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Psychiatry > Neuropsychiatry > Flashcards

Neuropsychiatry Flashcards

1
Q

What is the DSM-5 name for dementia?

A

Major Neurocognitive Disorder

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2
Q

Generally, how is MAJOR Neurocognitive Disorder defined/diagnosed?

A
  • 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
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3
Q

What are some “cognitive domains” that can decline in Neurocognitive disorder?

A
  • Complex attention
  • Executive function
  • Learning and memory
  • Language
  • Perceptual‐motor
  • Social cognition
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4
Q

Generally, how is MINOR Neurocognitive Disorder defined/diagnosed?

A

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

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5
Q

In normal aging, what types of cognitive functions decline?

Which stay the same?

A 
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

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6
Q

How does sleep change with age?

A
  • Becomes fragmented

- Less stage 4, phase‐advanced

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7
Q

How much does brain weight decrease with age?

Which brain lobes are first affected by aging?

A

85% of previous

Frontal and temporal lobes

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8
Q

What types of neurons are lost during aging?

What materials can build up?

A
  • Loss of large cortical neurons
  • Loss of neurons in some brainstem and deep structures

Senile amyloid plaques, neurofibrillary tangles (limited number), Lipofuscin granules

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9
Q

What’s another name for Minor Neurocognitive Disorder?

A

Mild Cognitive Impairment (MCI)

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10
Q

What % of mild cognitive impairment patients have psych sx?

A

43-59%
(Dysphoria, apathy, irritability, anxiety)

  • Cortical and hippocampal atrophy are common
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11
Q

What % of dementias in the elderly does Alzheimer’s Disease (AD) account for?

A

60-70%

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12
Q

90% of patients with AD are __ years or older.

A

65

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13
Q

What are the main cognitive changes in AD?

Is it gradual or rapid?

A
  • 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
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14
Q

How does DSM-5 diagnose AD?

A

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.)

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15
Q

What are some cognitive and psych sx of early AD? (just read)

A

Cognitive

  • Deficient verbal and visual encoding
  • Impaired delayed recall
  • Concrete thinking
  • Mild anomia

Psych

  • Apathy
  • Depression (can predate dx by 10 years)
  • Anxiety
  • Irritability
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16
Q

What are some cognitive and psych sx of later AD? (just read)

A

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)
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17
Q

What are the pharm tx options for AD?

A
  • Acetylcholinesterase inhibitors: donepezil, galantamine, rivastigmine
  • Memantine
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18
Q

Trade name for donepezel?

A

Aricept

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19
Q

Trade name for galantamine?

A

Razadyne

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20
Q

Trade name for rivastigmine?

A

Exelon

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21
Q

Trade name for memantine?

A

Namenda

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22
Q

How do AChE-inhibitors work to help AD?

A

Increase availability of acetylcholine at synaptic cleft
• First and most prevalent areas involved in AD
• Memory systems

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23
Q

What is the MoA of memantine (Namenda) in treating AD?

A
  • 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
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24
Q

What med should you avoid to treat depression/anxiety in AD?

A

Benzos

also, antipsychotics have black box warning

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25
Q

Is vascular dementia typically found separate from AD or with AD?

A

With AD (often a mixed picture)

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26
Q

What are some subtypes of vascular dementia? (just read)

A

• Post-stroke Dementia
• Strategic infarct dementia
• CADASIL (cerebral autosomal dominant arteriopathy with
subcortical infarcts and leukoencephalopathy)
• Subclinical vascular brain injury

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27
Q

What is the classic pattern of deterioration seen in vascular dementia?

A

Step-wise (eg w/each infarct)

  • See lesions on MRI
28
Q

Dementia with Lewy Bodies (DLB) seen in ___% of late‐onset dementias

A

15-20

29
Q

What are some s/s of DLB?

how is it different from AD?

A
  • *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)

30
Q

*What drug should be avoided in treating DLB?

A

Neuroleptics/antipsychotics (D2 blockade)
- Eg autonomic instability worse

(be careful because can be confused w/delirium, which is treated w/antipsychotics)

31
Q

How is DLB different from PD w/dementia?

A

in DLB, get dementia first, then PD sx.

In PD + dementia, get PD sx first, then dementia

32
Q

Are neuropsych sx more common EARLY in DLB or AD?

A

DLB (eg hallucinations, delusions early)

33
Q

What is the age range for onset of Frontotemporal dementia (FTD)?

A

35‐75 years

34
Q

What’s another name for FTD?

A

Pick’s disease

35
Q

What s/s are seen in FTD?

Does FTD have early or late-onset neuropsych sx?

What other disease can it be a/w?

A

*Behavioral and/or language disturbances, can be have ALS syndrome

Late

  • Can be a/w motor neuron dz
36
Q

What is Creutzfeldt‐Jakob (Prion) Disease? (s/s?)

A
  • Rapidly progressive dementia
  • Often with movement disorder (Parkinsonism, cerebellar signs)
  • Neuropsychiatric sx can be prevalent at first, though pattern is variable
37
Q

What can be seen on MRI in prion dz?

EEG?

A

MRI: Cortical ribbon, basal ganglia hyperintensity

EEG: typically periodic sharp-wave processes

38
Q

What are some potential sx of limbic encephalitis?

A
  • Catatonia
  • Seizures
  • Rapid onset of dementia
  • Mutism
  • Opthalmoparesis
  • Ataxia
39
Q

What should you check for in limbic encephalitis?

Tx?

A
  • Check for AB’s, get MRI, *look for paraneoplastic

Tx: IV IG, plasmaphoresis, etc.

40
Q

Review some other causes of neurocognitive decline.

A
  • 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
41
Q

How does DSM-5 define delirium?

A

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.

42
Q

What are some of the “core sx” of delirium?

What are the associated sx?

A 
Core
• Attentional deficits
• Memory impairment
• Disorientation
• Sleep‐wake cycle disturbance
• Thought process abnormalities
• Language disturbances
• Motor alterations

Associated:
• Perceptual disturbances
• Delusions
• Affective changes

43
Q

What are the 3 motor categories of delirium?

A
  • Excited/hyperactive
  • Lethargic/hypoactive
  • Mixed
44
Q

In delirium, which type of sx are dominant early vs late:

  • cognitive
  • psych
A
  • Psych sx dominant early

- Cognitive sx dominant later

45
Q

What’s a mnemonic for the causes of delirium?

A

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

46
Q

Does the MMSE differentiate delirium from dementia?

A

No

47
Q

What s/s are different b/w delirium and dementias? (read)

A 
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
48
Q

What are some common prodromal sx in delirium?

A
  • Background slowing on EEG
  • Sleep disturbance
  • Anxiety
  • Calls for assistance
  • Disorientation
49
Q

Why are 1/3-2/3 of delirium cases missed?

A
  • “Expected” to occur
  • “Depressed”
  • Ignored for more immediate problems
  • Lack of screening
50
Q

What are some r/f’s for delirium?

A
  • Age – elderly (and children?)
  • Pre‐existing cognitive impairment
  • Medications
  • Neurological Insults
  • Pain
  • Nutrition
  • Smoking / nicotine withdrawal
  • Perioperative factors
  • Genetic factors
51
Q

What EEG changes are seen with delirium?

What about in DTs?

A
  • Generalized slowing, poor organization of background rhythm, loss of reactivity to eye opening/closing
  • Triphasic waves

DTs: Low voltage fast activity

52
Q

*What are some non-pharm tx’s for delirium?

A 
*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
53
Q

What is the most often used drug for delirium?

A

Haldol (but any D2-blocker will work)

54
Q

What are the routes of administration for Haldol?

Why is it the favorite delirium drug?

What labs must you be careful monitor? (3)

A
  • IV, IM, PO
  • No anticholinergic effects
  • K+, Mg2+, QTc
55
Q

In delirium 2/2 acute/subacute TBI, what types of drugs are better than Haldol?

A

Atypical antipsychotics (not Haldol)

56
Q

In treating delirium with antipsychotics, there is a possible increase in risk of _______ /_______ in dementia pts.

A

Stroke/death

57
Q

What is the first-line tx of delirium in ictal states?

A

Anticonvulsants (duh)

58
Q

*What labs should you order in delirium?

A
  • Clin Chem
  • CBC
  • Mg, Ca, Phos
  • LFTs, ammonia
  • CXR
  • Blood Cultures
  • EKG
  • TSH/T4
  • EEG
  • Imaging
  • LP
59
Q

*What labs should you order in dementia?

A
  • Clin Chem
  • CBC
  • TSH/T4
  • LFTs, ammonia
  • Folate, B12
  • EEG
  • CT/MRI, PET?
  • Neuropsychological Eval
  • ANA
  • RF
  • RPR
  • HIV
  • Sleep eval?
60
Q

A lesion to which side of the brain will cause aphasia vs. hemispatial neglect?

A

Left: aphasia
Right: neglect

61
Q

What are some of the consequences of temporal lobe impairments?

A
  • Difficulty with identification of, and verbalization about objects.
  • Short-term memory loss/impaired storage
  • Difficulty locating objects in environment
62
Q

What are some of the consequences of parietal lobe impairments?

A
  • Difficulties naming objects (Anomia)
  • Inability to focus visual attention
  • Difficulty performing math calculations (Dyscalculia)
  • Difficulty drawing/constructional apraxia
  • Poor visual perception
63
Q

Medial Temporal Lobe Atrophy is a strong risk-factor for progression to __________.

A

Dementia

64
Q

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

A

65
Q

Which regions of the brain show the most atrophy in AD? (2)

A

Temporoparietal

66
Q 
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
A

D

Psychiatry (16 decks)

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