cognitive disorders

Created by ptot85 

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Significant impairment in function having to do with

Memory
Judgment
Language
Attention

becoming confused at the end of the day

sundowing

iappropiateness or exacerbation of underlying-undesireable-personality traits

disinhibition

decreased vocabulary and use of clichés

poverty of speech, alogia

MMSE done to obtain

GROSS estimate of cognition

MMSE aka ______, used to assess _______

Folstein, assesses cognition

in about 10 minutes the MMSE assesses what parts of cognition

MOA
Memory, orientation, Arithmetic

Name 3 objects: 1 second to say each. Then ask the patient to name
all 3 after you have said them. Give 1 point
for each correct answer.
Then repeat them until he/she learns all 3. Count trials and record.

Registration

Serial 7's. 1 point for each correct answer. Stop after 5 answers.
Alternative: spell "world" backward.

Attention and calculation

2 ( ) Name a pencil and watch.
1 ( ) Repeat the following "No ifs, ands, or buts"
3 ( ) Follow a 3-stage command:
"Take a paper in your hand, fold it in half, and put it on the floor."

Language

On a clean piece of paper, draw intersecting pentagons (as below), each side about one inch and ask him/her to copy it exactly as it is. All ten angles must be present and two must intersect to score 1 point. Tremor and rotation are ignored.

copying

Normal score, borderline score

27-30 normal
23-26 borderline

Low to very low scores correlate closely with the presence of

Dementia

A score of 22 or less generally suggests

dementia, acute confusion, schizophrenia or severe depression

A score of less than _____ may indicate dementia in some patients who are well educated and who do not have any of the above conditions.

24

Next 3 questions: Scoring with individuals with Dementia of Alzheimers Type
20-26
10-19
<10

Mild disease
Moderate
Severe

Lab tests to measure, besides standard

"HMFB"
Homocysteine
Methylmalonic acid (more sensitive)
Folate
B12

Alteration (fluctuating) level of consciousness
Associated with altered attention and cognition
Rapid Onset
May be reversible

Delirium

Delirium is always due to

a Medical/Surgical cause

Causes of general medical ways to get delerium

Infections
Metabolic
Post surgical
Hyper/hypo- thyroidism
Ictal/postictal
Head Trauma
Miscellaneous (e.g. anemia, Thiamine deficiency).
Whole Brain Radiation Therapy

Substance related delirium

Intoxication
Withdrawal
Medication-Induced
Toxins (Carbon Monoxide, organophosphates).

Delirium is found is what % of ICU pts, what % of General medical pts over 65

60-87%-> ICU
10-15%-> Gen Med over 65

Highest incidence of delirium where, next highest

Surgical ICU, next highest Cardiac ICU

Delirium now seen as an independent risk factor for

death and dementia, about 22-76% of pts hospitalized with delirium die

When diagnosing delirium the Most widely used bedside rating scale patients is the

CAM (Confusion Assessment Method)

Most significant elements of the diagnosis are ________ and broad ________ of symptoms

inattention, fluctuations
Not components of any other psych illness of late life

NOT considered an essential element of dx of delirium

orientation

Clinical feature of delirium is the atttention complex phenomen, this involves

Distractibility, vigilance, and concentration

Inattention may present in subtle ways

Pts exhibiting QUIET delirium may be mistaken for

fatique
uncooperativeness
dysphoria
disinterest

Grossly agitated and irritational pts present as

hyperactive delirium
Marked state of: Agitation
Physical aggression
Violence
Hyper-attentiveness (inability to suppress responses to environment or to internal states)
Emotional lability

Obvious deficits in focused attention and fluctuations of presentation

Hyperactive delirium

State reflects INABILITY to attend in sequential fashion to demands of environment and marked by
Withdrawal
Lack of involvement in or communication with environment
Bland or flat affect
Depressed level of consciousness that is short of frank stupor

Quiet delirium

Highest proportions of pts have what type

Mixed delirium (45%)
Active delirium (30%)
Quiet delirium (25%)

Unless marked are often missed
Written off as differing responses to variety of health practitioners or varying hospital situations/environment
Nurses more likely to recognize early signs
Staff notes help with diagnosis

Fluctuations

All subtypes can present with these motor symptoms

Dysarthria
Difficulty swallowing
Gait disturbances

Affective symptoms seen with all subtypes

LAD
Lability
Dysphoria
Anxiety

Associated with incorrect cerebral processing of sensory data- difficulties hearing, appreciation of pain, etc

Sensory deficits

Psychotic like symptoms in delirium

Disorganized speech
Visual halluncinations: Although usually more illusory than hallucinatory: Ex: Clowns on bicycles; tires on the ceiling

Worse outcome than with definite mild delirium

SUB-Syndromal delirium

3 steps in DDx of delirium

Rule out potentially life-threatening causes: "WWHHHIMP"
Rule out the impact of medications
Continue to search for a cause even though no obvious cause found

WWHHHIMP DDx

Wernickes: Confusion, Ataxia, Opthalmoplegia
Withdrawal
Hypertensive Encephalopathy
Hypoxia
Hypoglycemia
Intracranial Bleeding: HA, neuroimaging
Meningitis and Encephalitis: almost always FOCAL deficits
Poisons: heavy metals

Differentiate delirium from dementia and prominent psychotic illnesses- including

schizophrenia, Schizoaffective Disorder, and Bipolar Disorder, can be problematic

Which presents more ACUTELY delirium or dementia

DELIRIUM

In DEMENTIA pts level of attention is as _______ _______ as delirium

not as severely affected

Most often delirium is a

catastrophic and abrupt event

Patients with delirium superimposed on dementia had more than ______ the risk of mortality at 12 months than patients with delirium alone, dementia alone, or patients with neither

2x

Asterixis most commonly seen is pts with

encephalopathies

BUT 60% of patients with delirium have symptoms of ______ AND 52% have passive or active thoughts of _______

Dysphoria
Suicide

pt presents with ACUTE suicide ideation think

Delirious pt, suicide rarely an acute disorder

Tx of Delirium

Identify and treat the contributing medical conditions).
Low dose, high potency anti-psychotic and/or benzodiazepines for symptomatic treatment of agitation.

Cognitive Deficits and Memory Impairment
Consciousness is NOT impaired as in Delirium
Course is generally gradual and progressive
Very rarely is reversible

DEMENTIA

memory impairment is shown by one or more of the following in pts w/ dementia

Aphasia- disturbance in compresion or expression of language
Apraxia- impaired ability to perform a purposeful motor activity despite intact motor ability
Agnosia- failure to recognize objects despite intact sensory function
Impaired executive functioning- planning, orgnanizing, sequencing and abstraction

Deficits must be

clinically significant, must interfere w/ social or occupational functioning

______ accounts for 70% of dementia cases

Alzheimers

overall incidence, men compared to women

equal

Lower rates of Alzheimers in

Men

Higher vascular dementia in

Men

Extracellular senile plaques
Intracellular fibrillary tangles
Synapse degeneration
Loss of neurons in cortex and subcortex
Neuron loss affects neurotransmitter system
Decrease in acetylcholine in forebrain neurons
Neurofibrillary tangles

Alzheimers (MC type of Dementia)

Tactile Sensation
Visuospatial Function (Right)
Reading (left)
Calculation (left

Parietal lobe

Voluntary Movement
Language Production (L)
Motor Prosody (Right)
Comportment
Executive Function
Motivation

Frontal lobe

Audition
Language Comprehension (Left)
Sensory Prosody (right)
Memory and Emotion

temporal lobe

Loss of short term memory
Word-finding and naming difficulty
Vague speech
Circumlocution
Use of clichés
Develop apraxias
Affects dressing (motor apraxia)
Affects eating

Early states of Alzheimers

Judgment becomes impaired
May develop personality changes
Apathy
Hostility
Social withdrawal
Disturbed sleep-wake patterns

Later states of Alzheimers

Depression in what % of Alzheimers pts

40

Delusions are common and affect what % of Alzheimers pt

50%

individuals living in skilled nursing homes with Behavioral and Psychological Symptoms of Dementia (BPSD)

80%

Depression in dementia is genetically related to

primary affective disorder, ie have depression in family, get dementia, more likely to get depression as well

most common personality change seen in dementia: 48%- 92%

Apathy: Lack of interest, less affection in personal relationships, loss of enthusiasm, decreased initiative, and social withdrawal

Belief that a friend, family member, or acquaintance been replaced by an identical-looking imposter

Capgras Syndrome

Commonly include false beliefs of theft or identity

Delusions

An unseen individual is living in the home

Phantom Boarder Syndrome

Which is seen more visual or auditory hallucinations

VISUAL

Risk factors for Alzheimers

Increasing age
Positive family history
History of head trauma
Down's Syndrome
Genetic component of the disease is suggested by fact that up to 50% of those with a first degree relative with the disease will be affected by the age of 90 yrs

THREE CHROMOSOMES HAVE BEEN LINKED TO DEVELOPMENT OF EARLY ONSET ALZHEIMER'S DISEASE

Trisomy 21
Chromosome 14
Chromosome 1

Chromo 14 contains

presenilin 1 gene
-Mutations on this site account for most cases of familial early-onset Alzheimer's

Chromo 1 contains

presenilin 2 gene
-Associated with the disease in families from the Voga River area in Russia

Chromo mutations account for only

5% of alzheimers disease

Associated with an increased risk for Alzheimer's disease and with an earlier age of onset, what gene

Apo-E4 allele

what to get this test with dementia pts

VDRL

Scales commonly used to assess for Behavioral and Psychological Symptoms of Dementia (BPSD)

Apathy Inventory
Behavioral Pathology in Alzheimer's Disease Rating Scale (BEHAVE-D)
Columbia University Scale for Psychopathology in Alzheimer's Disease (CUSPAD)
Consortium to Establish a Registry for Alzheimer's Disease Behavior Rating Scale for Dementia CERAD-BRSD)
Cohen-Mansfield Agitation Inventory (CMAI)
Cornell Scale for Depression in Dementia (CSDD)
Neuropsychiatric Inventory (NPI)

2nd MC type of dementia

Vascular

Progression of vascular dementia is

step wise, with diffuse distribution

Risk factors for vascular dementia

vascular dz
vasculitis
embolic disease including AFIB

yields a nine-fold increased risk of dementia

Stroke

Tx is what, focused on

Anticoag with coumadin or aspirin
Focused on secondary prevention

transmissible spongiform encephalopathies (TSEs).
Spongiform
Infected brains become filled with holes and begin to look like sponges when viewed under a microscope microscope. CJD is the most common of the known human TSEs. Other human TSEs

CJD

Most common category of Creutfelt Jakob Disease (CJD)

Sporadic-85%
Hereditary- 5%
Acquired- most infrequent

CJD progresses, onset usually

rapidly
onset 40-50 yrs old

Signs to look for with CJD

Ataxia
Extrapyramidal signs
Choreoathetosis
Dysarthria
Myoclonic jerks

CJD usually fatal by

6-12 mos of dx

Tx CJD

NONE

Autosomal Dominant Disease
Chromosome 4
Chance for development of disease in a person who has one parent with disease is 50%

Huntingtons

Dx of Huntingtons

Onset in 30-40's (Patient usually has children by this time)
CHOREIFORM MOVEMENTS seen first and become more severe

Dementia in Huntingtons presents

later, often with psychotic features
May first be described as a personality change

MC associated change seen with Huntingtons Dementia

Mood (50%)
Dementia develops in 90%

pathophysiology of Huntingtons Dementia

Brain atrophy
EXTENSIVE involvement of basal ganglia and caudate nucleus

Choreiform movements often misinterpreted

tics or spasms

Up to 75% of Huntingtons pts misdiagnosed with

psychiatric illness and classic choreiform movement disorder

Progressive course with Huntingtons, usually leads to death in

15-20 years, suicide common

Another more common type (up to 25%)
Parkinson-like symptoms
Extreme sensitivity to antipsychotic drugs
Visual Hallucinations
More marked response to cholinesterase inhibitors

Lewy Body Dementia

Postmortem studies reveal the presence of Lewy bodies in up to ____% of dementia cases

25%, some say it may the the 2nd MCC of dementia in U.S

Clinical presentation of Lewy Body Dementia

Shares features of both Alzheimer's disease and Parkinson's disease
May have repeated falls
Unusually SENSITIVE to adverse effects of NEUROLEPTICS

Common psychiatric symptoms

DEPRESSION and systematized delusions

Consensus criteria for clinical diagnosis

Progressive cognitive decline

At least 2 of the following for probable Dx of Lewy Body Dementia

Recurrent (WELL FORMED) visual hallucinations. May see auditory hallucinations
Parkinsonism
Fluctuating cognition (with variation in attention and alertness)

More prevalent in, onset

males 2:1
onset 50-80

Typical neuropathic finding is a Lewy body which is

a ROUND eosinophilic intraneuronal inclusion
-found in cortex or subcortex
-sometimes found in Alzheimers and Parkinsons

bradykinesia, resting tremor, pill-rolling tremor, mask-like faces, shuffling gait, etc

Parkinsons

Parkinsons associated with dementia is

70% of cases

Frontal lobe is predominately involved
See frontal signs of disinhibition
Relative preservation of cognition
May have Kluver-Bucy Syndrome (hypersexuality, hyperorality, placidity)
5% of all dementias

Pick's Disease

hypersexuality, hyperorality, placidity

Kluver-Bucy Syndrome, may be seen with Picks Disease

Must obtain history from family members when evaluating dementia, why

pts do not report deficits because they do not see them

Depression that presents with cognitive and memory impairment that resembles dementia
Treat with anti-depressant medication or ECT

Pseudodementia

Tx of Dementia:
Use medication that increases the level of __________ in the brain, enabling neurons to communicate with one another more effectively

acetylcholine

Meds used block the action of

acetylcholinesterase

drugs that enhance cognition,

cholinesterase inhibitors
Tacrine
Doneprezil- less GI
Revastigmine- available as patch

Improvement documented in Dementia associated with Parkinsons and Lewy Body dementia

Revastigmine

Inhibits acetylcholine
Also selective enhancement of nicotinic activity

Galantamine

Manipulating the ______ receptor (a part of the neuron receiving a specific chemical signal at the synapse) allows a treatment option
Excessive stimulation of NMDA receptors may cause neuronal cell death. A compound that blocks such excessive stimulation may sow the progression of moderate to severe Alzheimer's dementia

NMDA

NMDA (N-methyl-D-aspartate) antagonist. Slows down the progression of the disease by blocking excessive stimulation of NMDA receptors

Memantine Hydrochloride (Namenda)

3 types of amnestic disorders

1. med condition ie head trauma
2. substance induced
3. NOS

MC form of amnestic disorder caused by

Thiamine deficiency associated with alcohol dependency

Occurs in pts with hx of arachnoid insult-
Infection or bleeding affects ability to absorb spinal fluid
Can be seen with MRI or CT scan
Have sxs that resemble subcortical dementia
Can take years to manifest

Hydrocephalus: approx 6% of pts with normal pressure hydrocephalus are misdiagnosed as having dementia

Triad of hydrocephalus symptoms

Wet, Wacky, and Wobbly:
Unsteadiness of gait
Psychomotor retardation
Urinary incontinence: 90% of pts after gait issues, can't control detrusor

Tests for hydrocephalus

MRI to look for large ventricles
Gait tests before and after 100cc lumbar drain for 3 days

Tx when fluid is excess, outcome

shunt
1/3 significantly improve
1/3 stabilize
1/3 decline

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