Neurocognitive Disorders Flashcards
What are the types of neurocognitive disorders?
- Delirium
- Major neurocognitive disorder
- Mild neurocognitive disorder
What is the definition of delirium?
Acute confusional state
What is the differential diagnosis of delirium?
- Another neurocognitive disorder (major or mild)
- Psychotic disorders or mood disorders with psychotic features
- Acute stress disorder (if precipitated by trauma and experienced concurrently with severe anxiety, fear or dissociative symptoms)
- Malingering or factitious disorder
What are the six cognitive domains?
- Complex attention
- Executive functioning
- Learning and memory
- Language
- Perceptual and motor ability/visuospatial ability
- Social cognition
What are the differences between major and mild NCD?
Evidence of significant decline from previous performance in one or more of the cognitive domains versus evidence of modest decline from previous performance in one or more of the cognitive domains. Mild NCD does not affect activities of daily life.
What are the causes of NCD?
- Alzheimer’s disease (50 to 70%)
- Vascular dementia
- Lewy body dementia
- Frontotemporal dementia
- Alcohol related dementia
What is the greatest risk factor for NCD?
Age
What is the clinical presentation of Alzheimer’s disease?
Triad of memory, language and visuospatial deficits
What investigations and treatments would you use in unspecified NCD?
Investigations:
- MMSE/ACE-R
- CT Head (evidence of atrophy or infarct)
- Metabolic screen (HbA1c, lipids, blood pressure)
- Collateral history
Treatments:
- Biological: treatment of metabolic conditions (in vascular dementia), donezepil (Alzheimer’s primarily, but also LBD, vascular dementia), medications for depression (anti-depressants), REM sleep disorder (clonazepam) and hallucinations (anti-psychotics)
- Psychological: active stimulation of brain
- Social: engaging in meaningful social activities and hobbies (e.g. music, dance), support groups for the patient and their family/friends, occupational therapy involvement, NASC involvement, driving assessment, simplifying tasks through planning, organisational tools, discussion around setting up an EPOA and advanced care planning.
What are the features of frontotemporal dementia?
- Younger onset (<65)
- Personality, behaviour and language changes
- Strong genetic link
What is the presentation of Lewy Body dementia?
- Problems with motor skills
- Problems with alertness
- Problems with concentration
- Visual hallucinations (well-defined, usually small animals, pleasant)
- Day-to-day fluctuation in severity of symptoms
- Parkinsonism
- REM sleep disorder
When would you consider adding an antipsychotic medication in an NCD?
- For severe agitation or aggression with acute risk of harm
- Hallucinations and delusions
What are the potential causes of a delirium?
Drugs/polypharmacy Eyes, ears Low oxygen state (MI, stroke) Infection Retention of urine or stool Ictal Underhydration, undernutrition (anaemia) Metabolic Sleep/subdural haematoma
How should you treat a delirium?
- Treat the underlying cause
- Introduce tools to help with re-orientation - e.g. calendars, clocks etc.
- Encourage familiar visitors - family and friends
- Use verbal de-escalation, but as a last resort if someone is severely agitated, aggressive to the point of self-harm or injury to others or hallucination/delusional, you may introduce an anti-psychotic medication (e.g. haloperidol 0.5mg - 1mg PO or IM).
What investigations would you order in a delirium?
- CAM [Confusion Assessment Method]
- Drug + alcohol screen
- Otoscope + ophthalmoscope
- ECG, CT Head, neuroimaging
- FBC [WCC, neutrophils], CRP, MSU, CXR, blood gases, LFTs
- Urine output + stool chart
- EEG, LP/CSF
- U+E’s, FBC [Hb, MCV], iron studies, B12, folate
- TFTs, BGLs, iron studies, B12, folate
- Neuroimaging
