Neurocognitive Disorders I

Question 1

describe delirium

Answer 1

acute confusional state, acute brain syndrome

• delirium involves:
  
  1. a disturbance in awareness and attention
     
     • awareness is assessed by one’s orientation to the environment
     • attention is assessed by one’s ability to direct, focus, sustain and shift attention
  2. an additional disturbance in a cognitive domain
     
     • memory, language, thoughts (delusion) and perceptions (hallucinations)
  3. sudden onset of symptoms (over hrs to a few days) that typically fluctuate during the day
  4. evidence for a direct physiological cause
     
     • medical condition, drug intox/withdrawal

Question 2

describe the confusional assessment method chart for delirium

Answer 2

Question 3

describe contrast delirium with dementia

Answer 3

• dementia = cognitive impairment but with full consciousness
• delirium = reduced level of consciousness

Question 4

describe the pathology of delirium

Answer 4

• multiple etiologies (e.g. fever, dehydration)
• widespread brain regions affected
• core deficits in central cholinergic functioning
• deficits in the RAS and its ascending connections
  
  • important for attention and arousal

Question 5

describe risk factors for delirium

Answer 5

• non-modifiable: poor health, older age, male gender
• modifiable: immobilization, poor sleep, use of benzos in an ICU

Question 6

describe the course of delirum

Answer 6

• symptoms persist until cause is reversed
• resolution typically occurs within 3-7 days
• amnesia for events during delirium is common
• delirium is a poor prognostic sign for long-term survival and results in longer ICU stays

Question 7

describe the treatment for delirium

Answer 7

• treat underlying medical condition
• manage associated symptoms (agitation, psychosis)
  
  • use antipsychotics to treat associated symptoms (agitation, psychosis) of most delirium
  • use benzodiazepines to treat delirium caused by alcohol withdrawal

Question 8

describe non-pharmacological treatment for delirium

Answer 8

• utilize environmental supportive measures
  
  • regulate amount of environmental stimulation
  • provide orienting stimuli
    
    • lighting, personal effects, sensory aids
  • provide for safety needs
    
    • attendant, bedrails and possibly restraints

Question 9

describe amnesia

Answer 9

• significant acquired memory deficit
• caused by a medical condition or the effect of a substance (not from dissociation)
• NOT diagnosed if it occurs in the context of general cognitive decline (i.e. a dementia)
• typically caused by damage to the hippocampus

Question 10

describe a typical profile of amnesia

Answer 10

• intact short-term (working) memory
• short-duration retrograde amnesia
• if lengthy retrograde amnesia, there is often a temporal gradient to the memory loss with recent long-term memories (LTMs) more impaired than remote LTMs
• prominent anterograde amnesia

Question 11

describe the treatment of amnesia

Answer 11

• treat underling cause
  
  • B1 deficiency in Korsakoff’s to stop amnesia progression
• cognitive rehabilitation
  
  • restoration of function: memory exercises to strengthen memory through repetition
  • compensation (e.g. using mnemonics):
    
    • external strategies (non-mental activities such as using lists, calendars, other person)
    • internal strategies (mental activities such as acronyms and acrostics)

Question 12

describe dementia

Answer 12

• refers to multiple and severe cognitive impairment without impaired consciousness
• is usually progressive and irreversible
• most commonly occurs in the elderly
• note: mild cognitive impairment (MCI) refers to cognitive decline that doesn’t cause impairment in activities of daily living

Question 13

describe Alzheimer’s dementia (AD)

Answer 13

• significant memory impairment plus impairment in at least 1 other cognitive domain
  
  • a gradual onset with steadily progressive decline
  • exclusion of other causes of the symptoms (stroke)

Question 14

describe the general course of AD

Answer 14

• typically onset in late 70s with 10+ year progression:
  
  • early stages: memory deficits (rapid forgetting) and anomia (aka word finding struggle)
  • middle stages:
    
    • further memory and language decline
    • visuospaital deficits
    • agnosias
      
      • anosognosia = unaware of mental condition
      • prosopagnosia = unable to recognize familiar faces
    • mood changes, personality changes
    • psychosis
  • late stages: global aphasia, motor dysfunction, death from opportunistic infxns

Question 15

describe neuropatholgy and neurochemical changes in AD

Answer 15

• neuroanatomical:
  
  • cortical atrophy
  • hippocampal atrophy
  • enlarged ventricles
• neurochemical:
  
  • multiple neurotransmitter deficiencies
  • focus has been on loss of cholinergic (ACh) neurons in the nucleus basalis of Meynert due to its role in memory formation

Question 16

describe neurofunctional and histopathological changes seen in AD

Answer 16

• neurofunctional: posterior hypometabolism (parietal/temporal)
• histopathological: B-amyloid plaques and neurofibrillary tangles
  
  • in vivo biomarkers of AD:
    
    • CSF amyloid and tau levels
    • PET imaging of amyloid plaques
  • definitive AD diagnosis still depends on post-mortem histopathological confirmation

Question 17

describe the 4 FDA approved drugs for treating AD

Answer 17

• 3 cholinesterase inhibitors, approved for mild-moderate AD
  
  • donepezil (Aricept)
  • galantamine (Razadyne)
  • rivastigmine (Exelon)
• 1 NMDA receptor blocker, approved for moderate-severe AD
  
  • memantine (Namenda)

Question 18

describe the effectiveness and side-effects of AD treatment

Answer 18

• AD trugs are considered ineffective
• side effects (e.g. hypotension, GI disruptions) have notable consequences for the elderly (e.g. risk of falls)
• research efforts are on decreased production and increased clearance of B-amyloid through antibody drugs

Question 19

Answer 19

delirium requires problem with consciousness and problems with paying attention, therefore no, because she is alert and attentive

Question 20

Answer 20

reduced level of consciousness, confused, inattentive = delirium

antipsychotics = first choice, unless alcohol withdrawl

Question 21

clicker 3

Answer 21

dementia = close, but severe cognitive impairment

amnesia = only if memory problems and severe

delirium = pt is alert, so can’t be delirium

MCI = testing is lower than expected, but able to perform normal activities, so she has MCI

Question 22

clicker 4

Answer 22

misplacing objects and difficulty coming up with familiar words (anomia) = seen from beginning

seizures, motor weakness, vision loss = end stages

middle stages = change in personality, therefore social reclusiveness

Question 23

describe other interventions for AD

Answer 23

• treatment of neuropsychiatric symptoms (e.g. aggression, agitation)
• non-pharm methods: music therapy
• antipsychotics
  
  • used off-label for demented patients
  • FDA black box warning of increased mortality risk if used with this population
• anticonvulsants and antidepressants
• rule out non-dementia causes of behavioral problems (e.g. pain) in AD patients

Question 24

describe psychosocial consideration in treating AD

Answer 24

• use of external mnemonics in early AD stages
• assessment and restriction of driving
• “Safe Return Program” for wanderers

Question 25

describe support for AD patients’ caregivers

Answer 25

• risk of “Care Giver Syndrome” from psychological, social and financial sequelae of caregiving
• resources through AD association/AD foundation
  
  • support groups
  • caregiver tips (e.g. how to respond to psychosis)
  • long-term care options
  • legal and financial planning