Trastornos Neurocognitivos Flashcards
3.1.
A 75-year-old woman in an assisted living facility becomes
irritable several evenings a week about an hour after dinner,
and questions where she is and how she got there. She has a
standing order of as-needed quetiapine, which settles her and
helps her sleep through the night. When she wakes in the
morning, she is alert and oriented to person, place, and time,
socializes easily with the staff and friends she has made, and
does not recall much of her behavior from the night before.
What neurotransmitter most likely plays the primary role in
the patient’s evening behaviors?
A. Acetylcholine
B. Dopamine
C. Ciprofloxacin
D. Glutamate
E. Serotonin
3.1. A. Acetylcholine
Sundowning is a type of delirium that occurs usually in elderly who
have a diagnosis of dementia. The phenomenon is marked by
confusion and behavioral changes. Though symptoms are often
mitigated with an antipsychotic, which acts primarily on dopamine
and, in some medications, serotonin, the primary neurotransmitter
involved in delirium is thought to be acetylcholine
3.2.
A 75-year-old woman is brought to the emergency department
by her son, with whom she lives, due to intermittent periods of
agitation, increased forgetfulness, and memory difficulties.
Symptoms suddenly began 3 days ago and come and go with no
apparent precipitating factors. Her son is especially concerned
because she wandered out of the house last night looking for
her husband who died 7 years ago. When her son asked her this
morning where her husband was, she replied, “Son, you know
he’s been dead for 7 years!” She is diagnosed with
hypertension, Alzheimer dementia, and diabetes, and takes
hydrochlorothiazide (HCTZ), memantine, and metformin, all of
which she has been out of for the last week due to a delay in the
arrival of the mail-order medications. Examination shows a
thin female who looks her stated age, in no acute distress. Vital
signs are normal. O2 saturation is 96% on room air. Complete
blood count (CBC) shows leukocytosis, and urinalysis shows 2+
protein and moderate bacteria. What medication would most
likely resolve this patient’s symptoms?
A. HCTZ
B. Metformin
C. Metronidazole
D. Memantine
E. Haloperidol
3.2. C. Metronidazole
The patient is displaying symptoms of delirium, including waxing
and waning of consciousness, visual hallucinations, and impaired
judgment. When possible, the underlying cause should be treated. In
this case, the likely underlying cause is the urinary tract infection, as
opposed to being off of HCTZ, memantine, and metformin for a
week. Though haloperidol may temporarily alleviate the symptoms,
it will not ultimately resolve them
3.3 One of the earliest and most prominent features of dementia is
the decline of what function?
A. Attention
B. Memory
C. Executive function
D. Social cognition
E. Language
3.3. B. Memory
Though dementia can affect many cognitive functions such as
attention, executive function, social cognition, and language,
memory is usually an early and prominent feature.
As opposed to delirium, what aspect of neurocognition remains
intact in dementia?
A. Attention
B. Orientation
C. Memory
D. Consciousness
E. Social skills
3.4. D. Consciousness
Whereas, by definition, delirium involves a waxing and waning of
consciousness, consciousness is preserved and remains clear in
dementia. Deficits in attention, orientation, memory, and social skills
can be present in both dementia and delirium.
3.5.
An 82-year-old man presents to the primary care clinic along
with his daughter for a routine visit. He last saw his primary
care physician a year ago. He is diagnosed with coronary artery
disease and atherosclerosis. He states that he is having
problems remembering where he put his car keys and the
names of his grandchildren, “but otherwise, my mind is as
sharp as it ever was!” Vital signs are within normal limits.
Physical examination reveals no acute abnormalities. After the
doctor walks out of the room, the patient’s daughter follows
him and says “It’s much worse than forgetting his car keys. I
had to hide them at first, then had to disable the car, because it
seems like once he turned 75 he started getting lost on the way
home. He stayed like that for a while, then started forgetting
his grandkids’ names about a year ago. Then last month, he
suddenly started developing headaches and said he felt dizzy.”
His memory has not gotten worse, but has not improved. What
is the most likely diagnosis?
A. Vascular dementia
B. Delirium
C. Transient ischemic attacks
D. Alzheimer dementia
E. Normal aging
3.5. A. Vascular dementia
Memory problems to the extent that he gets lost driving home cannot
be attributed to normal aging, as he is demonstrating significant
impairment in functioning. The son does not report changes in
consciousness, which rules out delirium. Though Alzheimer is the
most common dementia, it is characterized by a gradual, progressive
course of symptoms, as opposed to vascular dementia, in which
symptoms typically occur in a stepwise fashion. Because he is not
recovering between episodes, these are not transient ischemic
attacks, after which function is regained
3.7.
Emergency medical services are called to the home of a 74-
year-old man by his home health nurse who, upon arriving to
work, discovered that he had fallen and was covered in urine
and feces. She reports to the emergency medical technician
(EMT) that she witnessed him passing out and falling to the
ground after getting out of bed a week ago, and was able to get
him back into the bed. She states that over the past 3 years he
has had progressive difficulty remembering the names of his
children and grandchildren, and that over the last month, he
has been asking her to put the dog outside. When I tell him he
does not have a dog, he points and says, ‘The dog is standing
right there! Put him outside!’” Despite getting 9 hours of sleep
a night, he often seems drowsy, but then “perks up 10 minutes
later, then gets sleepy again an hour later.” She has been
concerned about the way he walks. Temperature is 99.1 F, BP 110/70 sitting, 80/55 standing. Pulse is 80 sitting and 85
standing. Respirations 18. Cogwheeling rigidity is noted in his
arms, along with a resting tremor. What is the most likely
cerebral pathology?
A. Blanching of the substantia nigra
B. Pick bodies in the frontotemporal regions
C. Multiple subcortical white matter infarctions
D. Amyloid plaques in the cortex and hippocampus
E. Lewy inclusion bodies in the cerebral cortex
3.7. E. Lewy inclusion bodies in the cerebral cortex
Memory impairment with the presence of visual hallucinations,
autonomic disturbances, and Parkinsonian symptoms (cogwheeling,
resting tremor, bradykinesia) are symptoms of Lewy body disease.
The Lewy inclusion bodies are found in the cerebral cortex.
Parkinson disease, with its blanching of the substantia nigra, is not
associated with visual hallucinations. Alzheimer disease,
characterized by amyloid plaques in the cortex and hippocampus,
also does not usually feature visual hallucinations. Subcortical white
matter infarctions are the hallmark of Binswanger disease, also
called subcortical arteriosclerotic encephalopathy, in which the main
characteristic is psychomotor slowness. The Pick bodies are the
pathognomonic sign of frontotemporal dementia, which is marked
by personality and behavioral changes.
3.6.
What is the average length of time until death once an
individual is diagnosed with dementia of the Alzheimer type?
A. 3 years
B. 8 years
C. 13 years
D. 18 years
E. 23 years
3.6. B. 8 years
Alzheimer dementia is a terminal illness, as the accumulation of
plaques and tangles throughout the brain and the loss of brain tissue
leads to progressive severity of impairment. Affected individuals lose
the ability to swallow, which greatly increases the risk of aspiration
pneumonia, dehydration, and cachexia. Other causes of death
include pulmonary embolism and cardiovascular disease. The
average life expectancy after diagnosis is 8 years
3.8.
A person with an amnestic disorder is most likely to be able to
correctly answer what mental status examination question
posed to them?
A. “Flag, ball, tree. Can you repeat those three words?”
B. “What did you have for breakfast this morning?”
C. “What is the name of this building?”
D. “What is today’s date?”
E. “Where did you go yesterday?”
3.8. A. “Flag, ball, tree. Can you repeat those three words?”
Short-term and recent memory are usually impaired in amnestic
disorder, so a person likely would not be able to answer questions
about what they ate that day or what activities they engaged in the
day before. In severe amnestic disorder, orientation to place and
time can be impaired. However, immediate memory remains intact,
so a person can recall numbers or words right after they are said. The
person would likely not be able to remember them for a 5-minute
recall.
3.9.
A 60-year-old man is brought to the outpatient clinic by his
daughter, who reports that her father calls several times during
the day. He is always surprised when she tells him that they
had already talked earlier, after which he usually says that he
wanted to ask her one more thing. When she is at his house,
she notices that he asks her several times if she would like him
to make her lunch, even though she has told him that she has
already eaten. He then will tell her that he could not have asked
that question already because she would have taken off her
shoes if she had eaten. She first noticed the memory loss a
couple years ago, and notes that it has gotten worse over the
last year since his wife died and he has lived alone. She is
concerned that he is not eating well, as his wife did all the
cooking, and believes that he has lost 10 pounds since she died.
She has been especially concerned because she has smelled
alcohol on his breath a few times when she has visited him. He
has hypertension and is on an angiotensin-converting enzyme
(ACE) inhibitor, which she makes sure he takes daily. Blood
pressure is 140/90. Other vitals are within normal limits During the cognitive examination, he confidently gives
incorrect answers to the three-word recall, even explaining the
associations he made between the words in his mind to help
him remember them. What is the most appropriate treatment
for this patient?
A. Selective serotonin reuptake inhibitor (SSRI)
B. Thiamine replacement
C. A cholinesterase inhibitor
D. An increase in antihypertensive medication
E. An N-methyl-D-aspartate (NMDA) receptor antagonist
3.9. B. Thiamine replacement
The amnesia is most likely due to poor nutritional deficiency and
lack of thiamine in the diet, which is the cause of Korsakoff
syndrome. This is often seen with chronic alcohol use. One of the
hallmarks is confabulation, in which a person tries to cover up
memory loss by filling in the gaps with a story, which can range from
completely plausible to completely implausible. The proper
treatment is to replace thiamine, which may lead to improvement
after 3 months. Cholinesterase inhibitors and NMDA receptor
antagonists can be useful for
Alzheimer dementia. An SSRI could be
helpful if depression were thought to be the reason for the cognitive
deficits. Better hypertension control could be helpful for vascular
dementia.
3.10.
A 66-year-old woman wakes from anesthesia following a
round of electroconvulsive therapy (ECT) for chronic
depression. The patient is most likely to demonstrate difficulty
when asked which of the following questions to test memory?
A. “What did you have for dinner last night?”
B. “What are the names of your children?”
C. “What is your birthdate?”
D. “What were the three words I just asked you?”
E. “Where do you currently live?”
3.10. D. “What were the three words I just asked you?”
ECT is associated with anterograde amnesia for a few hours after a
treatment. During this time, the patient may have difficulty forming
new memories, and would therefore have trouble with a three-word
recall. The patient would likely also have trouble remembering past
events that occurred a few minutes before the treatment.
3.11.
A 14-year-old boy is brought to the emergency department
(ED) by emergency medical services (EMS) after being
unconscious for about 60 seconds. His parents report that he
was playing football in the driveway with the neighborhood
children when he and another boy collided, and he fell and hit
his head on the pavement. He was not wearing a helmet. When
he regained consciousness he was lethargic, which prompted
them to take him to the ED. The child is fully awake,
complaining of a headache, and looks confused. Neurologic
examination is normal. Vital signs are within normal limits.
When asked by his parents what he remembers about the
accident, what is the most likely response?
A. “Who are you people?”
B. “I was playing football, got tackled, and fell and hit my
head.”
C. “What accident?”
D. “We were in the car and another car hit us.”
E. “Someone was running toward me, then I blacked out.”
3.11. C. “What accident?”
If a head injury results in amnesia, it will most likely be for the
period of time leading up to the event and for the event itself.
Therefore, the child is most likely simply not going to remember the
accident. Confabulating a story (being in a car accident) would be
most associated with Korsakoff syndrome. It is unlikely that he
would forget his parents, who he has known all of his life
3.13.
A 55-year-old woman is brought to the emergency
department (ED) by EMS from a restaurant where she had
been eating lunch with her best friend 15 minutes ago. The
friend states that the patient suddenly looked confused and
repeatedly asked where she was and how she got there, even
though she was given the answers several times. Her friend,
fearing that the patient was suffering from a stroke, called 911.
In the ED, the friend tells the care team that the patient has no
history of seizures or head injury, and has only been diagnosed
with mild hypertension. Vital signs are normal. The patient is
able to give her name and the name of her friend, but
continuously has to be told that she is at the hospital.
Consciousness is intact. Urine drug screen is negative, and
comprehensive metabolic profile, CBC, head CT, and EKG
reveal no abnormalities. Neurologic examination is normal.
What is the most likely prognosis for her memory over the
next 24 hours?
A. She will forget everyone but herself
B. Memory loss symptoms will wax and wane
C. She will regain past memories but not be able to form new
ones
D. Memory loss will remain the same
E. She will make a complete recovery
3.13. E. She will make a complete recovery
Transient global amnesia is marked by an abrupt onset of both
retrograde and anterograde amnesia in the absence of delirium.
Occasionally, the person may not be able to perform well-learned
tasks. The vast majority of people make a complete recovery within
24 hours
3.12.
Cerebrovascular disease is most likely to cause amnesia when
it affects the hippocampus and what other area of the brain?
A. Medial thalamus
B. Corpus callosum
C. Suprachiasmatic nucleus
D. Substantia nigra
E. Arcuate nucleus
3.12. A. Medial thalamus
Cerebrovascular diseases which affect the bilateral medial thalamus
are often associated with amnestic disorder. In addition to the
hippocampus, lesions affecting the cerebellum, amygdala, and
prefrontal cortex could also affect different types of memory. The
suprachiasmatic nucleus is associated with circadian rhythm. The
substantia nigra is associated with movement disorders such as
Parkinson. Lesions affecting the corpus callosum can be associated
with a myriad of dysfunctions. The arcuate nucleus regulates several
functions of homeostasis.
3.14.
As opposed to amnestic disorders, a person with dementia of
the Alzheimer type would have impairment in what area of
functioning?
A. Anterograde memory
B. Retrograde memory
C. Episodic memory
D. Semantic memory
3.14. D. Semantic memory
Dementia of the Alzheimer type leads to more severe loss of function
and memory than amnestic disorder. While both can affect
anterograde, retrograde, and episodic memory, amnestic disorders
do not lead to loss of language, general knowledge (semantic
memory), or praxis (the planning of movement to achieve a
purpose).
3.15.
The likelihood of benzodiazepines causing amnesia is
increased with the addition of what substance?
A. Alcohol
B. Anticholinergics
C. Psychedelics
D. Barbiturates
E. Stimulants
3.15. A. Alcohol
Benzodiazepines are the most commonly used prescription drugs
that can cause amnesia. This effect is magnified when combined with
alcohol, which can lead to anterograde and retrograde amnesia
