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Question 1

Physical Changes seen in aging

Answer 1

• GI - decrease gastric empyting, decrease gastric acid secretion, decrease GI blood flow (affects drug absorption)
• Hepatic blood flow is decreased, Phase 1 metabolism reduced (affects metabolism and clearance of drugs)
• Renal - decrease blood flow, decrease GFR (affects T1/2 elimination)
• Brain - white matter volume loss, grey matter volume loss, hippocampal volume loss leading to decline in episodic memory, frontal lobe volume loss

Question 2

Cognitive changes seen in aging

Answer 2

• Decrease in processing speed, decrease in registration, decrease rate of recall, decrease in working/immediate memory
• Memory of factual information, general work knowledge grammar, and language are generally well preserved with aging.
• Procedural memory less affected by age

Question 3

Delirium

Answer 3

• Disturbance of attention (reduced ability to direct, focus, sustain, and shift attention) and awareness (reduce oritentation to the environment).
• Develops over short period of time (hours to days), represents a change from baseline, and fluctuates in severity during the course of the day
• Changes in cognition
• It is not due another neurocognitive disorder or in context of coma
• Evidence that it is caused by physiological consequences of medical condition

Question 4

Clinical Variants of Delirium

Answer 4

• Acute (lasting a few hours or days) vs. persistant (lasting week or months)
• Hyperactive
  
  • Increase psychomotor activity
  • Agitation
  • More porminent in younger people
• Hypoactive
  
  • Psychmotor activity decreased
  • Common in olrder patients
• Mixed

Question 5

Differential Diagnosis Delirium

Answer 5

• Delirium may be confused with number of disorders, but the primary differential diagnosis are dementia, depression, and drugs.

Question 6

Etiology of delirium

Answer 6

• Infections
• Withdrawal
• Acute metabolic
• Trauma
• CNS pathology
• Hypoxia
• Deficiencies
• Endocrinopathies
• Acute vascular
• Toxins or durgs
• Heavy metals

Question 7

CAM

Answer 7

• Must have one and two
  
  • 1. Acute onset or fluctuations in course
  • 2. Inattention
• Can have either of 3 or 4
  
  • 3. Disorganized thinking
  • 4. Altered level of consciouness

Question 8

Baseline laboratory investigations delirum

Answer 8

• CBC with differential
• Electrolytes
• Renal functions
• Liver functions
• Glucose
• Calcium
• Phosphate
• Urinalysis
• ECG
• Chest xray if indicated
• EEG

Question 9

Management Delirium

Answer 9

• First, important to try and identify the underlying cause and treat it.
• Provide proper hydration and oxygenation
• Reduce, taper, and/or discontinue as many of the patients medications as possible
• Non-pharm management - well lit room and use of night lights; avoid excessive stimulation; clock and calender in the room; make effort to orient patient to time and place frequently
• Pharm management - avoid physical restraints; use lowerest possible dose of psychotropics, and if used try to discontinue as soon as possible (especially if its an antipsychotic); avoid anticholingeric meds; dont use benzo unless patient is in withdrawal
  
  • Haloperidol 1-2mg PO or 0.5-1mg IM max 2-4mg a day in the elderly

Question 10

Major Neurocognitive Disorder

Answer 10

• A criteria
  
  • Significant cognitive decline from a previous level of functioning in one or more of the following cognitive domains
    
    • Complex attention, executive function, learning and memory, language, perceptual motor, social cognition
• B criteria
  
  • Cognitive deficits interfere with independence in daily living
• C criteria
  
  • Not due to a delirium
• D criteria
  
  • Cognitive deficits are not better explained by another mental disorder

Question 11

Specifiers for Neurocognitive disorders

Answer 11

• Alzheimer’s disease
• Frontotemproral lobar degeneration
• Lewy body disease
• vascular disease
• traumatic brain injury
• substance/medication use
• HIV infection
• Prion disease
• Parkinson’s disease
• Huntington’s disease
• another medical condition
• Multiple etiologies

Question 12

Differential Diagnosis Dementia

Answer 12

• Delirium
• Depression
• Drugs
• Benign senescent forgetfulness
• Amnestic disorder
• Major depressive disorder
• Mental retardation
• Schizophrenia
• Factitious disorder
• Malingering

Question 13

Benign Senescent Forgetfulness

Answer 13

• Age related memory loss
• Due to slowing of neural processes
• New information can be learned
• Previously learned information is recalled more slowly
• Functioning remaining unaffected

Question 14

Alzheimer’s Disease

Answer 14

• Exact cause still unknown
• Hallmarks of the disease
  
  • Amyloid plaques
  • Neurofibrillary tangles - composed on highly phosphorylated and aggregated tau protein (destabilizes cells as causes it die off)
• Brain cells shrink
• A decrease in brain size
• A decrease in brain chemicals
• Amyloid hypothesis - amyloid precursor protein + beta and gamma secretases producing beta amyloid (congrates into plaques that become neurotoxic).

Question 15

Alzheimer’s Disease symptoms

Answer 15

• Disease process begins slowly
• Memory loss
• Aphasia - language problems
• Agnosia - problems with identifying and recognizing things
• Apraxia - problems with activities and coordination
• Executive functioning issues

Question 16

Treatment Alzheimers Disease

Answer 16

• Symptomatic treatment is currently based on cholinergic hypothesis - i.e., cognitive failure derives from a reduction in brain acetylcholine activity due to loss of cholinergic neurons in the brain
• Medications
  
  • Acetylcholinesterase inhibitors - prevents breakdown of acetylcholine
  • Donepzil - central AchEI
  • Rivastigime - pseudo-irreversible AChEI and BChEI
  • Galantamine - competitve reversible AChEI and nicotonic receptor modulator (enhances cholinergic transmission)
• Caution - cardiac conduction defects; history of GI bleeds, active peptic ulceration; asthma

Question 17

Vascular Dementia

Answer 17

• Symptoms usually occur quicky and progress in a step-wise pattern.
• Presentaation depends on what area of the brain is affected
  
  • Confusion/memory loss
  • Abnormal movements/gait/coordination
  • Language problems
  • Inappropriate emotions
• Risk factors for stroke - high BP, diabetes, high cholesterol, coronary artery disease, arrhythmia, smoking and EtoH abuse

Question 18

Lewy Body Dementia

Answer 18

• Abnormal deposits in the brain
• Marked deficit of choline acetyltransferase
• Characterized by dementia, fluctuating cognition, recurrent visual hallucinations, parkinsonism.

Question 19

Frontotemperal Dementia

Answer 19

• Dorsolateral - executive dysfunction
• Orbitofrontal - hyperactive behaviours, utilization behaviours
• Medial/anterior cingulate - apathy
• I - insight loss
• P - personal conduct or language impairment
• O -onset insidious and progression gradual
• S - social conduct decline
• E - emotional blunting

Question 20

Types of frontotemperal dementia

Answer 20

• Progressive non-fluent aphasia (PNA) - expressive language deficits seen first. Comprehension is initially spared.
• Semantic dementia (SD) - receptive lanugage deficits seen first. Understanding and meaning of words are lost, comprehension is a problem, repetition is initially spared.