Neurocognitive Disorders. II

Question 1

What are the differential diagnoses of Ahlzeimer’s dementia?

Answer 1

➢ There are multiple causes of dementia that must be ruled out before diagnosing AD

➢ Dementias due to:
– Vascular disease
– Frontotemporal degenerative diseases
– Lewy body disease
– Parkinson’s disease
– Huntington’s disease
– Prion disease (e.g., Creutzfeldt-Jakob)

Question 2

What is vascular dementia?

Answer 2

Vascular Dementia
– Dementia results from multiple infarcts caused by cerebral vascular disease (CVD)
– Typical patient history includes risk factors of CVD (e.g., high blood pressure)

Sudden onset with stepwise progression
– Usually focal/lateralizing neurological signs
– Headaches and seizure onset are more common
in early stages of vascular dementia than AD
– Treatment involves addressing the underlying CVD to prevent further damage

Question 3

Describe frontotemporal dementia

Answer 3

Question 4

Describe Lewy Body Dementia

Answer 4

Question 5

What are the specific treatment considerations?

Answer 5

Specific Treatment Considerations

– Cognition: Cholinesterase inhibitors are typically used despite lack of FDA approval
▪ These drugs may improve hallucinations and agitation

– Psychotic symptoms: Antipsychotics tend to cause serious reactions (e.g., NMS, worsening Parkinsonism) and are typically avoided in LBD

– Motor symptoms: L-dopa may worsen psychosis and is used cautiously and in low dose

Question 6

Describe Parkinson’s disease with dementia

Answer 6

Parkinson’s Disease with Dementia (PDD)
– Up to 50% of PD patients develop dementia
– Similar pathology to LBD

–Use “1-year rule” for classifying PDD vs LBD:
▪ If dementia develops after 12 months of
motor symptoms → PDD
▪ If dementia develops within first 12 months of motor symptoms → LBD

Question 7

Describe the Huntingtons disease dementia

Answer 7

Dementia develops AFTER the onset of choreoathetosis and psychiatric symptoms

Question 8

Describe Prion disease

Answer 8

Prion Disease (e.g., Creutzfeldt-Jakob)
– Dementia progresses rapidly over a few months
with death within 2 yrs
– Spongiform degeneration (tiny holes) giving brain a “spongy’” appearance

Question 9

What are the reversible dementias?

Answer 9

Reversible Dementias (e.g., infections, normal pressure hydrocephalus)

Question 10

What is benign Senescent Forgetfulness?

Answer 10

Cognitive decline associated with the normal aging process

Question 11

What is Mild Cognitive Impairment (MCI)?

Answer 11

Mild Cognitive Impairment (MCI)

‒ Cognitive decline exceeding the normal aging process but that does not cause impairment in activities of daily living
‒ Patients with MCI are at increased risk for developing a dementia

Question 12

What is pseudo dementia?

Answer 12

Pseudodementia (AKA “Dementia Syndrome of Depression”)

– Cognitive deficits associated with a psychiatric disorder such as depression
– The deficits do not reflect a true dementing process but relate to the effects of the psychiatric condition

Question 13

Describe the assessment of NCDs

Answer 13

To assist in the diagnosis of NCDs, patients may be referred for neuropsychological testing:

– A comprehensive evaluation of a person’s cognitive functions
– Performance on neuropsych tests reflects functioning of specific brain areas
– Patterns of performance help to determine whether brain dysfunction (and which kind) is present

Question 14

What are the tests of a neuropsych evaluation?

Answer 14

Tests of:
• Intelligence

Perceptual reasoning test
– Wechsler intelligence tests (produces overall IQ score and several indices [e.g., Verbal Comprehension, Perceptual Reasoning])
– Assess for intellectual decline and look for hemispheric lateralizing and localizing signs

• Attention
– Visual attention (e.g., cancellation test)
– Verbal attention (e.g., serial 7s)

• Memory
– Verbal vs visual memory tests
▪ Oral word lists/short stories (lt hemi)
▪ Spatial designs (rt hemi)

– Immediate recall vs. delayed recall
▪ In delayed recall, look at rate of forgetting of information that was encoded during immediate recall

Question 15

Describe the tests of memory

Answer 15

• Free (uncued) recall: Free recall tests (no hints) help to establish a memory deficit exists but do not identify the specific memory process affected

• Cued recall: Cued recall tests (hints given) help to determine if the memory deficit is encoding-based or retrieval-based:
‒ If cues don’t help: Encoding didn’t occur; thus, the problem is encoding-based (medial temporal)
‒ If cues help: Encoding did occur; thus, the problem is retrieval-based (prefrontal)

Question 16

What are the tests of language and visuospatial functions?

Answer 16

Tests of:
• Language
– Left hemisphere language areas
– Naming and verbal fluency (words
  starting with “b”)

• Visuospatial functions
– Right parietal
– Copying and drawing tests (e.g., draw-a-clock, cube)

Question 17

What are the executive functions(prefrontal) evaluations?

Answer 17

Executive Functions (prefrontal)
– Abstraction (proverb interpretation,
similarities [between two words])

– Concept formation and mental flexibility (Wisconsin Card Sorting Test)

– Inhibiting responses (Stroop Test)

Question 18

What are the motor functions neuropsych tests?

Answer 18

Motor Functions
– Dexterity and speed (finger tapping,
pegboard test)
– Looking for lateralizing signs

Question 19

What are the neuropsychological test results used for?

Answer 19

Neuropsychological test results

– Used to assist in differential diagnosis of NCDs

– Examples (next slides)
▪ Alzheimer’s vs Vascular Dementia?
▪ Alzheimer’s vs Pseudodementia
(depression

Question 20

Contrast Ahlzeimer’s vs Vascular Dementia

Answer 20

Alzheimer’s vs Vascular Dementia?
• Different onset & progression (as described before)

• Memory deficits:
– Alzheimer’s: Encoding problem
– Vascular: Retrieval problem

• Motor functioning
– Alzheimer’s: No Lt-Rt discrepancy
– Vascular: Lt-Rt discrepancy

Question 21

How do we contrast Ahlzeimer’s dementia and Parkinson’s dementia?

Answer 21

Important distinctions are in:
– The onset and duration. of problems
– The pattern of neuropsych deficits (esp. whether memory
deficits relate to memory encoding vs. retrieval)

Ahlzeimer’s- encoding defeceit (cues don’t help)
Pseudo dementia- retrieval defeceit (cues help)

Ahlzeimer’s- long duration
Pseudo dementia- short

Onset-
Ahlzeimer’s- Indeterminent
Pseudodementia- pinpointable