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5. HDS Neuro Psych > Neurocognitive Disorders > Flashcards

Neurocognitive Disorders Flashcards

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1
Q

Classification of Psychiatric Disorders

A
  • “Organic” versus “Functional”
  • Neurocognitive Disorders
  • Psychiatric Disorders Secondary to General Medical Condition
  • Psychiatric Disorders Secondary to Substance Abuse
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2
Q

DSM‐5:

Neurocognitive Disorders

A
  • Delirium
  • Major and Mild Neurocognitive Disorders (Dementia)
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3
Q

Disorders Secondary to a General Medical Condition

A
  • Delirium and Neurocognitive Disorders are not the only psychiatric disorders that are secondary to a medical condition
  • Mood Disorders secondary to GMC
  • Psychotic Disorders secondary to GMC
  • Catatonic Disorders secondary to GMC
  • Personality change secondary to GMC
  • Anxiety Disorders secondary to GMC
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4
Q

Delirium

Definition

A

Delirium is characterized by a disturbance in attention and awareness that develops over a short period of time

  • Attention: reduced ability to direct, focus, sustain and shift attention)
  • Awareness: reduced orientation to the environment
  • Acute onset
  • Fluctuating course
  • Impairment of attention is associated with global impairment of cognitive functions
    • Memory deficits, disorientation, language or perception
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5
Q

Delirium

Syndromes

A
  • Substance withdrawal delirium
  • Medication‐induced delirium
  • Delirium due to another medical condition
  • Delirium due to multiple etiologies
  • Specify if:
    • Acute: Lasting a few hours or days
    • Persistent: Lasting weeks or months
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6
Q

Medical Conditions Commonly Associated with Delirium

A
  • Central nervous system disorder
  • Metabolic disorder
  • Cardiopulmonary disorder
  • Sepsis / Infection
  • Systemic illness
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7
Q

Delirium

Types

A
  • Hyperactive:
    • The individual has a hyperactive level of psychomotor activity that may be accompanied by mood lability, agitation, and/or refusal to cooperate with medical care
  • Hypoactive:
    • The individual has a hypoactive level of psychomotor activity that may be accompanied by sluggishness and lethargy that approaches stupor
  • Mixed level of activity:
    • The individual has a normal level of psychomotor activity even though attention and awareness are disturbed
    • Also includes individuals whose activity level rapidly fluctuates
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8
Q

Delirium

Pathophysiology

A
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9
Q

Delirium

Epidemiology

A
  • Low in community samples ~ 1‐2%
  • The prevalence of delirium in the hospitalized medically ill ranges from 10% to 30%
  • In the hospitalized elderly, the delirium prevalence ranges from 10% to 40%
  • 70‐90% in the ICU
  • 51% of postoperative patients develop delirium
  • 80% of patients with terminal illnesses develop delirium near death
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10
Q

Recognizing Delirium

A
  • It is important clinically to recognize delirium
  • Delirium is due to a serious underlying condition, and that condition must be identified and treated
  • The confused, delirious patient must be protected from delirium‐related accidents
  • Delirious patients tend to have longer hospital stays
  • Delirium is associated with higher morbidity and mortality
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11
Q

Clinical Features of Delirium

A

Essential feature of delirium is disturbance of attention or awareness

  • It develops over a short period of time
  • Fluctuation of symptoms over the course of the day
  • Confusion
  • Disorientation
  • Illusions /Hallucinations
  • Emotional disturbance; Apathy, Anxiety, Fear
  • Emotional Disturbance may manifest as calling out, screaming, shouting
  • Disturbed sleep awake cycle
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12
Q

Delirium Management

A
  • Supportive treatment
  • Treat the cause
  • Repeated orientation, cues
  • Evaluate and treat for pain
  • Pharmacologic management of Agitation
  • ? Restraints
  • Prevention is the best strategy
  • Orientation and Therapeutic activities for the cognitively impaired
  • Early mobilization
  • Non-pharmacologic interventions for sleep difficulties
  • Minimum use of psychoactive agents
  • Communication and adaptive equipment (eyeglasses, hearing aid)
  • Early Rx for volume depletion
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13
Q

Major Neurocognitive Disorders

Overview

A

A. Evidence of significant cognitive decline from previous level of performance in one or more cognitive domains

(Complex attention, executive function, learning and memory, language, perceptual motor and social cognition)

Based on:

  • History
  • Neuropsychological testing

B. Cognitive deficits interfere with everyday activities

C. Not due to delirium

D. Not better explained by another mental disorder like schizophrenia or major depression

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14
Q

Major Neurocognitive Disorders

Subtypes

A
  • Alzheimer’s Disease
  • Vascular Disease
  • Fronto‐Temporal Lobar Degeneration
  • Traumatic Brain Injury
  • Lewy Body Disease
  • Parkinson’s Disease
  • HIV Infection
  • Substance Use
  • Huntington’s Disease
  • Prion Disease
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15
Q

Major Neurocognitive Disorders

vs

Mild Neurocognitive Disorders

A

Degree of impairment in Activities of Daily Living

and

Instrumental Activities of Daily Living

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16
Q

Delirium

vs

Neurocognitive Disorders (Dementia)

A
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17
Q

Neurocognitive Disorders

Clinical features

A
  • Disturbance in the SIX domains
    • Complex Attention: sustained, divided and selective attention + processing speed
    • Executive Function: planning, decision making, inhibition, mental flexibility)
    • Learning and Memory: immediate, recent, remote, new learning, declarative (semantic & episodic) and implicit (procedural)
    • Language
    • Perceptual Motor: visual perception, visuo‐ constructional, praxis and agnosis
    • Social cognition
  • Insidious onset
  • Gradual progression
  • Patients are adept at minimizing their sx
  • Collateral hx important
  • Always assess patient’s ADL’s and IADL’s
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18
Q

Neurocognitive Disorders

Assessment

A
  • History
  • Physical Exam
  • Mental Status Examination
  • Assessment of Higher Mental Functions (MOCA, Folstein’s)
  • Neuropsychological Assessment
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19
Q

Dementia Work-up

A
  • CT Head
  • TSH
  • RPR (rapid plasma reagin)
    • Screening test for syphilis
  • B12 & Folate levels
  • Others depending on history
20
Q

Assessment of Cognitive Functions

A
  • Levels of Consciousness
  • Attention
  • Language
  • Memory
  • Constructional Ability
  • Higher cognitive fx: Fund of information; Calculation; Proverb interpretation
21
Q

Levels of Consciousness

A

Alertness: Awake and fully aware of internal and external stimuli

Lethargy: Not fully alert and tends to drift of to sleep when not actively stimulated

Obtundation: Difficult to arouse, and when aroused the patient is confused

Stupor or semi coma: Patient responds only to vigorous stimulation

Coma: Completely unarousable

22
Q

Consciousness

Assessment

A
  • Clinical evaluation
  • Glasgow Coma Scale (GCS)
    • Assesses 3 things:
      • Eye opening
      • Best verbal response
      • Best motor response
23
Q

Attention & Concentration

A

Attention is the ability to attend to a specific stimulus without being distracted by extraneous stimuli

Concentration is the ability to sustain attention over a sustained period of time

Anatomical Localization: Ascending reticular activating system

24
Q

Attention & Concentration

Evaluation

A
  • Digit repetition
  • Random letter test
  • Serial subtraction
  • Spell “WORLD” backwards
25
Q

Language

Definitions

A

Dysarthria: disorder of articulation

Dysprosody: loss of speech melody

Aphasia: a true language disturbance in which patient demonstrates impaired production / comprehension of spoken language

Alexia: loss or reading ability in a previously literate person

Agraphia: is an acquired disturbance of writing

26
Q

Evaluation of Language

A
  • Handedness
  • Spontaneous speech
  • Comprehension
  • Repetition
  • Naming
  • Reading
  • Writing
27
Q

Aphasic Syndromes

A
28
Q

Memory

A

A general term for a process that allows an individual to store information for later recall

  • Three stages:
    • Registration
    • Encoding
    • Recall
  • Clinically, memory is divided into three types:
    • Immediate memory / Short term memory
    • Recent Memory
    • Remote memory
29
Q

Evaluation of Memory

A
  • Digit repetition (Immediate memory)
  • New learning ability (Short term memory)
  • Recent memory (Orientation)
  • Remote memory (Historical facts about patient’s experiences)
30
Q

Memory

Localization

A
  • Immediate memory: Any condition in which there is impaired attention
  • Recent Memory: Mamillary bodies, medial temporal lobe, hippocampus and dorsal medial thalamic nuclei
  • Remote memory: Association cortex
31
Q

Constructional Ability

A

This is the ability to draw or construct two or three dimensional figures or shapes

Constructional tasks are extremely sensitive in detecting organic brain disease

32
Q

Constructional Ability

Assessment

A
  • Copying geometric shapes
  • Drawing on command
  • Three-dimensional block construction
33
Q

Constructional Ability

Localization

A

Parietal lobe

Right parietal lobe lesions produce a higher incidence and greater severity of defect than left-sided lesions

34
Q

Other Higher Cognitive Functions

A
  • Fund of information
  • Calculation (Parietal)
  • Proverb interpretation (Frontal)
  • Social judgment (Frontal)
35
Q

Apraxia

A

Apraxia is an acquired disorder of learned, skilled, sequential movements that cannot be accounted for by elementary disturbance of strength, coordination or lack of comprehension or attention.

An inability to carry out motor commands in the absence of any gross motor deficit.

36
Q

Agnosia

Types

A

The inability to interpret sensations and hence to recognize things.

  • Visual agnosia
    • Inability to recognize visually presented objects despite the preservation of elementary sensory functions
  • Prosopagnosia
    • Inability to recognize the faces of familiar people
  • Finger agnosia
    • Inability to distinguish, name, or recognize the fingers
    • Not only the patient’s own fingers, but also the fingers of others, and drawings and other representations of fingers
  • Astreognosis
    • Inability to identify an object by active touch of the hands without other sensory input, such as visual or sensory information
37
Q

Gerstmann’s Syndrome

A
  • Finger agnosia
  • Right left disorientation
  • Dysgraphia
  • Dyscalculia
  • Caused by parietal lobe lesions – dominant or bilateral
    • Angular gyrus
38
Q

Clinical Assessment Scales

A
  • Montreal Cognitive Assessment (MOCA)
  • Folstein’s Mini Mental Status Examination (MMSE)
  • Luria Nebraska Neuropsychological Battery
  • Halstead‐Reitan Battery
39
Q

Montreal Cognitive Assessment (MOCA)

A

Sum all subscores listed.

Add 1 point for an individual who has 12 years or fewer of formal education, max 30 points.

Final total score of 26 or above is normal.

40
Q

Folstein’s Mini Mental Status Examination (MMSE)

Components

A
  • Orientation Time (5)
  • Orientation Place (5)
  • Registration (3)
  • Serial Subtraction or spell “WORLD” backwards (5)
  • Recall (3)
  • Name ‘pen’ & ‘watch’ (2)
  • Repetition “No ifs ands or buts” (1)
  • Three step command (3)
  • Read and obey (1)
  • Write a sentence (1)
  • Copy a design – intersecting pentagons (1)
  • TOTAL: 30 points
41
Q

Folstein’s Mini Mental Status Examination (MMSE)

Interpretation

A
42
Q

Other Important Scales

A
  • Wechsler Memory Scale
  • Bender Gestalt Test (Constructional ability)
  • Wisconsin Card sorting test (Abstraction)
  • Trail Making test (Constructional)
43
Q

Dementia

Types

A
  • The most common types of dementia:
    1. Alzheimer’s Dementia
    2. Vascular
    3. Dementia of Lewy Body
  • Alzheimer + Vascular Dementia = 80‐90% % of all cases
  • *Frontotemporal Dementia (FTD)
44
Q

Dementia

Epidemiology

A
  • 5% of people at age 65
  • 20 – 40% of people > 85
  • 50% of all nursing home beds occupied by patients suffering from Alzheimer’s
45
Q

Alzeimer’s Dementia

Etiology / Pathophysiology

A
  • Genetic Factors
    • *Down Syndrome (Trisomy 21) there are three copies of the amyloid precursor protein gene
  • Neuropathology
  • Neurotransmitters
  • Neuroradiology
46
Q

Dementia

Management

A

Agitation and aggression are common in neurocognitive disorders, esp. in advanced stages of Alzheimer’s Dementia

  • Result from disease related biological factors, care needs and environmental factors
  • Risk factors for agitation include infection, pain, sensory loss, caregivers inadequate understanding of disease process, poor communication, overcrowding, excessive environmental stimuli
  • Patients function best in an environment that is safe, calm, and predictable
  • Do not neglect caregiver burnout
  • Initial assessment & therapeutic approach
    • Comprehensive assessment of the frequency, severity and context of reported agitation or aggression
    • Investigation of precipitating and perpetuating factors is the first step
  • Psychosocial & nonpharmacological interventions
    • Non-pharmacological strategies should be considered first
    • Psychosocial interventions and person-centered approaches to care
    • Unmet general medical needs and environmental factors should also be addressed
  • Pharmacological interventions
    • When pharmacological treatment is necessary, antipsychotics have most evidence of efficacy
    • Limited evidence for other agents such as citalopram and carbamazepine
    • Pharmacological treatment should be reviewed regularly and consideration given to withdrawal if it is no longer necessary or the risk/benefit ratio no longer favors continuation
    • Risks of Using Neuroleptics
      • Cardiac side effects – Prolongation of QTc – Risk of Torsade
      • CVA – increased risk of Stroke
      • Extrapyramidal side effects
47
Q

Neurocognitive Disorders

Conclusions

A
  • CNS lesions have a wide variety of psychiatric manifestations
  • In any pt with psychiatric manifestations, it is important to rule out a general medical condition
  • Deficits in higher mental functioning are often the first signs
  • History, Physical exam, Labs, Imaging and assessment of cognitive functioning are important in making a diagnosis and planning treatment and rehabilitation

5. HDS Neuro Psych (46 decks)

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