Progressive Cog Disorders

Question 1

what normally happens to cognition as we age?

Answer 1

disturbances in ability to register, retain, and recall certain recent experiences

1. slowed rate of learning new material
2. slowed motor learning capabilities
3. slowed motor performance on tasks that require speed

Question 2

List 10 early warning signs of abnormal cognitive decline

Answer 2

1. impaired immediate/short-term memory, repeats self frequently
2. difficulty doing familiar but difficult tasks
3. word-finding difficulty, mis-naming, comprehension difficulties
4. disorientation to time, place
5. worsening judgement
6. impaired problem-solving or reasoning
7. misplacing things - finding them in “odd” places
8. personality changes
9. mood or behavior changes
10. loss of initation

Question 3

if you notice any abnormal cognitive decline, what else could it be other than dementia?

Answer 3

1. meds side effect
2. hearing loss, visual loss
3. depression, anxiety
4. acute illness

Question 4

what is dementia?

Answer 4

1. a group of symptoms that involve a decline in memory, reasoning, and other cognitive skills, despite full alterness
2. typically involves memory and orientation, plus addition of one or more of the following:
   
   • impaired abstract thinking
   • impaired judgement and problem solving
   • impaired language
   • personality changes

Question 5

list some potential causes of dementia

Answer 5

1. CVA
2. NPH
3. toxin exposure
4. infection
5. TBI
6. neurodegeneration
7. idiopathic

Question 6

describe the general pathophysiology of dementia

Answer 6

both a chemical and structural change in the brain

Question 7

List some subtypes of dementia

Answer 7

1. Alzheimer’s Disease
2. Vascualr dementia
3. Lewy Body dementia
4. Fronto-temporal lobe dementia
5. Other

Question 8

what is the prevelence and incidence of Alzheimer’s disease?

Answer 8

1. most common neurodegenerative disease
2. acounts for 60-80% of all dementia cases
3. prevalence gradually increases by 20% every 5 years >/=85 years
4. onset at any age, most likely after 65

Question 9

describe the pathophysiology of Alzheimer’s disease

Answer 9

cause = ultimately unknown, genetics and environmental factors may play a role

Amyloid Cascade Hypothesis:

• abnormal buildup of amyloid beta and tau plaques throughout the brain
• leads to toxicity → inflammation, oxidative stress, impaired homeostasis → neuronal death and dysfunction → AD

Question 10

Compare Alzheimer’s disease to normal cognitive decline

Answer 10

1. AD
   
   • absent immediate recall
   • rarely retrains short-term memory
   • gradual decline in languge capabiilties
   • gradual decline in response to memory aids
   • gradual progression to complete dependence in ADLs and functional mobility
2. age-related memory loss
   
   • impaired immediate recall
   • often shows retention of short-term memory
   • language typically intact
   • respond well to memory aids
   • typically retains some degree of independence in ADLs and functional mobility

Question 11

List the general characteristics of AD

Answer 11

1. initially slow, insidious onset with subtle loss of interest or withdrawal from enjoyable activities as well as early memory loss
2. as disease progresses, dysfunction includes perceptual deficits
   
   • anomia, apraxia, and visuospatial disorders
3. moderate to advanced stages may see behavioral changes such as wandering, paranoid, agitation, aggression, sexual disinhibition, or failure to recognize family/friends
4. cog dysfunction is usually seen in absence of many other neuro functions
   
   • memory, sensory functions and procedural memory usually spared

Question 12

describe the mild stage of AD

Answer 12

1. lasts 2-4 years
2. marked by minor memory loss as well as difficulty learning and remembering new info
3. long-term memory and some reasoning remains intact
4. pts may be aware of their decline and hide it well

Question 13

describe the moderate stage of AD

Answer 13

1. lasts 2-10 years
2. pt experiences withdrawal, confusion, increasing difficulty in self-care and daily task, poor judgement and difficulty communicating
3. behavior changes often include
   
   • anger, anxiety, frustration, and restlessness
4. caregiver assistance becomes increasingly necessary

Question 14

describe the severe stage of AD

Answer 14

1. usually lasts 1-3 years
2. pts are completely incapacitated, retreat into themselves, and will not eat unless fed
3. pts may not speak and do not recognize people, even family members
4. loss of bodily function control (swallowing, bladder, bowel)
5. violent episodes and aggression are common

Question 15

describe memory, language and mood in the mild stage of AD

Answer 15

1. Memory
   
   • decreased short-term memory
   • slowed processing
   • decreased attention
   • awareness of deficits intitially maintained
2. Language
   
   • word-finding difficulties
   • cog failure leads to language compromise
3. Mood
   
   • frustration, irritability, agitation
   • apathy, depression
   • anxiety

Question 16

describe function, behavior and safey concerns in mild AD

Answer 16

1. Function
   
   • breakdown in IADL and ADL function
2. Behavior
   
   • frequent losing items
   • constant repitition
3. Safety Concerns
   
   • driving
   • exploration

Question 17

describe memory and thinking, languge and mood in moderate AD

Answer 17

1. Memory and thinking
   
   • continued decline in short-term memory, beginning to see decline in long-term
   • inability to recognize family/friends
   • inability to recognize simple items
   • inability to understand time
   • decreased insight
   • increased self-absorption and withdrawal
2. Language
   
   • decreased verbal and written comprehension
   • decreased verbal expression
   • frequent rep of words
3. Mood
   
   • decreased stress tolerance
   • very flat affect, blunted emotions
   • Sundowning

Question 18

describe function, behavior, and safety concerns in Moderate AD

Answer 18

1. Function
   
   • ADL dependence
   • functional decline when task involves cog load
   • altered VS perception
   • impairements with starting an activity, execution tech
   • often show a resistance to mobility attempts
   • deconditioning
2. Behavior
   
   • withdrawal from socialization
   • fear of abandonment, very clingy to family
   • refusing care and services
   • increased confusion, agitation, beligerence
   • psychosis, paranoia
   • insomnia
3. Safety Concerns
   
   • elopment
   • problems with eating and drinking

Question 19

describe memory and thinking, language and mood in severe AD

Answer 19

1. Memory and thinking
   
   • memory severely compromised
2. Language
   
   • sig limited verbal output
3. Mood
   
   • agitation, irritability
   • lability
   • apathy
   • delusions, hallucinations
   • sleep and appetite changes

Question 20

describe function, behavior, and safety concerns in severe AD

Answer 20

1. Function
   
   • ADL dependence
   • incontinent bowel/bladder
   • ineffective swallow
   • functional dependence
   • progressive fatigue
2. Behavior
   
   • still recognizes comfort
3. Safety Concerns
   
   • high rates of dehydration and aspiration pneumonia
   • seizures may occur

Question 21

how is AD diagnosed?

Answer 21

1. dx of exclusion
2. imaging (late stages)
   
   • MRI → hippocampal atrophy
   • PET → temporal and parietal hypometabolism
3. Gold standard → postmortem autopsy

Question 22

List some trxs and the prognosis for AD

Answer 22

1. Trx
   
   • no curative trx for AD
   • some meds found to slow the process of cog decline
2. Prognosis
   
   • 6-15 years to mortality from dx
   • 6th leading cause of death
     
     • main causes → pneumonia, infection, dehydration, malnutrition

Question 23

Describe Vascular Dementia

Answer 23

1. 2nd most common cause of dementia
2. results from multiple cortical and/or subcortical ischemic or hemorrhagis strokes over time
3. Risk factors:
   
   • age
   • DM
   • HTN
   • metabolic syndrome (presence of 3 of the 4 → obesity, HTN, dyslipidemia, insulin resistance)

Question 24

how is Vascular Dementia treated and diagnosed?

Answer 24

1. diagnosis → clinical exam + neuroimaging
2. treatment/management
   
   • largely focused on CVA management

Question 25

describe the presentation of vascular dementia

Answer 25

dementia + neurological defictis

• abrupt onset, stepwise regression seen in presentation
• unlike AD, will often see S/S of UMN injury, sensory deficits, aphasia
• severe depression is often predominant feature

Question 26

Describe the cause and pathophysiology of Frontotemporal Dementia

Answer 26

1. average age of onset 50-60
2. commonly misdx as psychiatric disorder
3. Cause
   
   • genetic mutations have been linked
   • unknown in ~50% of cases
4. Pathophysiology
   
   • variability, not entirely understood
   • protein build up is thought to be occuring, but not seen consistently with these pts and various involved proteins have been suggested
   • ultimately, see atrophy and neuronal death in frontal and temporal lobes of brain

Question 27

List S/S of frontotemporal dementia

Answer 27

1. Frontal S/S (most prominent)
   
   • disinhibition
   • apathy
   • loss of sympathy/empathy
   • rep/compulsive/ritualistic behavior
   • changes in eating and bathing habits
2. Temporal S/S
   
   • progressive aphasia
   • speech apraxia

Question 28

T/F: frontotemporal dementia doesn’t ever spread to other parts of the brain

Answer 28

FALSE

as dementia progresses, can start to see widespread cortical involvement

coordination, motor control, balance impairments, EOM dysfunction, dysphagia

Question 29

describe the clinical course for frontotemporal dementia

Answer 29

• usually starts with either frontal S/S or temporal S/S
• 10-15 years to mortality from onset of symptoms
  
  • faster progression with early onset and higher degree of temporal involvement