontotemporal Degeneration (FTD)
4) Lewy Body NCD/ Dementia w/Lewy Bodies (DLB)
5) Parkinson Disease NCD/ Parkinson Disease Dementia (PDD)
6) Progressive supranuclear palsy (PSP)
7) Multiple system atrophy (MSA)
8) Corticobasal degeneration
9) Cerebral autosomal dominant arteriopathy w/subcortical infarcts and leukoencephalopathy (CADASIL)
10) Neurosyphilis
11) HIV NCD
12) Huntington disease
List the 3 major risks to self and others in elderly w/NCD
1) Cooking as elderly may leave the fire on unattended
2) Getting lost
3) Taking medication
Outline the triad in normal pressure hydrocephalus
In the order of AID
1) Ataxia (gait disturbance)
2) Incontinence
3) Dementia
List the cutoffs for NCD screening by MMSE
Outline the components of the MMSE
1) YYYY/MM/DD + season + day of week 5 points
2) Territory + Area+ Building + Block + Floor 5 points
3)
Outline the components of the Abbreviated Mental Test (AMT)
How does one interpret the results? What is the screening cutoff value for abnormal cognition?
Each component is 1 point,
Outline the list of investigations for NCD patients
Blood Tests
1) CBC
2) RLFT
3) Calcium
4) TFT
5) B12, folate
6) Thiamine
7) VDRL (now EIA) –> if positive then FTA-Abs
8) HIV antibody
9) 24h urinary free cortisol OR overnight 1mg dexamethasone suppression test
10) 8 AM serum cortisol and plasma ACTH
Imaging
1) CT brain
- rule out chronic subdural hematoma
- Alzheimer = medial temporal lobe + hippocampal + parietal atrophy
- Vascular = global atrophy + diffuse periventricular hypodensities in white matter + strategic infarcts in areas of cognitive function
- Frontotemporal = asymmetric frontal lobe + whole temporal lobe atrophy + knife blade appearance in late stage (sharp gyrus)
2) MRI brain
3) PET scan
- using Pittsburgh compound B (PiB) a radioactive analogue to thioflavin T can help identify beta-amyloid plaques in hippocampus of Alzheimer cases
- flurodeoxyglucose (FDG) for hypometabolic regions in posterior cingulate gyri and temporal parietal lobes
Outline the functional assessment stage test (FAST)
1: normal adult w/no cognitive decline
2: normal elder w/subjective functional deficit
3: early Alzheimer w/noticeable deficits in complex tasks
4: mild Alzheimer w/difficulties in instrumental ADL
5: moderate Alzheimer needing assistance w/attire
6: moderately severe Alzheimer w/difficulties in basic ADL
7: severe Alzheimer speaks
Outline the management for neurocognitive disorders
1) Setting of Care
- outpatient until carer can no longer handle OR no carer OR high risk cases w/psychosis or suicide
- maintain outpatient as long as possible as non-familiar environment precipitates delirium
- be wary of carer stress
2) Investigations to rule out delirium and reversible dementias
3) Non-pharmacological management
1. Carer psychoeducation about NCD, safety measures, and home modification
- e.g. electric stove instead of gas; use timer on stoves
- e.g. signs on drawers, use clear plastic drawers
- e.g. remove sharp objects
- e.g. install railings to prevent falls
- e.g. install safety alarm in patient’s home
2. correct any sensory impairment (glasses, hearing aids)
3. Assess need for community assitance
4) Pharmacological management
1. Cholinesterase inhibitors (donepezil, rivastigmine, galantamine) for mild to moderate NCD (i.e. MMSE >10)
2. NMDA receptor antagonist (memantine) for severe NCD (i.e. MMSE
Explain the rationale for cholinesterase therapy in NCD
1) In most NCDs except frontotemporal dementia, there is reduced acetylcholine (ACh) in the brain
2) Inhibiting cholinesterase allows ACh to remain longer in the brain thus elevating ACh levels
3) Induces improvements in cognition and ADL
4) This effect is small and no longer clinically significant if patients have already progressed to severe NCD
Explain the rationale for memantine therapy in NCD
1) Neuroprotective effect by reducing glutamate excitatory effect in cortex and hippocampal neurons
