Trans 044: Dementia and Neurobehavioral Flashcards
a syndrome – usually of a chronic or progressive
nature – in which there is deterioration in cognitive function
(i.e., the ability to process thought) beyond what might be
expected from normal ageing.
Dementia
T/F?
Dementia results from a variety of diseases and injuries that
affect the brain, such as Alzheimer disease or stroke.
TRUE
T/F? Dementia is not a normal part of aging
T
Diagnostic criteria for dementia?
the presence of an acquired impairment in memory, associated with impairment in one or more cognitive domains:
executive functioin
language
praxis
gnosis
impairments in cognition mus be severe enough to interfere c daily function
The diagnostic process in dementia has 3 major conceptual components:
conceptual components:
1) the clinical diagnosis,
2) a logical search for the cause,
logical search for the cause is important because some of the causes of dementia may be irreversible
3) the identification of treatable comorbid conditions and other contributing factors, such as the degree of cerebrovascular disease.`
The diagnostic process should involve 6 main steps:
o taking the patient’s history,
o interviewing a caregiver or family member,
o physical examination,
o brief cognitive tests,
o basic laboratory tests,
o structural imaging for patients meeting certain criteria.
It is important to interview not only the patient but also the family, all close members and caregiver. T or F?
T
what laboratory tests would we request for dementia?
In laboratory tests test for iron deficiency & thyroid disease
remains the most widely used instrument, with high sensitivity and specificity for separating moderate dementia from normal cognition.
MMSE
Kapag mild lang, hindi ganun kasensitive ang test”
mild dementia? moderate? severe? SCORES IN MMSE
A rough rule of thumb is that patients with mild dementia usually have a score of 18–26 out of 30, those with moderate dementia a score of 10–18, and those with severe dementia a score of 10 or less than
is a more expanded version that also includes assessment of delayed recall.
Modified Mini-Mental State Examination
test that focuses on memory, attention, construction and orientation domains.
MMSE
3 tests for cognitive function
- Mini-Mental State Examination Test (MMSE)
- Clock Drawing Test
- Montreal Cognitive Assessment Test
evaluates general executive functioning of the frontal lobe, as well as visuospatial abilities.
• It requires 5–10 minutes to administer and has achieved widespread clinical use.
may lack sensitivity for the diagnosis of early or mild dementia.
CLOCK DRAWING TEST
causes of dementia?
is caused by damage to or loss of nerve cells and their connections in the brain.
If the patient is suffering from the dementia and you want to know, the better imaging test is MRI for dementia” T OR F?
T
a condition that is a transient, usually reversible, acute confusional state. : clinical hallmarks are impaired attention and fluctuations in levels of consciousness.
Delirium
In considering diagnosis of a degenerative dementia, it is important to exclude delirium. T or F?
T
is a medical emergency with an increased risk for morbidity and death. It calls for immediate investigation and management of treatable medical conditions.
delirium
T or F? Individuals with dementia are at risk for delirium; however, the initial diagnosis of dementia should not be made while the patient is in a delirious state.
T
characterized principally by an alteration of consciousness and by prominent disorders of attention and perception, which interfere with the speed, clarity, and coherence of thinking, the formation of memories, and the capacity for performance of self-directed and commanded activities.
Acute confusional and delirious states:
(new mental confusion) is a sudden change in mental status, or sudden confusion, which develops over hours to days.
In the history, it is always important to ask the relatives when did this state started
Delirium
2 types of delirium
1) hyperactive delirium and hypoactive delirium. Hyperactive means overactive (agitation, restlessness)
2) Hypoactive means underactive (sleepy and hard to respond). Sometimes both types can occur together.
identify if delirium vs dementia? abrupt
delirium (dementia is insidious)
identify if delirium vs dementia? course is slow decline?
dementia. fluctuation in delirium
identify if delirium vs dementia? duration? hours to weeks
Delirium. Dementia is months to years
identify if delirium vs dementia? Alertness is impaired
Delirium
identify if delirium vs dementia? word finding problems?
Dementia
decreased level of consciousness, but rapid arousal to verbal or noxious stimuli
Drowsiness
impaired arousal to noxious stimuli, but preserved purposeful movements
Stupor
sleep-like state of unresponsiveness, with no purposeful response to stimuli
Coma
risk factor gender for delirium?
Male
(Binswanger’s Disease aka
Subcortical Vascular Disease
Neurodegenerative conditions that could lead to dementia
- Pick’s Disease
- Huntington’s Chorea
- Parkinson’s Disease
Infections that can cause dementia? (4)
- Creutzfeldt Jackob’s Disease
- HIV (AIDS Dementia Complex)
- Viral Encephalitis
- Progressive Multifocal Leukoencephalopathy
nutritional causes that can lead to dementia
- Wernicke Korsakoff (Thiamine Deficiency)
- B12 Deficiency (Folate Deficiency)
metabolic causes that could lead to dementia? (4)
- Hepatic Disease
- Thyroid Disease
- Parathyroid Disease
- Cushing’s Syndrome
how many percent of dementia are reversible?
10-15%
While several different genes are probably involved in Alzheimer’s disease, one important gene that increases risk is
apolipoprotein E4 (APOE).
alzheimer’s is Due to alteration on what chromosome (3)
1, 14 and 21
Mutation on chromosome 14 – produces a protein
PRESENLIN 1 (PSEN1)
Mutation on chromosome 1 – produces a protein
PRESENLIN 2 (PSEN2)
PRESENLIN 1 & 2 encode for membrane protein involved for
AMYLOID PRECURSOR PROTEIN (APP).
mutations on the chromosomes affected in AD will lead to decreased activity of?
Mutations lead to decreased activity of γ-secretase, an enzyme important in Β-amyloid peptide (ΒAP) formation.
APP is encoded on what chromosome?
chromosome 21
amyloid cascade hypothesis?
altered APP procesesing > overproduction of BAP > plaque formation > neurodegeneration > neuronal loss > dementia
ΒAP aggregation & deposition – leads to
plaque formation
Hyperphosphorylation of Tau protein – leads to
NFT development
Gene responsible for production of apoE gene – chromosome ?
chromosome 19
provides structural support to microtubules, cell’s transportation and skeletal system support.
Tau protein
When Tau filaments undergo abnormal phosphorylation at specific site, they can’t bind to microtubules thereby collapses.
act as potential neurotoxins for AD.
Glutamine & other excitatory amino acid NTs; If glutamate remains in synapse for a long period of time : destroys nerve cells
Blocking of NMDA receptors decreases/increases the glutamate activity in synapse
decreases
This is the reason why in the management of patients with AD, usually the target is the different neurotransmitters.
ApoE4 is associated with increased/decreased deposition of ΒAP
increases
AD risk factors
- Age!!
- Mild cognitive impairment (MCI)
- ApoE-e4 positivity
- Family hx in first degree relative (especially if younger onset)
- Vascular risk (diabetes, heart disease, etc.)
- Low education and physical/social activity
- Female sex
This second most common type of dementia is caused by damage to the vessels that supply blood to the brain
vascular dementia
The most common symptoms of vascular dementia include
difficulties with problem-solving, slowed thinking, focus and organization. These tend to be more noticeable than memory loss.
For Vascular Dementia, the risk factors are correctable except for
age.
suspect vascular dementia when?
• Suspect when o Abrupt onset and/or stepwise decline o Fluctuating course o H/o stroke o Focal neurologic symptoms or signs
are abnormal balloon like clumps of protein that have been found in the brains of people with Lewy body dementia, Alzheimer’s disease and Parkinson’s disease.
Lewy body
Common s/sx of lewy body dementia?
Common signs and symptoms include acting out one’s dreams in sleep, seeing things that aren’t there (visual hallucinations), and problems with focus and attention. Other signs include uncoordinated or slow movement, tremors, and rigidity (parkinsonism).
Core features of lewy body dementia?
Core features
o Parkinsonism
o Recurrent early visual hallucinations
o Fluctuations (clue: recurrent delirium evaluations)
Suggestive features of lewy body dementia?
Suggestive features include REM sleep disorder (dream enactment) & neuroleptic sensitivity
what part of the brain has early degeneration in lewy body dementia
Relatively earlier occipital and basal ganglia degeneration
this dementia has this clinical feature
Progressive non-fluent aphasia
Frontotemporal dementia
identify what type of dementia is this based on the affected area: earliest changes in medial portion of the parietal cortex, parietal and superior/posterior temporal abnormalities; bilateral temporoparietal hypoperfusion
AD
identify what type of dementia is this based on the affected area: temporoparietal associated with occipital hypoperfusion
Diffuse Lewy Body Disease
identify what type of dementia is this based on the affected area: motor/premotor frontal cortex, anterior cingulate gyrus, hippocampus, basal ganglia and thalamus
progressive supranuclear palsy
identify what type of dementia is this based on the affected area: frontal, anterior cingulate gyrus, anterior temporal lobe, hippocampus, basal ganglia, and thalamus
frontal dementia
what dementia is this pathology?
Pick cells and pick bodies in cortex
Frontotemporal
For slowly progressive “typical” dementia in adults >65, most essential tests:
B12, TSH, brain image (CT is ok)
approved to differentiate AD from FTD
FDG (Functional Digital Imaging) PET
The most widely used CSF biomarkers for Alzheimer’s disease measure certain proteins:
o beta-amyloid 42 (the major component of amyloid plaques in the brain),
o tau, and
o phospho-tau (major components of tau tangles in the brain).
`ADHD is closely related with poor regulation of some neurotransmitter which are?
Dopamine and norepinephrine
