Neurocognitive Disorders & Geriatrics Flashcards
Normal Aging Cognitive Changes
Memory recall may require more cues
Decreased processing speed
Crystalized intellegence (Facts) continues to increase, Fluid intelligence declines (processing ability)
Normal age associated decline should NOT dramatically interfere with instrumental activities of daily living
Typical Cognitive Domains that can be affected by Dementia
- Attention
- Processing speed
- Language
- Visuospatial ability
- Memory (verbal & visual)
- Executive functioning
- Psychomotor ability
Dementia Screening questionnaires
MoCA (Montreal cognitive assessment)
MMSE (Mini-mental status exam)
only for dementia NOT delirium
When should you refer someone for a neuropsychological evaluation?
when they have changes in cognitive and/or IADL function
Get a baseline & repeat testing to monitor
same type of test for ADHD
Spectrum of Neurocognitive Disorders
- Delirium (acute change; medical problem)
- Major ND…Dementia –> WITH IADL dysfunction
- Minor ND…Mild cognitive impairment –> W/O IADL dys
Delirium Definition
Disorientation, recent memory loss, and clouding of attention
Rapid onset! Hours to days
Fluctuating course – confusion waxes and wanes
Causes –> infection, illicit drugs, endocrine, pulm, cardio, electrolyte dysfunction
Elderly patients at highest risk… >80 very high risk
Delirium Diagnostic Criteria
- Disturbance in attention & orientation to the environment and awareness
- Disturbance develops over a short period of time & represents a change from baseline…fluctuates in severity during the course of the day
- Disturbance in cognition
Not better explained by another preexisting problem
Delirium Treatment
Treat underlying causes!!!
Avoid polypharmacy – Benzos make confusion worse!
Types of Dementia
- Alzheimers (MC)
- Frontotemporal Dementia
- Lewy Body Dementia
- Vascular Dementia
- Traumatic Brain injury
- Substance Induced
- HIV
- Prion Dz
- Parkinson’s
- Huntingtons
Symptoms of Dementia aka Major Neurocognitive Disorder
Cognitive impairment in 1+ cognitive domains
- reduced memory, language, executive function, etc.
- Aphasia –> deterioration of language
- Echolalia –> repeating what was heard
- Apraxia –> inability to execute common actions (dressing)
- Agnosia –> failure to recognize people or objects
IADL dysfunction
Possible changes in personality
Possible incontinence
Possible sensory changes (loss of taste and smell)
Alzheimer’s Dz
50% of dementia
Often comorbid with vascular disease
Slow gradual decline over 8-20 years
Only definitive diagnosis is autopsy so have to diagnose clinically which is 85% accurate!
- brain atrophy
- amyloid plaques
- neurofibrillary tangles
Alzheimer’s treatment
Medications just slow progression…not a cure!
- Donepezil (common 1st line treatment for mild-mod)
- Namenda (mod-severe)…can use in combo with above
Combo drug = Namzaric…mod-severe symptoms
Can give meds to address specific symptoms
- antipsychoits
- depressive symptoms – SSRI
- sleep disturbance – Belsomra
Vascular Dementia
Caused by infarcts in the brain…stroke, TIA, etc.
Sudden onset, symptoms wax and wane
Variable progression – not a consistent decline like youd expect in Alzheimer’s
Dx with CT or MRI –> lacunar infarcts
Screen for correctable risk factors!!!!
Frontotemporal Dementia
Onset typically in 50’s
Behavioral and Language subtypes
Can see personality changes…decrease in executive functioning
Parkinson’s Dz dementia
Occurs in 1/3 of patients later in PD disease
PD = unilateral tremor, men in their 60’s
Can see associated cognitive changes
- attention
- processing speed
- memory
- language…naming
- depression
EPS symptoms are common
- hypophonic speech
- bradykinesia
- micrographia (small handwriting)
Differences between Delirium & Dementia
Delirium
- fast, rapid onset
- fluctuating course
- all memory is impaired
- treat underlying cause & pt recovers
Dementia
- slow onset
- stable course
- recent memory is affected more
- loss of neurons…will not recover
What is an organic cause you should think of when an elderly patient has sudden change in mental status?
UTI!!
Elderly don’t have the common symptoms of UTI seen in younger patients
Geriatric Depression Dx & Tx
Risk factors?
- stroke
- Parkinson’s
- MS
- Grief and loss
*May just complain of somatic symptoms like difficulty sleeping, stomach ache, etc. – think depression
SSRI
-Lexapro & Zoloft work well
Preferred treatment is psychotherapy
Risk factor of SSRI’s in edlerly?
Hyponatremia! Monitor sodium
Geriatric Suicide risk
After age 65 50% of attempted suicides will succeed
Always ask!!!
Geriatric Bipolar Mania
More likely to be irritable or dysphoric (negative energy)
More likely to be paranoid
Tx:
- Carbamazepine
- Valproic acid
- Lamotrigine
Lithium can be toxic at lower levels
Elder Abuse
often live with their perpetrators
10% of persons >65 yo
ex: omitting or withholding food, medicine, clothing, etc.
* Family conflict is often the underlying cause *
Screeners
- Brief Abuse Screen for the elerly
- Elder Assessment Instrument
