Week 6 - Neurocognitive and Psychiatric Disorders Flashcards
Mild cognitive impairment
cognitive changes beyond what is expected from normal aging but with preserved function – family members may report symptoms
Dementia
Cognitive dysfunction across multiple domains with impaired functioning.
Dementia Clinical tools
- Clinical dementia rating scale (CDR)
- MMSE
- Montreal cognitive assessment instrument (MOCA)
- SLUMS
- AD8 <5min
- Mini-cog
Mild dementia
CDR score 1
MMSE 20-26
Poor memory, forgetting key events, repetitive questioning, misplacing familiar objects, maintain ADLs, and some iADLs, live independently
Moderate dementia
CDR =2
MMSE 12-19
Worsening memory loss, difficulty using language, problems reading/writing, impulsive behavior, difficulties with multistep tasks like dressing/bathing, gradual dependence on others for ADS and iAdls, emergence of paranoia, delusions, hallucinations
Severe dementia
CDR=3
MMSE<12
inability to communicate verbally, sleep dysregulation, lose motor function, dysphagia, weight loss, lose desire to eat/drink, dysmobility - bedridden
- incontinence
Non-modifiable risk factors for dementia
- Age
- genetics
- family history
- low level of educational attainment
- CKD
- AF
- Depression
Potentially modifiable risk factors for dementia
- HTN
- CVD
- Obesity
- Social isolation
- Alcohol/smoking
- Medications
- Diabetes
- Sedentary lifestyle
- Sleep disorders
- Hearing impairment
- Brain trauma
- Environmental pollutants
Cognitive impairment screening recommendations
Not currently recommended by the USPSTF
Labs to check with cognitive impairment
- CBC
- CMP
- LFT
- TSH
- Vitamin B12
- HIV & Syphyllis
- neuroimaging (falls, abnormalities with exam, anticoagulants, atypical features–> CT or MRI)
Treatment for cognitive impairment
- Cholinesterase inhibitors (donepexil, galantamine, rivastigmine)
- GI distress
- Weight loss
- Urinary urgency
- Bradycardia
- Syncope
- Sleep disturbances - N-methyl-D-aspartate receptor inhibitor – memantine (can help with behavioral symptoms)
Frontotemporal neurocognitive disorder symptoms
Behavioral disturbances such as:
- impulsivity
- socially inappropriate behavior
- hoarding
- apathy
- personality changes
- decline in language abilities
Memory is typically intact.
Neurocognitive disorder with Lewy Bodies symptoms
Memory loss, difficulty in executive function, depressed mood, and cardiovascular risk factors
Risk factors for delirium
- Cognitive impairment
- Depression
- Alcohol abuse
- Hearing loss
- Vision loss
- Assistance with 2 ADLs
- Anticholinergics
- Oxybutynin
- Diphenhydramine
- Atenolol
- Meclizine
- Ranitidine
- scopalamine - CV – HTn CHF, DM, CVA, AF
Precipitating factors for delirium
- Physical restraints
- Malnutrition
- Three new meds
- Catheterization
- Surgery
How is delirium different from dementia?
inattentiveness, altered level of arousal, fluctuation of symptoms
Symptoms of delirium
- Acute change in mental status
- Fluctuating course
- Attention disturbance
- Memory disturbance
- Orientation disturbance
- Perceptual disturbance
- Thought disturbance
- Sleep disturbance
- Consciousness disturbance
- Speech disturbance
- Psychomotor activity disturbance
Assessment tools for delirium
- The confusion assessment method severity (CAM)
- Acute onset and fluctuating through the day
- Inattendtion
- Disorganized thingking
- Altered LOC - Confusion state examination
- Delirium-o-meter
- delirium observation scale
- delirium rating scale
- memorial delirium assessment scale
Delirium diagnosis
Delirium is diagnosed if a patient has an acute change in mental status with inattention accompanied by disorganized thinking or a change in alertness.
Prevention strategies for delirium
- Orientation activities
- Early mobilization
- Minimize use of psychoactive drugs
- Use of glasses/hearing aids
- Treating volume depletion
Treatment for delirium
Rispiradone
Modifiable risk factors for stroke
- HTN
- DM
- HLD
- AF
- OSA
- Tobacco
- Alcohol
- Physical inactivity
Ischemic stroke
Sudden unilateral weakness of the face, arm, and leg; sudden unilateral sensory loss; sudden speech difficulties (producing or understanding speech); sudden slurring of speech; sudden loss of vision or double vision; sudden loss of balance, vertigo, or clumsiness; and sudden onset of severe headache
Clinical assessment for stroke
- Accurate history
- Onset of symptoms
- Chornololgoy
- PMH
- Stroke hx
- Recent surgery
- Bleeding disorder
- Use of anticoagulants
Neurological exam for stroke
- Conscious
- Speech
- Paralyzed
- Gaze deviation
- Pupil size
- Facial weakness
- Motor tone
- Spontaneous movements
- VSS
- Capillary glucose
What stroke tool is used to gauge stroke severity?
National Institutes of Health Stroke Scale (NIHSS) is a systematic, quantitative assessment tool to measure stroke-related neurological deficit.
Labs to check if stroke is suspected
- CBC
- CMP
- BUN/creatinine
- Troponin
- Glucose
- INR (if on warfarin)
- Noncontrast head CT
Management of acute stroke
- 0-3 hours – alteplase/mechanical thrombectomy
- 3-4.5 hours – alteplase, mechanical thrombectomy
- 4.5-6 hours – mechanical thrombectomy
- 6-24 hours – mechanical thrombectomy
- Wake up stroke – MRI brain
- Thrombolysis if abnormal DWWI and no signal change in FLAIR
BP goals after
acute ischemic stroke
- Not a candidate for thrombolysis: <220/120 mmHg
- Candidate for thrombolysis: <185/110 mmHg
- After thrombolysis: <180/105 mmHg
- After revascularization: <140/80 mmHg
Options for HTN treatment after acute ischemic stroke and acute reperfusion therapy
- Labetalol
- Hydralazine/enalaprilat
- Nicardipine
- Clevidipine
TIA
transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, without evidence of CNS infarction. Most patients have symptoms for 15 to 20 minutes with complete recovery
ABCD2 score
Predict future stroke risk after TIA.
- Age ≥60 years (1 point)
- BP ≥140/90 mmHg on presentation (1 point)
- clinical symptoms of focal weakness with the spell (2 points) or speech impairment without weakness (1 point)
- duration of symptoms ≥60 minutes (2 points) or 10 to 59 minutes (1 point)
- diabetes (1 point).
- 2-day risk of stroke is 1.0% with a score of 0 to 3, 4.1% with a score of 4 to 5, and 8.1% with 6 to 7
How is a TIA diagnosed?
- Imaging within 24 hours of episode – MRI
- Blood vessel imaging including intracranial nerves
- Baseline EKG
TIA treatment
- Aspirin, clopidogrel or aspirin ER dipyridamole
- Statins for patients with HLD
What is the most important treatable risk factor for stroke?
Blood PRessure
Complications of cerebrovascular disease
- Hemiparesis
- Dysphagia
- Poststroke fatigue
- Poststroke pain
- Seizures
- Sleep disorders
- OSA
- Spasticity (baclofen)
- Cognitive change
- Depression (SSRIS)
Primary features of Parkinson’s Disease
- Resting tremor
- Bradykinesia
- Rigidity
- Asymmetric onset
- Responsiveness to levodopa
Features of Parkinson’s Disease
- Response to levodopa
- Expressionless face
- Drooling
- Speech/swallowing problems
- Loss of fine motor skills
- Abnormal gait
- Reduced upward gaze
Diagnosis of Parkinson’s disease
Improvement in condition with levodopa is a positive test for Parkinson’s
Treatment for Parkinson’s Disease
- Increased dopaminergic stimulation
- Decreased cholinergic stimulation
- Decreased glutamatergic stimulation
Non-motor symptoms of Parkinson’s Disease
- Autonomic dysfunction – orthostatic hypotension, urinary symptoms, constipations, sexual dysfunction
- Depression – SSRIs – sertraline, citalopram venlafaxine
- Sleep disorders - melatonin
- Dementia –
- Bladder impairment – nocturia, urgeny, frequency – timed voiding, meds
- Thermoregulation and sweating
Non-pharmacological interventions for Parkinson’s Disease
- Aerobic exercise
- Tai chi
- PT
Medications for Parkinson’s Disease
- Levodopa
- Ropinirole or pramipexole in younger patients – more side effects better tolerated, use because of lower incidence of motor side effects, more expensive
- Types of meds
- Levodopa-carbidopa – take on empty stomach 30-60 min before meals or 45-60 after
- Dopamine agonists – ropinirole or pramipexole
- Amantadine
- Anticholinergics – trihexyphenidyl
Vertigo
- Sensation of room spinning, falling
- Involves cranial nerves VII or VIII
Benign paroxysmal positional vertigo
intense vertigo lasting a minute or so after movement. Comes in bouts lasting for days to weeks, occurring several times in a several week period, and then not recurring for months to years. Lag in symptoms of 5-10 seconds after movement. Usually caused by small calcific particles in ear that break loose and then amplify rotational movements, resolve on own.
Acute labyrinthitis
Sudden onset vertigo with nausea, vomiting, diaphoresis, horizontal nystagmus. Supportive treatment. May be precipitated by URI or vascular injury
Vestibular neuritis
Sudden onset of vertigo lasting hours may be with N/V, tinnitus may be present. May follow ear infection.
Meniere Disease
abrupt onset severe vertigo accompanied by low frequency hearing loss, tinnitus aural fullness n/v. Unilateral hearing loss – diazepam or meclizine
Disequilibrium
Feel like fall imminent.
- Usually affects trunk & lower extremities, disappears when sitting or lying. Multisensory disorder. Symptoms worse in dark –> PT
Types of near syncope (dizziness)
Orthostatic hypotension – eliminate medications as possible cause, IFT if needed
Vasovagal episodes – caused by stress, fatigue, GI (diarrhea, constipation) severe pain – causes reduced cerebral blood flow – low dose beta blocker
Postprandial hypotension– w/in 1-2 hours of eating
Non-specific causes of dizziness
- Anxiety, depression, substance use
- Acoustic neuroma (unilateral hearing loss is an indicator)
- Cerebrovascular disease –
- Anemia, metabolic disorders, DM, thyroid disease, infection, dehydration, trauma, neurovascular compression
What is the most common type of dizziness in older adults?
Benign paroxysmal positional vertigo – provoked by changes in body and head position
In patients reporting dizziness what serious causes should be ruled out?
Ruling out cardiac or cerebrovascular causes is critical as they may be serious and life threatening
Medications that induce dizziness
- anticonvulsants,
- aminoglycosides,
- anxiolytics,
- antidepressants,
- antihypertensives
- benzodiazepines,
- chemotherapeutics,
- neuroleptic
- NSAIDS
Labs to check with complaints of dizziness
- CBC, BG, BUN, Ca, LFT, TSH
- EKG
- Audiometry for hearing loss
- Brain imaging
- Dizziness handicap index
Pharmacological management of dizziness
- Meclizine & antihistamines – for vestibular issues (meniere, acute labyrinthitis)
- Antiemetics
- Withdraw medications which may cause
Management for dizziness
- pharmamcological
- vestibular rehabilitation
- Surgery for turmor removal, severe Meniere’s Disease or refractory BPPV
Vestibular rehabilitation
- Exercise based program to reduce dizziness and vertigo (habituation – repeated exposure to stimulus, gaze stabilization – improve control of eye movements, balance training)
Risk factors for depression
- Chronic illness
- Loss of a loved one
- Relocation
- Disability
- Social isolation
Mild Depression
The intensity of symptoms is manageable with minimal impairment in functioning. There are few symptoms beyond those required for diagnosis.
Moderate Depression
The number of symptoms, intensity, or impairment in functioning is between mild and severe.
Severe Depression
The intensity of symptoms is unmanageable and distressing. Symptoms interfere with functioning. The number of symptoms is beyond what is required for diagnosis.
Symptoms of Depression in Older Adults
- GI complaints
- Illness
- Anxiety
- Irritability
- Weight loss
- Decreased appetite
Diagnosing depression with screening tools
Geriatric depression scale (>5)
PHQ-9 (>10)
DSM-V
Lab testing for depression
- Hypo/hyperthyroidism
- Vitamin deficiency (b12, MMA, Vit D, folate)
- CBC (anemia)
- UA for UTI
Treatment for depression in older adults
- SSRIs are first line- Chose one by considering:
- Safety
- Side effects
- Ease of DC
- Ease of admin (once a day)
- Safety with frail patients
- Few dosage adjustment steps
- Minimal drug interaction potential - SNRIs
- Bupropion - also used for smoking cessation
- TCAs
- Psychostimulants - effective within days, use when other treatment fail
Depression treatment should continue for a minimum of 1 year
SSRI side effects
- transient GI symptoms
- jitteriness
- hyponatremia (check Na 2 weeks after starting)
- GI bleeding
- Tremors
Delayed sleep-wake phase disorder
normal sleep patterns but fall asleep between 1 and 6AM and get up between 10am and 2pm
- Treat with exposure to bright light 7-9am and avoiding bright light evening
Advanced Sleep-Wake Phase disorder
Normal sleep patterns, develop sleepiness in afternoon/early evening
- Treat with bright light for 1-3 hours when patient experiencing sleepiness
Irregular sleep/wake disorder
naps of differing lengths at irregular intervals throughout the day and night (often occurs with dementia) – patients see less light & do less physical activity (LTC and SNF residents)
- Activities during the day, bright morning light, quiet at night
Categories of sleep disorders
- Circadian rhythm
- Breathing disorders
- Hypoventilation
- Movement disorders
- Parasomnias
- Primary insomnias
Obstructive sleep apnea
recurrent and reversible obstruction of the pharyngeal airway during sleep. Decrease in muscles that dilate the airway, decrease pharyngeal lumen leading to upper airway resistance
- Diagnose with polysomnography – cessation of airflow for more than 10 seconds indicates OSA and AHI is >5 per hour
- CPAP or APAP (self-
Conditions that cause sleep related hypoventilation/hypoxemia
COPD, Guillan-Barre, ALS, muscular dystrophies, ankylosing spondylitis, other lung disorders
Restless leg syndrome
- Diagnostic criteria = urge to move legs accompanied by unpleasant sensation, worse when at rest, relieved by movement, worse at night or only occur at night (based on patient history)
- Treatment – dopaminergic agonists – pramiprexole, ropinirole (carbidopa/levodopa are second line), oral iron if ferritin is low
Periodic limb movement disorder
- Repetitive limb movements (toes, ankles, knees, hips) that occur during sleep and are separated by 20-40 second intervals
- Diagnose with sleep study
- Benzodiazepine and clonazepam are first line treatment, also help with pramipexol, ropinirole
Parasomnias
Abnormal or unpleasant motor, verbal, or behavioral events occurring during sleep or at sleep-wake/wake-sleep transitions
- REM Sleep behavior disorder – shift in dream content (violence) and dream enactment. Treated with clonazepam in younger adults, melatonin or donepezil or rivastigmine
Primary insomnias
long-term sleep complaints not attributed to circadian rhythms, breathing disorders, movement disorders, parasomnias
- Paradoxic – chronic severe insomnia including long latency to sleep without functional or cognitive impairments - education, CBT and relaxation
- Adjustment insomnia – acute lasting days to months. Accompanies stressors. Self-limiting
- Psychophysciologic – common learned habit causing increased anxiety at bedtime – CBTI
- Idiopathic – occurs early childhood, few remissions – occurs due to underactive/overactive CNS substrates
- Treatment with CBTI, education and sleep hygiene
Hypersomnia
Individual is unable to appropriately sustain alertness during circadian epochs of wakefulness and activity. daytime sleepiness, difficulty remaining alert, and lapses into drowsiness and sleep. Routine overwhelming need to sleep, frequent naps, amnesia
- Idiopathic
- Recurrent
- Insufficient sleep syndrome
Narcolepsy
Excessive daytime sleepiness, hypnagogic hallucinations, sleep paralysis, disturbed nighttime sleep, and memory problems. Some individuals with narcolepsy experience sleep attacks, where symptoms are triggered by sudden or strong emotions.
- Increase calorie expenditure, good sleep hygiene, gamma globulin therapy IV, modinafil, addderall
- Ramelteon – safe and effective in older adults
