Neurocognitive disorders Flashcards
Dementia - areas of impaired functioning
- getting lost in familiar areas
- difficulties with dressing
- maintaining personal hygiene
- food acquisition/intake
- self-administration of meds
- social interactions
- operating common appliances
- usually unaware of deficits, do not complain of memory loss
MMSE - (Sn for major NCD’s)
20-24: mild dementia
13-20: moderate
less than 12: severe
6 cognitive domains
Complex attention Executive function Learning and memory Language Perceptual-motor skills Social cognition (interaction)
Delirium
Medical emergency.
Cause: medical conditions, polypharmacy, pain, ICU and postop settings
MCC children: febrile illnesses, medications
Categories:
- Substance intoxication delirium
- Substance withdrawal delirium
- Medication induced delirium
- Delirium due to another medical condition
- Delirium due to multiple etiologies
Sx: Confusion Assessment Method: (1 + 2 + either 3/4)
1. Acute onset, fluctuating course
2. Inattention: digit span, serial 7’s, WORLD (sp - mundo)
(distractibility, diff maintaining focus)
3. Disorganized thinking
4. Altered consciousness (vigilant, alert, lethargic, stuporous, comatose)
Other:
- Visual hallucinations
- Impairment in recent memory
–> diffuse slowing on EEG (EXCEPT in DTs - hyperkinetic)
Mgmt:
- Treat underlying cause
- Reorient pt regularly
- D2 antags (haldol) to treat agitation PRN
* use w caution in pts with parkinsonism
Do not use BZ’s!!! Unless in alc/BZ withdrawal.
What are the three types of delirium?
- Mixed type (most common)
- stable psychomotor activity at baseline, or fluctuating - Hypoactive (“quiet”) type
- likely to go unnoticed, esp in elderly - Hyperactive type (“ICU psychosis”)
- more common in drug withdrawal or toxicity
Difference between mild and major NCD?
Mild: IADLs preserved
Major: Impaired performance of IADLs
What are some reversible causes of NCD?
1a. Hypothyroidism (fatigue, cold intolerance)
1b. Hyperthyroidism (“apathetic thyrotoxicosis” - depression, lethargy)
2. Vit B12 def
3. Wilson’s ds (?)
4. Normal pressure hydrocephalus
What are 2 screening tests for NCD?
- MMSE
* Dysfunction: <25 - Mini-Cog (3 item recall + clock drawing)
* Positive (aka need further w/u) screen:
- no items recalled after 3 mins
- only 1-2 items recalled with abn clock drawing
If positive screen –> need formal neuropsych testing
Alzheimer’s disease
MCC; 2/3 are women, usually after age 65
Domains: Learning and memory, Language
[personality changes, mood swings, paranoia]
INSIDIOUS, GRADUAL
Pathophys:
*Extraneuronal B-amyloid plaques
*Intraneuronal tau protein tangles
*AD single gene mutation (APP, presenilin 1 or 2) –> early onset sx
*epsilon 4 variant of apolipoprotein gene –> RF for early onset
Mgmt:
- Mild-mod: Cholinesterase inhibitors
- Mod-severe: NMDA-R antag, memantine
- Agitation/aggression: antipsychotics
* Black box warning of incr risk death in dementia pts. Use in low doses for short pds of time, monitor closely. - Caregiver support
Why do Down Syndrome pts have greater risk of early onset Alzheimer’s?
B-amyloid precursor protein (APP), gene is on chrom 21 –> B-amyloid peptide (A-beta) –> senile plaques
Trisomy 21 –> overexpression of APP
Vascular dementia
2nd MCC (~20%)
Cause:
- lg vessel strokes (usually cortical)
- small vessel strokes (lacunar, to subcortical structures)
- microvascular disease affecting periventric white matter
RF: HTN, DM, smoking, obesity, HLD, afib, old age
Domains: Complex attention, Executive function
Dx: neuroimaging
Mgmt: Prevent future strokes, sx mgmt similar to AD
Lewy body dementia
pathophys core features suggestive features how to make dx? mgmt
Pathophys:
- Lewy bodies (alpha-synuclein aggregates)
- Lewy neurites (in brain, primarily in basal ganglia)
Core features:
- Waxing and waning cognition (Attention, Alertness –> resembles delirium)
- Visual hallucinations (animals, small ppl)
- EPS sx at least 1 YR AFTER cognitive decline becomes apparent (Parkinsonism)
Suggestive features:
- REM sleep behavior disorder (violent mvmts during sleep)
- Antipsychotic sensitivity
Possible dx: only 1 of the above
Probable dx: 2+ core, or 1 core and 1+ suggestive
Mgmt:
- Cog/behavioral sx: cholinesterase inhibitors
- Psychotic sx: Quetiapine (Seroquel) or clozapine
- Parkinsonism: Levodopa-carbidopa (can exac psychosis/REM sleep disorder)
- REM sleep disorder: melatonin, clonazepam
Frontotemporal dementia
Affects: Attention, Abstraction, Planning, Problem solving
- Two variants: BEHAVIORAL, LANGUAGE
- Increased Sn to adverse effects of antipsychotics
- Common misdiagnosis: late onset bipolar disorder
Pathophys: frontal, temporal lobe atrophy
Mgmt:
- Sx-focused
- Serotonergic meds (SSRI’s, trazodone) - help w sx
Definitive dx made at autopsy for __, __, __
Alzheimer’s
LBD
FTD
Describe the two variants of FTD.
BEHAVIORAL VARIANT:
- disinhibited verbal, physical, sexual behavior
- overeating or oral exploration of inanimate objects
- lack of warmth, empathy
- apathy or inertia
- perseveration, repetitive speech, rituals, obsessions
- decline in Social Cognition and Executive Abilities
LANGUAGE VARIANT (primary progressive aphasia):
- difficulties w/ speech and comprehension
- RELATIVE SPARING of learning/memory and perceptual-motor function
HIV infection
25% of those infected –> meet mild NCD criteria
RF: severe IC, high CSF viral loads, advanced infection
Sx: depends on part of brain affected
Dx: mild or major NCD attributed to confirmed HIV infec
Mgmt:
1. HAART
2. Fatigue, apathy, psychomotor retardation –> psychostimulants
