Neuropsychiatry Flashcards
What is the DSM-5 name for dementia?
Major Neurocognitive Disorder
Generally, how is MAJOR Neurocognitive Disorder defined/diagnosed?
- Evidence of SIGNIFICANT cognitive decline in 1+ cognitive domains based on:
1. Someone is concerned pt has had significant decline in cognitive function; and
2. Impairment in cognitive performance via
neuropsychological testing or other clinical assessment - Deficits interfere with independence in everyday activities
- Deficits do not occur exclusively in the context of a delirium.
- Not better explained by another mental disorder
What are some “cognitive domains” that can decline in Neurocognitive disorder?
- Complex attention
- Executive function
- Learning and memory
- Language
- Perceptual‐motor
- Social cognition
Generally, how is MINOR Neurocognitive Disorder defined/diagnosed?
Same as in Major neurocognitive disorder, but instead of significant cognitive decline, there is a MODEST cognitive decline.
- Also, the cognitive decline does NOT interfere w/independence in everyday activities
In normal aging, what types of cognitive functions decline?
Which stay the same?
Decline: • Memory (benign senescence, forgetfulness of old age, age‐associated memory impairment) • Remembering names • Recalling newly‐learned lists • Attention span • Learning (slowed) • Ability to perform complex tasks
Same:
- Vocabulary, language ability, reading comprehension, fund of knowledge, social deportment, political and religious beliefs, IQ
How does sleep change with age?
- Becomes fragmented
- Less stage 4, phase‐advanced
How much does brain weight decrease with age?
Which brain lobes are first affected by aging?
85% of previous
Frontal and temporal lobes
What types of neurons are lost during aging?
What materials can build up?
- Loss of large cortical neurons
- Loss of neurons in some brainstem and deep structures
Senile amyloid plaques, neurofibrillary tangles (limited number), Lipofuscin granules
What’s another name for Minor Neurocognitive Disorder?
Mild Cognitive Impairment (MCI)
What % of mild cognitive impairment patients have psych sx?
43-59%
(Dysphoria, apathy, irritability, anxiety)
- Cortical and hippocampal atrophy are common
What % of dementias in the elderly does Alzheimer’s Disease (AD) account for?
60-70%
90% of patients with AD are __ years or older.
65
What are the main cognitive changes in AD?
Is it gradual or rapid?
- Difficulty with encoding information, names, visuospatial functioning
- Gradual deterioration, though can have rapid changes due to delirium / other changes
- Difficulty in encoding new material
- Changes in language, visuospatial, executive / social functioning as dz progresses
- Growing retrograde memory loss as dz progresses
How does DSM-5 diagnose AD?
Either positive for genetic mutation
- or -
Neurocognitive d/o + all 3 of the following:
a) *Decline in memory and learning + 1 other cognitive domain (based on hx or neuropsych testing)
b) Progressive, gradual decline in cognition, w/o extended plateaus
c) No evidence of mixed etiology
(+ can’t be better explained by delirium, other dx, etc.)
What are some cognitive and psych sx of early AD? (just read)
Cognitive
- Deficient verbal and visual encoding
- Impaired delayed recall
- Concrete thinking
- Mild anomia
Psych
- Apathy
- Depression (can predate dx by 10 years)
- Anxiety
- Irritability
What are some cognitive and psych sx of later AD? (just read)
Cognitive
- Transcortical sensory aphasia (like Wernicke’s)
- Decline in IADLs, then ADLs
- Appetite loss
- Sleep-wake cycle disturbances
- Immobilization
- Aberrant motor behaviors
Psych
- Disinhibition
- Hallucinations
- Delusions
- Agitation
- Aggression
- Psychosis; Common (Delusional themes of paranoia, theft, infidelity. Misidentification syndromes)
What are the pharm tx options for AD?
- Acetylcholinesterase inhibitors: donepezil, galantamine, rivastigmine
- Memantine
Trade name for donepezel?
Aricept
Trade name for galantamine?
Razadyne
Trade name for rivastigmine?
Exelon
Trade name for memantine?
Namenda
How do AChE-inhibitors work to help AD?
Increase availability of acetylcholine at synaptic cleft
• First and most prevalent areas involved in AD
• Memory systems
What is the MoA of memantine (Namenda) in treating AD?
- Weak NMDA receptor blocker (Na-Men-DA)
- Prevent deleterious effects of continuous toxic levels of glutamate, while allowing large glutamate surges to exert required cognitive effect
What med should you avoid to treat depression/anxiety in AD?
Benzos
also, antipsychotics have black box warning
Is vascular dementia typically found separate from AD or with AD?
With AD (often a mixed picture)
What are some subtypes of vascular dementia? (just read)
• Post-stroke Dementia
• Strategic infarct dementia
• CADASIL (cerebral autosomal dominant arteriopathy with
subcortical infarcts and leukoencephalopathy)
• Subclinical vascular brain injury
What is the classic pattern of deterioration seen in vascular dementia?
Step-wise (eg w/each infarct)
- See lesions on MRI
Dementia with Lewy Bodies (DLB) seen in ___% of late‐onset dementias
15-20
What are some s/s of DLB?
how is it different from AD?
- *Parkinsonism
- *Visual hallucinations
- *Severely impaired attention
- *Fluctuations in cognition
- Early falls, presyncopal episodes
- REM behavior disorder
(compared to AD, less impaired memory, cognitive/attention impairments worse)
*What drug should be avoided in treating DLB?
Neuroleptics/antipsychotics (D2 blockade)
- Eg autonomic instability worse
(be careful because can be confused w/delirium, which is treated w/antipsychotics)
How is DLB different from PD w/dementia?
in DLB, get dementia first, then PD sx.
In PD + dementia, get PD sx first, then dementia
Are neuropsych sx more common EARLY in DLB or AD?
DLB (eg hallucinations, delusions early)
What is the age range for onset of Frontotemporal dementia (FTD)?
35‐75 years
What’s another name for FTD?
Pick’s disease
What s/s are seen in FTD?
Does FTD have early or late-onset neuropsych sx?
What other disease can it be a/w?
*Behavioral and/or language disturbances, can be have ALS syndrome
Late
- Can be a/w motor neuron dz
What is Creutzfeldt‐Jakob (Prion) Disease? (s/s?)
- Rapidly progressive dementia
- Often with movement disorder (Parkinsonism, cerebellar signs)
- Neuropsychiatric sx can be prevalent at first, though pattern is variable
What can be seen on MRI in prion dz?
EEG?
MRI: Cortical ribbon, basal ganglia hyperintensity
EEG: typically periodic sharp-wave processes
What are some potential sx of limbic encephalitis?
- Catatonia
- Seizures
- Rapid onset of dementia
- Mutism
- Opthalmoparesis
- Ataxia
What should you check for in limbic encephalitis?
Tx?
- Check for AB’s, get MRI, *look for paraneoplastic
Tx: IV IG, plasmaphoresis, etc.
Review some other causes of neurocognitive decline.
- Huntington’s, Parkinson’s+ Multiple Systems Atrophy,
- OSA and other sleep disorders affect cognition
- Can be mistaken for mood disorders, ADHD
- Infection
- Neurosyphilis
- HIV
- Multiple other infections (SSPE, HCV, Lyme, Whipple’s, etc.)
- Hypo and hyperthyroid
- Rheumatologic disease (SLE, vasculitides, sarcoidosis)
- White Matter Diseases
- Metabolic Disorders
- Toxic exposures
How does DSM-5 define delirium?
A. Disturbance in attention and awareness (to the
environment).
B. Develops quickly (hrs to days), is a change from baseline, and tends to fluctuate in severity
C. An additional disturbance in cognition
D. Not other neurocog d/o or coma
E. Evidence that it is due to a medical condition, intoxication, withdrawal, or multiple etiologies.
What are some of the “core sx” of delirium?
What are the associated sx?
Core • Attentional deficits • Memory impairment • Disorientation • Sleep‐wake cycle disturbance • Thought process abnormalities • Language disturbances • Motor alterations
Associated:
• Perceptual disturbances
• Delusions
• Affective changes
What are the 3 motor categories of delirium?
- Excited/hyperactive
- Lethargic/hypoactive
- Mixed
In delirium, which type of sx are dominant early vs late:
- cognitive
- psych
- Psych sx dominant early
- Cognitive sx dominant later
What’s a mnemonic for the causes of delirium?
VITTAMINSS
• Vascular: stroke, hemorrhage
• Infectious
• Toxic: medications, withdrawal, substances
• Trauma: TBI
• Autoimmune: SLE, Hashimoto’s, limbic encephalitis
• Metabolic: electrolytes (*esp low Na+), LFTs, blood oxygen
• Iatrogenic: medications, surgery, restraints, sleep deprivation, pain
• Neoplastic / paraneoplastic
• Seizure (includes postictal and nonconvulsive)
• Surgery
Does the MMSE differentiate delirium from dementia?
No
What s/s are different b/w delirium and dementias? (read)
Different in delirium vs. dementia: • Sleep‐wake problems • Thought processes • Motor agitation • Attention • Visuospatial Functioning
Does not clearly differentiate delirium and dementia: • Delusions • Affective lability • Motor retardation • Short or long term memory
What are some common prodromal sx in delirium?
- Background slowing on EEG
- Sleep disturbance
- Anxiety
- Calls for assistance
- Disorientation
Why are 1/3-2/3 of delirium cases missed?
- “Expected” to occur
- “Depressed”
- Ignored for more immediate problems
- Lack of screening
What are some r/f’s for delirium?
- Age – elderly (and children?)
- Pre‐existing cognitive impairment
- Medications
- Neurological Insults
- Pain
- Nutrition
- Smoking / nicotine withdrawal
- Perioperative factors
- Genetic factors
What EEG changes are seen with delirium?
What about in DTs?
- Generalized slowing, poor organization of background rhythm, loss of reactivity to eye opening/closing
- Triphasic waves
DTs: Low voltage fast activity
*What are some non-pharm tx’s for delirium?
*TX OF UNDERLYING CAUSE, + ... • Orientation techniques • Familiarizing pt with environment • Natural lighting and diurnal cues • Avoid restraints • Caregiver support and education • Reduce/discontinue unnecessary meds, opiates, anticholinergics, benzos
What is the most often used drug for delirium?
Haldol (but any D2-blocker will work)
What are the routes of administration for Haldol?
Why is it the favorite delirium drug?
What labs must you be careful monitor? (3)
- IV, IM, PO
- No anticholinergic effects
- K+, Mg2+, QTc
In delirium 2/2 acute/subacute TBI, what types of drugs are better than Haldol?
Atypical antipsychotics (not Haldol)
In treating delirium with antipsychotics, there is a possible increase in risk of _______ /_______ in dementia pts.
Stroke/death
What is the first-line tx of delirium in ictal states?
Anticonvulsants (duh)
*What labs should you order in delirium?
- Clin Chem
- CBC
- Mg, Ca, Phos
- LFTs, ammonia
- CXR
- Blood Cultures
- EKG
- TSH/T4
- EEG
- Imaging
- LP
*What labs should you order in dementia?
- Clin Chem
- CBC
- TSH/T4
- LFTs, ammonia
- Folate, B12
- EEG
- CT/MRI, PET?
- Neuropsychological Eval
- ANA
- RF
- RPR
- HIV
- Sleep eval?
A lesion to which side of the brain will cause aphasia vs. hemispatial neglect?
Left: aphasia
Right: neglect
What are some of the consequences of temporal lobe impairments?
- Difficulty with identification of, and verbalization about objects.
- Short-term memory loss/impaired storage
- Difficulty locating objects in environment
What are some of the consequences of parietal lobe impairments?
- Difficulties naming objects (Anomia)
- Inability to focus visual attention
- Difficulty performing math calculations (Dyscalculia)
- Difficulty drawing/constructional apraxia
- Poor visual perception
Medial Temporal Lobe Atrophy is a strong risk-factor for progression to __________.
Dementia
Neuropsychological assessment is broadly defined as____.
A. The application of standardized testing techniques to understand and measure underlying brain behavior relationships.
B. Measuring the impact of psychological adjustment on people with neurologic disease
C. Non-imaging based assessment of structural or evolving lesions of the CNS
D. The assessment of the impact of CNS factors in psychological functioning
A
Which regions of the brain show the most atrophy in AD? (2)
Temporoparietal
All of the following memory functions are typically impaired in mild AD except: A. Episodic memory B. Semantic memory C. Visual memory D. Procedural memory
D
