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126 terms

cognitive disorders

STUDY
PLAY
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