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Flashcards in Dimentia and Delerium Deck (29):
1

What is dementia?

DSM 5 criteria for Dementia Dx

Dementia is a term used to describe a cluster of sx including:
-forgetfulness (progressive), difficulty doing familiar tasks, confusion, poor judgement, decline in intellectual functioning

DSM5:
-significant cognitive impairment in at least one of the following cognitive domains:
-learning and memory
-language
-executive function
-complex attention
-perceptual-motor function
-social cognition
*cognitive deficits must interfere with independence in everyday activities/social/occupational impairment

2

Causes of Dementia

-alzheimers (70%)
-vascular dementia (strokes and TIA)
-parkinsons
-frontotemporal dementia
-Normal-pressure hydrocephalus
-dementia w/ Lewy Bodies
-delirium/depression

3

What are some modifiable causes of dementia?

-medications (anticholinergics)
-alcohol
-metabolic (B12, thyroid, hyponatremia, hypercalcemia, hepatic and renal dysfunction)
-depression
-CNS neoplasms chronic subdural hematoma
-NPH

4

Alzheimers Dz:
-what?
-what are the most common early and late stage signs?

What: progressive neurologic disorder that results in memory loss, personality changes, global cognitive dysfunction, and functional impairments.

Loss of short term memory is most prominent early.
In the late stages of dz pts are totally dependent on others for ADLS.

5

Alzheimers
-Dx
-clinical dx
-symptoms & behaviors

Dx of exclusion

Clinical Dx:
-Hx, mental status eval, depression screening, PE, neuroimaging, CBC, CMP, B12, TSH

Symptoms and Behaviors:
-short term memory loss
-long term memory loss (late)
-poor judgement
-disorientation/inability to adapt to new environments
-personality changes
-communication disorders
-demanding and repetitive behaviors
-behavior changes; aggression. delusions, hallucinations

6

Alzheimers Assessment:
-what does this consist of?

-Mini mental status exam
-Draw clock face w/ the time.
-3 item recall
-neuro exam (focality, grasp, apraxia, cogwheeling, eye movements)

7

Mini Mental Status Exam
-describe scores of 20-26, 10-20, less than 10

-what MMSE score is suggestive of dementia?

20-26: mild functional dependence

10-20: moderate, more immediate dependence

less than 10: severe, total dependence

MMSE score of 24/30 is suggestive of dementia

8

What are the 3 neuropathological hallmarks of Alzheimers dz?

-amyloid rich senile plaques
-neurofibrillary tangles
-neuronal degeneration

9

Describe the 7 stages of Alzheimers

Stage 1: free of symptoms, pathology has begun

Stage 2: normal aged forgetfulness, greater than 65yrs most likely, believe they can no longer recall names

Stage 3: mild cognitive impairment, deficits are subtle but are noted by persons who are in close contact (e.g repeated questions, job performance may decline)

Stage 4: Mild Alzheimers Dz, pt has decreased ability to manage instrumental activities of daily life. (manage finances, prepare meals for guests) Stage lasts 2 years

Stage 5: Moderate Alzheimers Dz,deficits in basic activities of daily life (e.g choose proper clothing to wear for the weather conditions,wearing same clothes everyday). Cannot recall such major events of their current lives (e.g current president, their current address, names of schools they attended for many years) Lasts 1.5years

Stage 6: Moderately Severe Alzheimers dz; basic activities of daily life become compromised (e.g not able to maintain living at home, cannot put their own clothing on properly) Stage lasts 2.5years

Stage 7: Severe Alzheimers Dz; all intelligible speech is essentially lost, ambulatory ability is lost, lose ability to smile, and ability to hold their head up independently. Re-emergence of so-called infantile or primitive reflexes

10

Alzheimers Dz:
-most frequent cause of death?
-pts in 7th stage are more vulnerable to what causes of mortality?

-most common cause of death is aspiration pneumonia

-Pts in 7th stage appear more vulnerable to all common causes of mortality including sstroke, heart disease, cancer

11

Alzheimers Dz:
-Tx general
-Tx: medications
--cholinesterase inhibitors & SE
--NMDA receptor agonists & SE
--Selegiline
--Vit E
--Antidepressant
--antipsychotics
--antiepileptics

-there is no cure

Cholinesterase inhibitors:
slow the breakdown of ach. may slow progression of sx.
*Examples:
-Donepezil: only tx approved by FDA for all stages of alzheimers dz

-Rivastigmine: approved for use in mild-moderate alzheimers dementia; skin patch, capsules, liquid

-Galantamine/Razadyne: approved mild-moderate, CI in renal/hepatic impairment

SE of all cholinesterase inhib: D/V/N, fatigue, insomnia, weight loss.

NMDA receptor antagonist:
-Memantine; regulates the activity of glutamate, brain cells in people wiith alzheimers release too much glutamate. moderate to severe

SE: dizziness, confusion, hallucinations

Selegiline: prevents breakdown of dopamine

Antidepressant:
-Zoloft, Paxil, Celexa (SSRI)

Anti-psychotics: hallucinations, delusions, aggression
-abilify, zyprexa, seroquel, risperdal, geodon
*these may increase risk of death

Anti-eleptics:
-dedakote and gabapentin

12

What drugs should be avoided in patients with dementia?

Benzodiazepines, antihistamines, anticholinergics
*may actually worsen symptoms

13

Vascular Dementia:
-how does one acquire this?
-criteria for vascular dimentia

onset of cognitive deficits associated with CVA, abrupt onset of symptoms followed by stepwise deterioration.

Criteria for VD:
-Cerebrovascular dz evident on hx, examination, or imaging in addition to:
--onset of dimentia within 3mo
--abrupt fluctuating or stepwise progression in dementia

14

Frontotemporal Dementia
-what is this?
-whats one subtype? characteristic of pathology?
-age at onset

-What: focal atrophy of the frontal and temporal lobes in the absence of alzheimers pathology

Picks dz is a subtype of FTD.
Pathology: pick bodies

Age: 35-75yrs

15

Frontotemporal Lobe Dementia:
-core features
-supportive features

Core:
-insidious onset and gradual progression
-early decline in social conduct
-early impairment of personal conduct
-early loss of insight
-emotional blunting

Supportive:
-behavior disorder (hygeine, dietary changes, perseverative behavior=wont let stuff go)
-speech and language
-akinesis, restlessness, rigidity, tremor, labile BP

16

Normal pressure hydrocephalus:
-what is this?
-Triad of sx
-dx
-tx

What: condition of pathologically enlarged ventricular size with normal opening pressures on LP.

Traid:
-wacky (dementia)
-wobbly (gait)
-wet (urinary incontinence)

dx:
-MRI
-miller fisher test: objective gait assessment before and after remove of 30cc of CSF


Tx:
ventriculoperitoneal shunt

17

Dementia w/ Lewy Bodies
-most commonly associated with what other disorder?

-sx

-Core features for clinical diagnosis

Parkinsonism

Sx:
-delirium, visual hallucinations, parkinsonism
-syncope*. falls*, sleep disorders, depression, transient loss of consciousness*

features for clinical dx:
-progressive cognitive decline of sufficient magnitude to interfere with normal social or occupational function.
-2 of the following:
--fluctuating cognition w/ variation in attention and alertness
--recurrent visual hallucinations
--spontaneous motor features of parkinsonsim

18

Parkinsons Dz Dementia
-when does the dementia hit?

-dementia usually occurs in the last half of the clinical course of PD

19

Progressive Supranuclear palsy
-aka
-mimics which disease?
-characteristics

aka: Steele Richardson Olszewski syndrome

mimics PD in early phases

Characteristics: restricted up down eye movement, postural instability (stand straight or even tilt their heads backwards & tend to fall backwards.

20

Creutzfeldt Jacob Dz
-aka
-caused by?
-characterized by?

aka: mad cow dz

caused by: prion, contracted from consuming material from animals (cows)

Characterized by: dementia with rapid onset and deterioration, motor deficits, seizures

21

What are some other infections that may cause dementia?

-neurosyphillis
-HIV dementia

22

Delerium:
-what is this?
-4 major causes
-risks

What; sudden and significant decline in mental functioning, reduced ability to focus, sustain, and shift attention

4 major causes:
-underlying medical condition (hypoglycemia)
-substance intoxication
-substance withdrawl
-combination of any or all of these.

Risk:
-elderly, greater than 80yrs
-hx of dementia
-post cardiac surgery
-burns
-drug withdrawl
-AIDS

23

Delerium:
-clinical features

Clinical features:
-Prodrome: restlessness. anxiety, sleep disturbance

-fluctuating course; develops over short period, sx fluctuate

-attention deficit: easily distracted

-arousal/psychomotor disturbance: hyperactive, hypoactive, or mixed

-impaired cognition: memory deficits, language disturbance, disorganized thinking, disorientation

SLeep-wake disturbance: fragmented or reversed normal cycle

Altered perceptions: illusions, hallucinations, delusions

Affective Disturbances: anxiety, fear, depression, irritability, apathy, euphoria, lability

24

Delerium:
-duration
-What is I watch death?

Duration:
-sx resolve in 10-12days may last up to 2 mo, dependent upon the underlying problem and management.

I WATCH DEATH = causes of delerium.
-infections (meningitis, urosepsis)
-withdrawl
-acute metabolic (liver/renal failure)
-Trauma
-CNS pathology (seiz, stroke, tumor)
-Hypoxia
-Deficiencies (thiamin, B12)
-endocrinopathies
-acute vascular (hypertensive; MI)
-toxins or drugs
-heavy metals (lead)

25

Mini Mental Status Exam:
-what does this test?
-what is a perfect score? what score indicates a problem?

Test orientation, short-term memory, attention, concentration, constructural ability

-perfect score is 30, score less than 24 suggests a problem...

26

Delerium Management

-treat the underlying cause
-increase observation, eval violence potential
-discontinue or minimize dosing or nonessential meds
-provide post-delerium education & educate family

Meds:
-agitation: haloperidol (QT prolongation; torsades) or inapsine (more sedating and rapid onset than haloperidol) (QT prolongation; torsades)

-antipsychotic: risperidone

27

WHat is the drug of choice for tx of alcohol withdrawl delerium? CI in which patients?

Benzodiazepines
^^these are CI in those with hepatic failure

28

Delirium may progress to what other serious disorders?

-stupor, coma, seizures, or death if untreated.

29

Take home points; Dementia vs Delirium

-onset
-cause
-reversibility
-attention?
-conciousness?
-memory?

Dementia:
-onset: slow gradual onset
-cause: chronic disorders
-progressive and not reversible
-attention not impaired until later stages
-no effect on conciousness
-loss of memory esp for recent events

Delerium:
-onset: acute
-causes infection, pain, meds, MI
-usually reversible
-attention is impaired
-conciousness varies from lethargic to hyperalert
-effect on memory varies.