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Setha: Neuro > Reisert: Dementia and Delerium > Flashcards

Reisert: Dementia and Delerium Flashcards

1
Q

acute confusional state with decreased attention that usually lasts over hours to days, but may last months to years

A

Delirium

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2
Q

Also known as:

  • confusion
  • encephalopathy
  • acute brain failure
  • acute confusional state
A

Delirium

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3
Q
  • Older age, baseline dysfunction (failing health, dementia, nursing home patients)
  • poor sleep
  • hospitalization (Catheters, restraints, sleep deprivation, multiple meds, pain)
A

Epidemiology of Delirium

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4
Q

Decreased attention is KEY

May have additional sx:

  • change in sleep awake cycles
  • hallucinations
  • delusions
  • ANS changes such as HR or BP problems
  • hypo or hyperactive status
A

PE features of Delirium

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5
Q
  • Usually due to diffuse cerebral dysfunction
  • May be r/t low Ach levels
  • May mimic Alzheimer’s, Lewy body dementia
  • High dopamine levels possible
A

Pathology of Delirium

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6
Q

Clinical at bedside

Compare baseline function (ask family)

Check for medications:

  • anti-cholinergics
  • sedatives/narcotics/benzodiazepines
A

Diagnosis of Delirium

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7
Q
  • ICU/ Post-op psychosis
  • Sundowning
  • Delirium tremens
A

Delirium syndromes

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8
Q

Illness:

sepsis, fever, dehydration, drug abuse

A

Causes of ICU/Post-op psychosis

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9
Q

Old people who get worse at night

  • common
  • worse if underlying mental health issues, especially dementia

Various degrees of delirium

A

Sundowning

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10
Q

Maintain day-awake cycle

Night-sleep normalcy

Reassurance/reorientation

A

Treatment of sundowning

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11
Q

Mild:

  • Tremor
  • Agitation, anxiety

DT’s

  • Intense reaction
A

Sx of alcohol withdrawal

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12
Q

Usually begins 5-10 hours after cessation

Peaks 2-3 days after cessation

A

Alcohol withdrawal

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13
Q

Alcohol withdrawal syndrome that is worse in context of illness (hospitalization)

A

Delirium tremens

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14
Q
  • Agitation
  • Tremor
  • Hallucinations
  • ANS instability (increased BP, pulse, resp)
  • Seizures
A

Sx of Delirium tremens

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15
Q

treat as status epilepticus

A

Tx for seizures during Delirium tremens

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16
Q

Don’t drink

Slow taper off EtOH

Safe enviro/reoreintation/family, B vitamins, hydrate, treat illnesses

Benzodiasepines

Phenobarbital (less proof?)

A

Prevention of delirium tremens

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17
Q
  • Benzo’s
    • Longer acting better
      • Diazepam (Valium)
      • Chlordiazepoxide (Librium)
    • IV or PO
    • Bad DT’s: high dose
  • Phenobarbital
  • Antipsychotics
    • Haloperidol (Haldol)
A

Tx of delirium tremens

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18
Q

Infection

Sepsis

Drugs

Medications

A

Reversible causes of delirium

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19
Q

HIgh mortality and morbidity

23-33% die (same incidence as sepsis)

longer length of stay

A

Outcomes of delirium

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20
Q
  • Toxins
  • Metabolic
    • liver, kidney, electrolytes, glucose
  • Infection
  • Endocrine
    • thyroid, Vit. B12 def.
  • Cerebrovascular
    • stroke, seizure/post-ictal, metastasis, HoTN
  • Vasculitis
A

Delirium workup

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21
Q

Labs (basics-case specific)

Imaging RARELY helpful

Lumbar puncture

EEG to r/o seizures

A

Delirium workup

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22
Q

Case by case directed-very difficult

Supportive (reorientation, safety)

Day/night normalcy

Home like enviro

bed alarms/sitters

Antipsychotics (Haldol, new “Atypicals”)

Benzo’s (not as good-sedation)

Bedrails

A

Tx of delirium

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23
Q

>4M americans

>$100B annual cost

A

Dementia

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24
Q

“Benign forgetfulness of elderly”

May progress to mild cognitive impairment

Can later develop in some

A

Dementia

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25
Q

Memory loss

10% >70 y/o

20-40% >85 y/o

A

Dementia

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26
Q

Continuum of diease with KEY features

Memory loss (KEY)

Other problems that develop later:

Speech and language difficulties, problem solving difficulties, impaired judgement, mood issues

Often progresive

A

Dementia

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27
Q

Mood disturbances may or may not be seen

  • Depression
  • Agitation
  • Delusions
  • Insomnia
  • Disinhibition
A

Dementia

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28
Q

Changes in cerebral circuits

Nerve loss

Changes in neurotransmitters: Acetylcholine, serotonin, glutamine

A

Neurological features of dementia

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29
Q

Age: by far the greatest

Viral: Creutzfeldt-Jakob

Genetics?: FH of presence of apolipoprotein ε4-a mutant apolipoprotein that may have implications in amyloid formation

A

Risk factors for dementia

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30
Q
  • Alzheimer’s disease: 50% of dementias!
  • Vascular: 10-20%
  • Multi-infarct
  • Frontotemporal: Huntington’s
  • Parkinson’s
  • With Lewy bodies
  • ETOH/Drugs
  • Viral/prion disease (Creutzfeld-Jakob: fast progression)
A

Major types of Dementia

31
Q

Depression

Hydrocephalus

ETOH

A

Dementia look-a-likes

32
Q

Memory loss is often subtle

Progressive over years

A

Alzheimer’s dementia

33
Q

Neuritic plaques (“senile plaques”)

amyloid (Aβ amyloid, Aβ42 amyloid or simply “Beta amyloid”) deposition in arterial walls of neurons

neurofibrillary tangles in cytoplasm of neurons

A

Pathology of Alzheimer’s dementia

34
Q

Affects more women due to longevity

Affects all intellecutal levels, but higher incidence in Down’s syndrome

A

Alzheimer’s dementia

35
Q

What must you rule out with ICU/Post-op psychosis?

A

Stroke!

36
Q

Difficulty with ADL’s

lack of recognition of disease (anosognosia)

Behavior changes-may get lost

Word finding issues/other speech difficulties

Can’t do puzzles

A

Dementia

37
Q
  • Wandering
  • Poor judgment
  • Delusions
  • Agression
  • Sleep disruption, altered sleep-awake cycle
  • Incontinence
  • Bedridden
  • Death (infection, malnutrition, heart disease) in 8-10 years (up to 25)
  • Confirm on autopsy
A

Late sx of alzheimer’s dementia

38
Q

Family education

Respite care, adult daycare

Safety (wandering, falls, driving)

Medications

A

Tx for Alzheimer’s dementia

39
Q

A type of vascular dementia

Classically in HTN patients

May progress different

A

Multi-infarct dementia

40
Q

Larger area, more dementia

Presentation more sudden onset

Looks like AD, may have amyloid, with increase risk of hemmorhage

A

Vacular dementias

41
Q

Diffuse what matter disease (Binswanger’s dx or leukoaraiosis)

Large or small infarcts, lacunar infarcts (HTN)

A

Vascular dementias

42
Q

Treat risk factors

Medications less helpful

A

Tx of vascular dementias

43
Q

Huntington’s chorea

Pick’s disease

Progressive supranuclear palsy

A

Examples of frontotemporal dementias

44
Q

Memory loss typically later in disease

Attention issues, judgment impairment, awareness, behavior problems

Aphasias seen

Males>females

A

Frontotemporal dementias

45
Q

Autosomal dominant inheritance

Chromoome 4

Family history

50% chance of getting

A

Huntington’s chorea

46
Q

Signs: writhing movements (chorea, dancing)

Sx: Motor and cognitive problems (emotional)

A

Signs/Sx of Huntington’s chorea

47
Q

Onet 35-45 years old

After childbearing

Fatal in about 20-25 years

A

Course of Huntington’s chorea

48
Q

Involuntary movements that look like jerks/tics that they can’t control

After 10 years –> movements are slow (Parkinsonoid like) with bradykinesias, rigidity, dystonia

mood changes

cerebral atrophy

A

Huntington’s chorea

49
Q

Family history

Genetic test

A

Diagnosing Huntington’s chorea

50
Q
  • Symptom treatment:
    • Dopamine blockers (tetrabenazine)
      • helps with chorea
    • Anti-psychotics
    • Anti-depressants
  • Genetic counseling?
A

Tx of Huntington’s chorea

51
Q

Anterior frontal and temporal cerebral cortex

Intracellular inclusions (Pick bodies) stain with silver stain

A

Pick’s disease

52
Q

No treatment

Just treat behaviors

A

Pick’s disease

53
Q
  • Parkinson’s like
  • Falls
  • Gaze parakysis (can’t look down)
  • Rigidity
  • Dementia
  • May development poor judgement, apasia

Treatment: not real helpful

Death 5-10 years

A

Progressive supranuclear palsy

54
Q

Classic features of Parkinson’s with dementia:

Tremor

Rigidity

Masked facies

Bradykinesia

Cogwheeling

A

Signs/Sx of Parkinson’s dementia

55
Q

Do all patients with Parkinson’s get Parkinson’s dementia?

A

NO!

56
Q
  • Visual hallucinations
  • Parkinson’s features
  • Decreased alertness
  • Presentation often delirium in face of infection or given L-dopa drug for Parkinson’s and get delirium
  • Episodic confusion that waxes and wanes, but persists
  • Lewy bodies are intraneuronal cytoplasmic inclusions that stain with PAS staining
  • May have cholinergic defect
  • May overlap with other dementias
A

Signs/Sx of dementia with Lewy bodies

57
Q

Treatment for dementia with Lewy bodies?

A

Anti-cholinergic drugs

58
Q

Gate ataxia

Dementia

Urinary incontinence

A

Normal pressure hydrocephalus

59
Q

Imaging shows large ventricles

Some use MRI for imaging

Some use supervised CSF tap

DIFFICULT diagnosis to make

A

Diagnostics for normal pressure hydrocephalus

60
Q

Treatment for normal pressure hydrocephalus?

A

Shunting

61
Q
  • Long term use
  • Vitamin deficiences: Wernicke’s encephalopathy
    • Thiamin deficiency
    • Confusion, ataxia, diplopia due to opthalmoplegia
A

Ethanol induced dementia

62
Q

Treatment for Wernicke’s encephalopathy/Thiamin deficiceny?

A

100mg IV thaimin x 3 days

63
Q

Can’t recall recent memory despite immediate memory retention

Get easily confused

Confabulation

A

Korsakoff’s syndrome

64
Q

Often spinal cord issues (myelepathy)

Macrocytosis

Treatment: replace wtih sv Vit. B12

A

Vitamin B12 deficiency

65
Q

Not a dementia

Awake and fine then later forget a moment of time

SCARY patient

A

Transient global amnesia

66
Q

Etiology of transient global amnesia?

A

Somewhat unknown?

Migraine, stroke?

67
Q

Tx for transient global amnesia?

A

Reassurance!

68
Q

Perhaps the most important thing!

Wrong diagnosis –> wrong treatment

A

Recognition and diagnosis of dementia

69
Q

What are some histories seen with dementia?

A
  • memory loss, duration
  • Other sx (driving, shopping, eating, depression, erratic behavior, hallucinations, tremor/Parkinson’s)
  • Strokes/CV risk factors (esp. multi-infarct dementia)
  • HIV.syphilis
  • head trauma (hydrocephalus)
  • Nutrition isses (ETOH/thiamin deficiency, gastric bypass/obesity surgeries)
70
Q

History

Mini-mental status exam

Full neuropsychiatric testing

Parkinson’s features?

Atrial fibrillation, HTN, etc

Labs: B12, Thyroid recommended by American Academy of Neurology

Exam/Work up for _____?

A

Dementia

71
Q

Delay progression of disease

Improve caregiver fatigue

decrease agitation

A

Pharm therapy in dementia

72
Q

CT or MRI

Looking for:

atrophy, hematoma, infarction, tumor

A

Imaging for dementia

73
Q

It is also important to treat who in dementia?

A

Caregivers

Setha: Neuro (9 decks)

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