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Psychiatry Clerkship > Neuropsychiatry > Flashcards

Neuropsychiatry Flashcards

1
Q

DSM-5 Diagnostic Criteria of a Major Neurocognitive Disorder?

A

A - evidence of significant cognitive decline from a previous level of performance in 1+ cognitive domains (complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition) based on 1. Concern of the individual, a knowledgeable informant, or the clinician that there has been a significant decline in cognitive function and 2. Substantial impairment in cognitive performance, preferably documented by standardized neuropsychological testing or, in its absence, another quantified clinical assessment
B - deficits interfere with independence in everyday activities
C - deficits do not occur exclusively in the context of a delirium
D - cognitive deficits are not better explained by another mental disorder

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2
Q

Specified etiologies of major neurocognitive disorder?

A 
Alzheimer's disease
Frontotemporal lobar degeneration
Lewy body disease
Vascular disease
TBI
Substance/medication use
HIV
Prion disease
Parkinson's disease
Huntington's disease
Another medical condition
Multiple etiologies
Unspecified
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3
Q

DSM-5 Diagnostic Criteria of a Minor Neurocognitive Disorder?

A

A - evidence of MODEST cognitive decline from a previous level of performance in 1+ cognitive domains (complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition) based on 1. Concern of the individual, a knowledgeable informant, or the clinician that there has been a significant decline in cognitive function and 2. MODEST impairment in cognitive performance, preferably documented by standardized neuropsychological testing or, in its absence, another quantified clinical assessment
B - deficits DO NOT INTERFERE with independence in everyday activities
C - deficits do not occur exclusively in the context of a delirium
D - cognitive deficits are not better explained by another mental disorder

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4
Q

List 4 changes to memory and other neuropsychological function that is a part of normal aging.

A
  1. Mild, relative memory impairment (forgetfulness of people’s names, delayed recall of newly-learned lists)
  2. Shortened attention span
  3. Slowed learning
  4. Decreased ability to perform complex tasks
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5
Q

List 7 changes to memory and other neuropsychological function that are NOT a part of normal aging.

A
  1. Vocabulary
  2. Language ability
  3. Reading comprehension
  4. Fund of knowledge
  5. Social deportment
  6. Political and religious beliefs
  7. IQ
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6
Q

Changes to sleep as part of normal aging?

A

Fragmented, less stage 4, phase-advanced

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7
Q

Changes to muscles, reflexes, gait, senses as part of normal aging?

A

Less muscle mass
Decreased DTRs
“Senile gait”
Sensory deterioration

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8
Q

List 10 general categories of dementias (+ additional DDx)

A
  1. Neurodegenerative
  2. Vascular
  3. Hydrocephalus
  4. Traumatic
  5. Neoplastic
  6. Infectious
  7. AI
  8. Demyelinating
  9. Substances
  10. Metabolic

Other - sleep (OSA, sleep disorders affect cognition, can be mistaken for neurocognitive disorder), thyroid and other endocrine conditions, vasculitis, sarcoidosis

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9
Q

List 7 Neurodegenerative dementias.

A
  1. Alzheimer’s disease
  2. Frontotemporal dementia (and its subtypes)
  3. Lewy body dementia and Parkinson’s disease dementia
  4. Parkinson syndromes and multiple system atrophy
  5. Corticobasal degeneration
  6. Wilson’s disease
  7. White matter disease
  8. Huntington’s
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10
Q

List 4 Vascular dementias.

A
  1. Post-stroke dementia
  2. CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy)
  3. Strategic infarct dementia
  4. Subclinical vascular brain injury
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11
Q

List 2 causes of hydrocephalus dementia.

A
  1. NPH

2. Obstructive

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12
Q

List 2 causes of traumatic dementia.

A
  1. Subdural hematoma

2. TBI

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13
Q

List 2 neoplastic causes of dementia.

A
  1. Brain tumor

2. Paraneoplastic

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14
Q

List 3 infectious causes of dementia.

A
  1. Syphilis
  2. HIV
  3. Encephalitides (and many more)
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15
Q

List 1 cause of AI dementia.

A

SLE

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16
Q

Alzheimer’s Disease accounts for ___% of dementias in older individuals. ___% of patients with AD are 65 years or older.

A

60-70; 90

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17
Q

Clinical features of Alzheimer Disease?

A

Difficulty encoding new material
Changes in language, visuospatial, executive/social functioning with disease progression
Progressive retrograde memory loss

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18
Q

DSM5 criteria for Alzheimer’s Disease?

A

A - criteria met for major or mild neurocognitive disorder
B - insidious onset and gradual progression of impairment in 1+ cognitive domains (for major, at least 2 must be impaired)
C - criteria are met for either probable or possible AD as follows
-For Major Neurocognitive Disorder: probable if either 1. Evidence of causative genetic mutation from family history or genetic testing
2. Clear evidence of a decline in memory and learning and at least 1 other cognitive domain + steadily progressive, gradual decline in cognition, without extended plateaus + no evidence of mixed etiology
-Possible otherwise
D - Cognitive deficits cause significant impairment in functioning and represent a significant decline from a previous level
E. Gradual onset and continuing cognitive decline
F. Cognitive deficits not due to other CNS conditions that cause progressive deficits in memory or cognition, systemic conditions known to cause dementia, or substance-induced conditions
G. Deficits do not occur exclusively during the course of a delirium
H. Disturbance is not better accounted for by another Axis I disorder

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19
Q

Early cognitive features of AD?

A
  • Deficient verbal and visual encoding
  • Impaired delayed recall
  • Concrete thinking
  • Mild anomia (difficulty naming objects)
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20
Q

Early neuropsychiatric features of AD?

A

-Apathy (up to 3 years prior to dx)
-Depressed mood (can predate cognitive decline by 10 years)
-Anxiety (apprehension, inner nervousness)
Irritability (4.6% in normal elderly, 42% in AD)

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21
Q

Later cognitive features of AD?

A
  • Transcortical sensory aphasia (similar to Wernicke’s, but with intact repetition)
  • Decline in IADLs, then ADLs
  • Appetite loss
  • Sleep-wake cycle disturbance
  • Immobilization
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22
Q

Later neuropsychiatric features of AD?

A
  • Disinhibition
  • Aberrant motor behaviors
  • Hallucinations
  • Delusions
  • Agitation
  • Aggression
  • Psychosis (common, delusional themes of paranoia, theft, infidelity, misidentification syndromes)
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23
Q

List medication treatment options for AD.

A
  1. Acetylcholinesterase inhibitors
  2. Memantine
  3. Treat symptoms
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24
Q

List 3 acetylcholinesterase inhibitors + MOA.

A
  1. Donepezil
  2. Galantamine
  3. Rivastigmine

Increase availability of ACh at synaptic cleft (involved in memory systems)

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25
Q

MOA of memantine?

A

Weak NMDA receptor blocker, prevents deleterious effects of continuous toxic levels of glutamate, while allowing large glutamate surges to exert required cognitive effect

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26
Q

Treatment of depression and anxiety in AD?

A
  • SSRIs (especially citalopram, sertraline, escitalopram, AVOID paroxetine)
  • Avoid benzos (cognitive issues, falls)
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27
Q

Treatment of agitation/aggression in AD?

A
  • Environmental management
  • SSRIs
  • Antipsychotics
  • Occasionally mood stabilizers?
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28
Q

Treatment of psychosis in AD?

A

Typically risperidone, quetiapine
Next - olanzapine, aripiprazole
Increased risk of stroke, death with antipsychotics

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29
Q

Treatment of sleep issues in AD?

A

Limited data for trazodone, quetiapine, mirtazapine, risperidone, zolpidem, olanzapine

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30
Q

What other dementia is often comorbid with AD and presents with a mixed picture?

A

Vascular dementia

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31
Q

Classic clinical presentation of vascular dementia?

A

Step-wise deterioration (with plateaus), often with some focal neurological signs

MRI with clear lesions

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32
Q

Cause of 15-20% of late-onset dementias?

A

Dementia with Lewy bodies

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33
Q

Clinical features of Dementia with Lewy Bodies?

A
  • Severely impaired attention, visuospatial, and visuoperceptual abilities
  • Less memory impairment
  • Cognitive fluctuations much worse
  • Parkinsonism
  • Early falls, presyncopal episodes
  • REM behavior disorder (no paralysis, act our dreams)
  • Sensitivity to neuroleptics
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34
Q

Neuropsychiatric symptoms of Dementia with Lewy Bodies?

A
  • Present earlier than neuropsychiatric symptoms in AD
  • Hallucinations - visual, complex, detailed, brightly colored 3D people and animals; can also be other domains
  • Depression
  • Delusions
  • Anxiety
35
Q

List the types of frontotemporal dementia.

A
  1. Behavioral variant (bvFTD)
  2. Primary Progressive Aphasia (PPA)
    a. Semantic Dementia
    b. Logopenic
    c. Non-fluent
36
Q

Clinical features of frontotemporal dementia?

A
  • Behavioral and/or language disturbances
  • Focal atrophy of frontal and/or temporal lobes
  • Age of onset between 35-75 years
  • Can be associated with late-onset psychiatric symptoms as well as motor neuron disease
37
Q

Clinical features of prion/Creutzfeldt-Jakob disease?

A
  • Rapidly progressive dementia
  • Often with a movement disorder (parkinsonism, cerebellar signs)
  • Neuropsychiatric symptoms can be prevalent at first, though pattern is variable
38
Q

MRI, EEG findings of prion/Creutzfeldt-Jakob disease?

A

MRI: cortical ribbon, basal ganglia hyperintensity
EEG: typically periodic sharp wave complexes

39
Q

DSM-5 Diagnostic Criteria for Delirium?

A

A - disturbance in attention and awareness
B - develops over a short period of time (usually hours to a few days), represents an acute change from baseline attention and awareness, and tends to fluctuate in severity during the course of the day.
C - additional disturbance in cognition
D - A and C not better explained by a pre-existing, established, or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal such as a coma
E. Evidence from H&P or labs that the disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal, or exposure to a toxin, or is due to multiple etiologies.

40
Q

List 7 core symptoms of delirium.

A 
Attentional deficits
Memory impairments
Disorientation
Sleep-wake cycle disturbance
Thought process abnormalities
Language disturbances
Motor alterations (excited/hyperactive, lethargic/hypoactive, mixed)

Neuropsychiatric symptoms dominate early, cognitive symptoms are later

Symptoms fluctuate over 24 hours

41
Q

List 3 non-core/associated symptoms of delirium.

A

Perceptual disturbances
Delusions
Affective changes

42
Q

Etiologies of Delirium?

A

VITAMINS

Vascular - stroke, hemorrhage
Infectious - urinary, pneumonia, meningitis, sepsis, encephalitis
Toxic - intoxication/OD, withdrawal (alcohol, benzos, barbiturates, heroin), medications
Trauma - TBI/concussion
AI - SLE, Hashimoto, limbic encephalitis
Metabolic - electrolytes, LFTs, blood oxygen, endocrine (thyroid, cortisol, glucose), uremic encephalopathy, vitamin deficiencies (B12, thiamine), malnutrition (albumin <2), dehydration
Iatrogenic - medications, surgery, restraints, sleep deprivation, pain, urinary catheters, multiple procedures
Neoplastic/paraneoplastic
Seizure - includes post-ictal and non-convulsive
Structural: hydrocephalus
Surgery

43
Q

True or false - MMSE differentiates delirium from dementia.

A

FALSE - MMSE does NOT differentiate delirium from dementia. Use a Dementia Rating Scale or CAM-ICU

44
Q

Features that are different in delirium and dementia?

A
  • Sleep-wake problems
  • Thought processes
  • Motor agitation
  • Attention
  • Visuospatial functioning
45
Q

Features that do not clearly differentiate delirium and dementia?

A
  • Delusions
  • Affective lability
  • Motor retardation
  • Short or long term memory
46
Q

Common prodromal symptoms of delirium?

A
  • Background slowing on EEG
  • Sleep disturbance
  • Anxiety
  • Calls for assistance
  • Disorientation
47
Q

Prevalence of delirium in hospitalized patients?

A

5-44%

Up to 90% in cancer, MICU, post-cardiac surgery
Only 4% with complete resolution at discharge

48
Q

List 9 risk factors for delirium.

A 
Age (elderly)
Pre-existing cognitive impairment
Medications
Neurological insults
Pain
Nutrition
Smoking/nicotine withdrawal
Perioperative factors
Genetic factors
49
Q

EEG findings in delirium?

A

Generalized slowing
Poor organization of background rhythm
Loss of reactivity to eye opening/closing
Triphasic waves (sometimes, especially hepatic encephalopathy, sepsis)

50
Q

EEG findings in DT?

A

Low voltage fast activity

51
Q

Treatment of delirium?

A
  • Rapid treatment of underyling cause
  • Prevention (limited evidence)
  • Non-pharmacologic treatments: orientation, familiarizing patients with environment, natural lighting and diurnal cues, avoid restraints, caregiver support/education, reduce/DC unnecessary medications, opiates, anticholinergics, benzos
  • Medications
52
Q

Medications used to treat delirium?

A
  1. Dopamine D2 antagonists/antipsychotics
    - Haloperidol - most often used/studied (IV/IM/PO, no anticholinergic effects, monitor K, Mg, QTc)
    - Atypicals
  2. Benzos
    - Reserved for EtOH/sedative withdrawal
  3. Anticonvulsants
    - First line in ictal states
53
Q

Labs for evaluation of delirium vs. dementia?

A

Both: CMP, CBC, LFTs, ammonia, TSH/T4, EEG, imaging

Delirium - Mg/Ca/Phos, CXR, blood cultures, EKG, LP

Dementia - folate/B12, neuropsych eval, ANA, RF, RPR, HIV, sleep evaluation?

54
Q

What Rx is contraindicated in DLB?

A

Antipsychotics

55
Q

List the 6 neurocognitive domains tested in neuropsych testing.

A
  1. Attention/concentration
  2. New learning/memory (verbal and visual)
  3. Speech/language (word reading/vocabulary, math computation)
  4. Visuo-spatial/visuo-construction
  5. Executive functions (reasoning, problem-solving, mental flexibility)
  6. Mood/affect/behavior
56
Q

What clinical features of AD can be localized to the temporal lobe?

A
  • Difficulty with identification of, and verbalization about, objects
  • Short-term memory loss/impaired storage
  • Difficulty locating objects in the environment
57
Q

What clinical features of AD can be localized to the parietal lobe?

A
  • Anomia
  • Inability to focus visual attention
  • Dyscalculia
  • Difficulty drawing/constructional apraxia
  • Poor visual percetpion
58
Q

What MRI finding is a strong risk-factor for progression to dementia?

A

Medial Temporal Lobe Atrophy

59
Q

Approximately ___% of patients with amnestic MCI (mild cognitive impairment) will convert to AD within 6 years.

A

80

60
Q

Types of mild neurocognitive impairment?

A
  1. Amnestic
  2. Executive Functioning
  3. Multiple domains
61
Q

When neuropsychiatric symptoms are present in patients with MNI, the risk of developing dementia is higher with quicker progression and poorer prognosis. List # of these symptoms.

A
  1. First time onset of depression or anxiety in older age
  2. Agitation
  3. Apathy/aspontaneity
  4. Delusoins
  5. Emotional lability
  6. Lack of empathy
  7. Loss of social tact
  8. Oral/dietary changes
  9. Sleeping disorders
62
Q

Performance pattern of neuropsych testing seen in AD?

A
  1. Memory - both recall and new memory formation are affected early, causing an amnesia
  2. Aphasia - difficulties with word meaning, reading expression, word finding, and object meaning, occurs fairly early
  3. Attention and visuospatial problems are quite common

Personality and behavior are well-preserved until later stages; behavioral signs such as aggression, PMA, psychosis can be common later. Problem-solving skills are initially preserved. Neurological exam is normal.

63
Q

Vascular Dementia commonly disrupts what parts of the brain?

A

Deep frontal white matter, frontal-subcortical circuitry, basal ganglia, and the thalamus

64
Q

Biological risk factors for VaD?

A

HTN, HLD, Cardiac disease, CHF, CABG
DM
OSA
TIA/stroke

65
Q

Compare AD vs. VaD.

A

AD:

  1. Cortical dementia
  2. Processing speed okay
  3. Amnestic/storage problems - prominent early on
  4. Organized but forgetful
  5. Written math impaired
  6. Impaired speech language
  7. Appears healthy
  8. N/A
  9. Less common to have a history of atherosclerotic disease
  10. Gradual onset with slow, progressive decline
  11. Normal neuro exam, gait usually normal
  12. Executive function impaired later on
  13. Imaging - normal or hippocampal atrophy

VaD:

  1. Frontal-subcortical dementia
  2. Processing speed slow
  3. Memory retrieval problems - mild early on
  4. Decreased organization/problem-solving/mental flexibility
  5. Written math preserved
  6. No speech/language problems
  7. Falls/weakness/tremors
  8. Micrographia
  9. Hx of atherosclerotic disease (TIA, strokes, DM, HTN, etc.)
  10. Sudden or gradual onset with slow or stepwise progression
  11. Neuro deficits, gait often disturbed early
  12. Executive function markedly impaired early on
  13. Imaging - infarction or white matter lesions
66
Q

When should a patient be referred for a memory evaluation?

A
  1. Impaired or borderline mental status testing
  2. MMSE in an individual with cognitive concerns
  3. Changes in personality or functioning at home or work
  4. Late onset depression/anxiety with cognitive complains
  5. Lack of treatment efficacy
  6. Safety
67
Q

Neuropsychological assessment is broadly defined as what?

A

The application of standardized testing techniques to understand and measure underlying brain behavior relationships

68
Q

Which regions of the brain show the most atrophy in AD?

A

Temporoparietal

69
Q

All of the following memory functions are typically impaired in mild AD except:

  • Episodic
  • Semantic
  • Visual
  • Procedural
A

Procedural

70
Q

Annual incidence of AD after age 65?

A

1-2%

71
Q

Prevalence of AD at ages 65, 75, and 85?

A

65: 5-7%
75: 15-20%
85: 25-50%

72
Q

What is the single most important risk factor for AD?

A

Age

73
Q

Other risk factors for AD?

A
  • Family history (up to 40%)

- Sex (F>M)

74
Q

Major known genetic risk factor for AD?

A

APOE E4 allele

75
Q

What percent of AD are early onset (<65 years?)

A

5-10%

76
Q

Compare dementia and pseudodementia.

A

Dementia:

  • Insidious onset
  • Increased effort, decreased complaints
  • Deficits > distress
  • Sundowning
  • Guesses liberally
  • Remote memory okay, recent memory decreased
  • Consistent profile

Pseudodementia:

  • Abrupt onset
  • Decreased effort, increase complaints
  • Distress > deficits
  • No sundowning
  • Says “I don’t know” when asked questions
  • Both remote and recent memory affected
  • Inconsistent pattern of memory problems
77
Q

Rx - pseudodementia?

A

SSRIs

78
Q

Idiopathic Parkinson’s disease vs. Parkinsonism?

A

Parkinsonism - broader clinical phenotype of bradykinesia and rigidity with or without substantial tremor

Non-idiopathic causes include multiple subcortical infarcts, viral encephalitis, trauma, toxicity, neuroleptics

79
Q

Compare Lewy Body vs. AD.

A

AD:

  1. Isolated memory impairment - 31.3%
  2. Parkinsonism less common and usually develops later
  3. Psychiatric symptoms less likely
  4. Fluctuation of cognitive function only when delirious
  5. Verbal memory is worse
  6. Episodic memory impaired
  7. Executive function less severe early on
  8. Less impairment in attention/visuospatial function/constructional abilities
  9. Visual halluciantions less prominent in early course
  10. Less common to have autonomic involvement
  11. Behavioral response to antipsychotics

DLB:

  1. Isolated memory impairment in 93.8%
  2. Parkinsonism more common
  3. Psychiatric symptoms more likely to occur with dementia symptoms early in the course
  4. Fluctuation of cognitive function in 50-70%
  5. Verbal memory is better
  6. Semantic memory impairment
  7. Executive function poor early on
  8. More impairment in attention/visuospatial function/constructional abilities
  9. Visual hallucinations common early
  10. Autonomic involvement common
  11. Antipsychotic use leads to EPS, mortality
80
Q

DLB vs. Parkinson’s (compare tremor, motor symptoms, axial predominance, parkinsonism at dx, response to levodopa, cognitive impairment)

A

DLB:

  1. Tremor less common
  2. Motor symptoms bilateral
  3. Common to have axial predominant (postural instability, gait difficulty, masked face)
  4. 25-50% have parkinsonism at dementia dx
  5. Poor response to levodopa
  6. Cognitive impairment before or within 1 year of motor symptoms

PD:

  1. Tremor common
  2. Unilateral motor symptoms predominant
  3. Less common to have axial predominant
  4. 100% have parkinsonism at dementia dx
  5. Good response to levodopa
  6. Usually develop cognitive impairment after motor symptoms for 4-5 years
81
Q

Frontotemporal vs. AD?

A

Frontotemporal:

  1. Rarely >75 years old
  2. Behavioral problems common early in course
  3. Less prominent memory impairment in early course
  4. May have isolated language problems without memory impairment (in progressive nonfluent aphasia type)
  5. Visuospatial defect rare
  6. Motor signs more common
  7. Marked irritability, anhedonia, euphoria, withdrawal, alexithymia, lack of guilt, apathy, SI
  8. Psychotic features (rare persecutory delusions, usually jealous, somatic, religious, and bizarre)
  9. Increased appetite and weight gain

AD:

  1. Increases markedly with age
  2. Behavioral problems unusual early in course
  3. Early and profound memory impairment
  4. Language problems associated with memory impairment
  5. Common visuospatial defects
  6. Motor signs less common
  7. Sadness, tears, anhedonia, apathy, guilt
  8. Usually delusion of misidentification or persecutory type, usually in middle or late stage
  9. Anorexia and weight loss
82
Q

What is decisional capacity?

A

The ability to make decisions

83
Q

4 components of capacity?

A
  1. Ability to understand the pertinent medical information including treatment options and diagnosis
  2. Ability to appreciate one’s situation and potential outcomes or consequences
  3. Ability to arrive at a decision through reasoning
  4. Ability to communicate a choice

Psychiatry Clerkship (8 decks)

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