Neurocognitive Disorders

Question 1

Delirium

Answer 1

• Definition:
  
  • state of acute confusion that fluctuates over hours or days. Usually cognitive manifestation of a serious underlying illness
• Pathophys:
  
  • widespread dysfunction in the cortical & subcortical regions of the brain; abnormalities in neurotransmitters
• Etiology:
  
  • acute illness - infection (Lyme), meds, drugs/EtOH abuse, toxic exposure, metabolic conditions, hypoxemia, liver failure, encephalopathies, HF, dehydration, malnutrition, anemia
• Risks:
  
  • older age, baseline cognitive dysfunction(ie dementia), sensory deprivation (hearing or visual impairment), immobility, malnutrition,alcohol abuse = most common cause of delirium: delirium tremens
• S/sxs:
  
  • *Abrupt:
  • -Deficit of attention with variable loss of memory, executive function, visuospatial tasks & language
  • -Altered sleep-wake cycles
  • -Perceptual disturbances: hallucinations, delusions
  • -Affect change
  • -Autonomic changes: HR, BP instability
  • **Visual hallucinations
• Subtypes:
  
  • Hyperactive: hyperarousal, hallucinations, agitation, autonomic instability → ex: EtOH withdrawal
  • -Hypoactive: psychomotor slowing, withdrawn, quiet → ex: Benzodiazepine intoxication
  • *patients usually fall between these two
• Dx:
  
  • Clinical Dx
  • Screening Tools:
  • Confusion Assessment Method
  • -Nursing Delirium Screening Scale
  • *Diagnostics are aimed at determining precipitating condition
  • -All patients: Fingerstick blood sugar, CBC, CMP, & UA
  • -Infection suspected? → CXR, EKG, lactate, blood cultures
  • -Consider: toxicology, ABG, brain imaging, LP, EEG
• Tx:
  
  • Delirium is usually reversible. Some episodes may continue for years d/t inadequate initial tx of the underlying etiology or permanent neuronal damage
  • *Treat the underlying cause
  • -Frequent re-orientation, clocks, calendars, outside facing windows
  • -Access to glasses, hearing aids, etc.
  • -Maintain normal sleep-wake cycle, dark environment at night
  • -Making environment as home-like as possible
  • -Haloperidol for agitation/psychosis

Question 2

Wernicke Encephalitis

Answer 2

• Definition:
  
  • Vitamin B1 Deficiency from malnutrition or alcoholism
• S/sxs:
  
  • Confusion
  • -Ophthalmoplegia
  • -Ataxia
  • -Severe → COMA
• Tx:
  
  • Thiamine (Vit B1)

Question 3

Hepatic Encephalopathy

Answer 3

• Definition:
  
  • liver failure -→ elevated serum ammonia & other toxins
• S/sxs:
  
  • -Confusion
  • -Sweet breath odor
  • -Asterixis, ascites
  • -Severe → COMA
• Tx:
  
  • Lactulose (PO or PR) → MOA: limit GI bacteria that are able to generate ammonia due to laxative effect; SEs: flatulence, diarrhea, dyspepsia, abd pain, dehydration, hypernatremia/hypokalemia
  • -Alt: Rifaximin (Xifaxan) PO: not absorbed systemically → remains in GI lumen; SEs: flatulence, peripheral edema, dizziness, fatigue, nausea, ascites
  • -Abx
  • 2nd line: neomycin & metronidazole
  • -Reducing ammonia levels through diet (limit amount of protein)

Question 4

Dementia

Answer 4

• Definition:
  
  • a decline in cognitive functioning that interferes with the individual’s ability to function independently. Acquired syndrome, not a specific disease
• Causes:
  
  • neurologic, neuropsychiatric, medical conditions
• Epidemiology:
  
  • ~7% of those > 65 yo
• S/sxs:
  
  • *Gradual/progressive
  • -Confusion
  • -Disorientation
  • -Impaired memory
  • -Agitation
  • -Delusions
• Tx:
  
  • Non-reversible

Question 5

Alzheimer Disease

Answer 5

Type of Dementia

• Most common in people 65+ yo
• Most common form of Neurocognitive disorders!
• Pathophys:
  
  • -Loss of brain cells, beta-amyloid plaques, and neurofibrillary tangle
• S/sxs:
  
  • Progressive cognitive decline
• PE:
  
  • Abnormal Alarm Clock Drawing
• Tx:
  
  • Anti-cholinesterase drugs (Tacrine, Donepezil)

Question 6

Vascular Dementia

Answer 6

• ¼ of all cases
• Risk factors:
  
  • HTN, dyslipidemia, DM, smoking, advanced age
• Associated with ateriolosclerotic small vessel diseas
• S/sxs:
  
  • Stepwise deterioration with periods of clinical plateaus
  • May cause a sudden decline
• Tx:
  
  • Blood pressure Control

Question 7

Lewy Body Dementia

Answer 7

• S/sxs:
  
  • Cognitive fluctuations, visual hallucinations, Parkinsonism sxs
  • Gait difficulties, and falls

Question 8

Frontotemporal Dementia

Answer 8

• Personality & social behavior changes
• Nonfluent speech
• Personality changes precedes memory changes