Neurocognitive disorders

Question 1

Hallmark of delirium

Answer 1

disturbance in consciousness

Question 2

Subtypes of delirium

Answer 2

Hyperactive
Hypoactive
Mixed

Question 3

Delirium with mental health disorders

Answer 3

Often we don’t recognize that the Delirium is a separate thing and we assume it’s just part of the mental health disorder

Question 4

High incidences of Delirium in

Answer 4

hospitalized people, especially with cancer or ICU patients

More common in men

Question 5

Prognosis for Delirium

Answer 5

within 1 year the mortality is 40%

Question 6

Risk factors for Delirium

Answer 6

The more physically ill, the higher risk
Substance abuse
V/H impairment
History of Delirium or other brain disorder

Question 7

Presentation of Delirium

Answer 7

Reversed sleep-wake cycle 
Impaired recent and intermediate memory 
Usually resolves in 3 to 6 months
Illusions are common. 
Might also have visual hallucinations

Tremors, incoordination, urinary retention, myoclonus, nystagmus, asterixis, increased tone and reflexes

Question 8

Delirium work up

Answer 8

You’re looking for whatever is the underlying cause.

Do all the normal labs, syphilis, HIV, chest radiograph, EEG

The EEG activity can be slow, or it could be fast if related to alcohol withdrawal

Question 9

Medication for Delirium

Answer 9

Haldol or 2nd gens for agitation

Benzos for insomnia

Question 10

Non-pharm management for Delirium

Answer 10

They shouldn’t be over or under stimulated

Have pictures of family in the room and a clock/calendar

Question 11

the high morbidity of Delirium is related to

Answer 11

injury, inactivity, pneumonia, nutrition/hydration deficits

Question 12

Not so obvious things that could contribute to Delirium

Answer 12

Myocardial factors, reduced sensory input

Question 13

Children and Delirium

Answer 13

they are especially susceptible because their brains are immature

Often mistaken for uncooperative behavior. If they aren’t able to be soothed by the parents, suspect Delirium.

Anticholinergics, other meds that affect cognition, and fever can cause it.

Question 14

Dementia

Answer 14

A group of disorders characterized by cognitive deficits

Impaired executive functioning
Impaired global intellect with preservation of level of consciousness
Impaired problem-solving
Organization skills
Altered memory

Question 15

Alzheimers

Answer 15

Gradual onset and progressive decline

No focal neuro deficits

The hallmark is amyloid deposits and neurofibrillary tangles. There is also diffuse cerebral atrophy and enlarged ventricles

Decreased ACh and NE

Question 16

Vascular dementia

Answer 16

Second most common (which makes sense because a lot of people have HTN, etc)

Step-wise declines

More common in men

Carotid bruits, fundoscopic abnormalities, enlarged heart chambers

Question 17

HIV dementia

Answer 17

it’s considered a subcortical dementia

Progressive decline and behavioral changes like alzheimers, but it also has motor abnormalities

It co-occurs with many other psych disorders.

It’s a bad sign, in the late stage they get psychotic (can also have mutism, mania, seizures), and they usually die within 6 months

Parenchymal abnormalities visualized on MRI scan

Antiretrovirals can interact with psych meds, so be careful.

(fyi, HIV neurocognitive disorder and HIV encephalopathy are less severe forms of HIV dementia)

Question 18

Pick’s disease

Answer 18

Also known as frontotemporal dementia

Personality and behavior change in the early stage, later there are cognitive changes (this makes it unique- first behavior changes, then cognition)

HYPERSEXUAL/HYPERORALITY

Neuronal loss, gliosis, and Pick’s bodies are present

More common men

Question 19

Creutzfeldt-Jakob disease

Answer 19

Fatal and RAPIDLY progresses

Initially: Fatigue, flulike symptoms, cognitive impairment

Later: Aphasia, apraxia, emotional lability, depression, mania, psychosis, marked personality changes, and dementia

Question 20

Huntington’s disease

Answer 20

Subcortical dementia

Biggest feature is motor abnormalities (choreoathetoid). It’s not until later that there will be memory, language, and insight problems.

High incidence of depression and psychosis

Question 21

Lewy Body disease

Answer 21

Caused lewy bodies in the cortex

VISUAL hallucinations and PARKINSONS features

Antipsychotics are not a good choice

Question 22

Genetics with Alzheimers

Answer 22

Chromosomes 1, 14, and 21 are implicated

It’s an autosomal dominant trait

Later onset is linked to E4 APOE4 on chromosome 19

Question 23

Dementia incidence

Answer 23

1.6% of people 65 and older

It’s often unrecognized

Question 24

Dementia risk factors

Answer 24

complex medical illnesses

genetics

substance use

Question 25

Dementia prevention/screening

Answer 25

Cognitive evaluation every 3 years for people 65 and up (however, USPSTF says there is not sufficient evidence to support this)

Question 26

Dementia: when taking their history

Answer 26

Screen for history of HTN, stroke, head trauma, and psych illness (depression, anxiety, schizophrenia)

Question 27

Assessment tools for dementia

Answer 27

MMSE MoCA (montreal cognitive) Mini-Cog SLUMS (St Louis university mental status

Question 28

Possible physical findings for dementia

Answer 28

Amaurosis fugax: unilateral transient vision loss, described as "curtain over the eye" Unilateral focal-motor weakness Asymmetrical reflexes

Question 29

In the late stages of dementia, a speech assessment could show

Answer 29

mutism, echolalia

Question 30

Differential dx for dementia

Answer 30

``` B12 and folate deficiency Hearing loss Parkinsons Hypothyroid Infection Mood disorder Anxiety and others ```

Question 31

Memantine

Answer 31

Use it for moderate to severe AD It may slow the degeneration May be used in combination with cholinesterase

Question 32

Cholinesterase inhibitors

Answer 32

Use for mild to moderate AD (donepezil can also be used for severe) It can cause a 2 to 3 point increase on the MSE Slows loss of function, and may improve some behaviors You might need to stop if they have side effects (nausea) Donepezil causes nausea, diarrhea, vomiting, appetite/weight loss, abnormal dreams, insomnia, dizziness Rivastigmine should be titrated slowly to avoid side effects. It can be used for AD and parkinson's dementia

Question 33

Benzos and dementia

Answer 33

May be used for anxiety and INFREQUENTLY for agitation

Question 34

Dementia and treatment of depression

Answer 34

Treat for 6 to 12 months, then taper. If it comes back, they may need indefinite treatment

Question 35

Psychotherapy for HIV dementia

Answer 35

You'll be dealing with guilt, self-esteem, and fear of dying

Question 36

Dementia and children

Answer 36

You can't dx it until 4 to 6 years old, when the cognition can fully be examined In children dementia presents as deteriorating function in school

Question 37

Criteria for neurocognitive disorder due to TBI

Answer 37

A head injury with loss of consciousness, posttraumatic amnesia, disorientation/confusion, or neurological signs (seizures, visual field cuts, etc) The symptoms must start soon after the injury

Question 38

neurocognitive disorder due to TBI

Answer 38

veterans, worsening of problems such as memory, balance, headaches (anything that would suggest a brain injury)

Question 39

neurocognitive disorder due to TBI, troops compared to civilians

Answer 39

It's harder to heal for troops, for obvious reasons

Question 40

Mild TBI symptoms

Answer 40

``` concentration Memory Intellect irritability depression anxiety ``` ``` Dizziness balance headaches tinnitus numbness/tingling vision changes sensitivity to light or sound extreme fatigue sleep problems ```

Question 41

Moderate TBI symptoms

Answer 41

Mild symptoms plus: ``` worsening headaches repeated nausea seizures difficult to arouse from sleep slurred speech unequal pupils confusion restless/agitated Extreme weakness/numbness loss of coordination ```

Question 42

There's a big risk for suicide with TBI, especially if they are

Answer 42

``` male 18 and 19 comorbid psych disorder Aggressive Substance use ```

Question 43

Imaging for TBI

Answer 43

it doesn't show anything

Question 44

Pharmacologic Treatment of TBI

Answer 44

There are no meds specific to TBI, but you can treat symptoms Be careful using meds that cause sedation, anticholinergics, TCAs/bupropion/amantadine (they can cause seizure), antipsychotics, benzos If they have a cognitive disorder with the TBI, you can use: Stimulants for inattention etc Bromocriptine (off label) for executive functioning Amantadine (off label) cognitive function, attention

Question 45

Non Pharmacologic Treatment of TBI

Answer 45

Follow up for 1 year after anyone attempts suicide Physical therapy to reduce dizziness Occupational therapy to help with vision problems and memory Psychotherapy: supportive therapy, CBT, behavioral, and family therapy are good. The hardest thing for families to adjust to is personality/behavioral changes.

Question 46

What to teach families of a TBI patient

Answer 46

The hardest thing for families to adjust to is personality/behavioral changes. Use common sense strategies to cope with poor memory and concentration (for example a note pad to write things down) If they get angry, the family should stay calm, give them space, maybe leave the room until they calm down

Question 47

Tips for the NP giving therapy for a TBI patient

Answer 47

adjust session length depending on their attention span

Question 48

Prognosis for Mild TBI

Answer 48

usually a full recovery in 3 months If they have residual symptoms, 80 to 85 % will clear up in 6 months

Question 49

Screening for TBI is important because

Answer 49

it is possible for symptoms to occur later, not right after the injury (which is different from a neurocognitive disorder due to a TBI, where the symptoms start immediately.