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Dementia and Delirium
Terms in this set (139)
is a chronic, progressive ____________ loss.
Not due to _________ or _________ disease.
_________ is main risk factor, followed by ________ and _________.
Age, Fhx, vascular disease
Dementia per DSM IV is manifested by both ______________ and one or more ____________ disturbance.
memory impairment, cognitive disturbance (aphasia, apraxia, agnosia, disturbance in executive function.
DSM V now recognizes a less severe level of cognitive impairment or NCD
mild neurocognitive disorder
Permits diagnosis of less disabling syndromes that may be the focus of concern or treatment
Mild cognitive impairment describes a decline that has not resulted in ... while major cognitive impairment (dementia) causes a...
a change in the level of functioning
change in the level of functioning
is there more insight in major or minor cognitive impairment?
Dementia typically begins after age _____
Most dementia cases are due to sporadic neurodegenerative disease (3) or result of another disorder such as a _________.
What is protective in dementia?
ongoing intellectual stimulation
RF for dementia
Vascular dz- DM, atherosclerosis
Significant head injury
F > M
Mild cognitive impairment
Higher than average blood level of homocysteine (aa) is a strong risk factor for the the development of ________ and _________.
Alzheimer's disease, vascular dementia
Symptoms of dementia depend on the part of the brain affected
Frontal lobe function
Working memory & memory recall
Naming of objects
Formation and management of memory
Understanding and concentration
What part of the brain is affected in STML
Repeating of question or stories and diminished ability to recall details
short term memory loss
Word finding is located in the...
temporoparietal junction of left hemisphere
Visiospatial dysfunction (getting lost)
right parietal lobe
Executive dysfunction (impulsivity, mental inflexibility, poor planning, slowed processing)
frontal lobes or basal ganglia
Apraxia (where in the brain)
left parietal lobe, frontal lobe
Symptoms of Dementia (3)
Anterograde amnesia (first sign)
Anosognosia (loss of insign into ones cognitive losses)
Neuropsychiatric Sx (loss of insight, apathy, loss of initiative, irritability (sundowning), hallucinations)
Sx of early dementia
-Difficulty managing finances
-Cannot travel independently
- Difficulty preparing meals
-Difficulty with bathing, toileting, feeding
-Problems with strength, coordination, and balance (occur in lewy body dementia and cerebrovascular dementia)
Common problems seen in Dementia pts
________ is an acquired disorder of language due to brain damage. This usually occurs on the _______ side of the brain.
May cause problems with speaking, writing, listening, and reading
Aphasia does not include (3)
- development disorders of language
-motor speech disorder (stuttering, dysathria, apraxia of speech)
-disorders of language that are not secondary to primary thought disorders (schizo)
Have difficulty understanding what is said to them, have fluent speech
When a stroke affects frontal regions of brain that leads to difficulty forming sentences.
Saying things that do not resemble sentences
Make mistakes following directions
Apraxia is a form of ___________ agnosia. Patients do not suffer from paralysis, but have lost of information about how to perform skilled movement.
Apraxia types (4)
Apraxia- localization to parts of the brain
- left inferior parietal lobe
The inability to recognize people or objects even when basic sensory modalities, such as vision are in tact
Types of agnosia: (3)
visual, auditory, somatosensory
Visual agnosia subtypes (4)
-prosopagnosia (inability to identify faces even though the person is known)
-object agnosia (inability to name objects)
-simultanagnosia (inability to recognize a whole image although individual are recognized)
Auditory agnosia subtypes (3)
-auditory/verbal (inability to head words)
-auditory (inability to hear environmental sounds)
-receptive amusia (inability to hear music)
Difficulty perceiving objects through tactile stimulation although basic tactile sensation is intact
Pure astereognosis is thought to be caused by lesions of the _____________ cortex
somatosensory (post central gyrus)
-acute confusional state
-impairment of consciousness (fluctuating level of consciousness)*
-usually results from drugs, ETOH, med side effects, metabolic abnormalities, or sleep deprivation
Amnesia is loss of ________ without other __________ dysfunction. There is/is not a change in sensorium
memory, cognitive, no change
Visuospatial dysfunction has (3)
getting lost in familiar places
impaired recognition of previously familiar faces/ places
Slow processing speed
Poor planning and organization
The motor disorder that appears earliest in the course of dementia
Examination of the demented patient
Frontal release sign (primiritve reflexes suggesting frontal lobe dysfunction)
5 Frontal release signs
Most widely used cognitive test for dementia
T/F: The MMSE is sensitive for mild dementia
Mini-Cog test consists of
uncued recall of 3 unrelated words & clock drawing
For the mini cog test, subjects recalling none of the words, 2 of the words, and all 3 are classified as
not sensitive for mild dementia
Do patients with alzheimer's disease have motor deficits at presentation?
In patients suspected of dementia, the AAN recommends screening for the ___________ and _________.
Screening for __________ is not recommended unless there is a high suspicion.
Structural neuroimaging with either _____________ or ___________ is recommended in the routine initial evaluations of all patients with dementia.
_________ scan with ________. May identify areas of the brain that are hypometabolic and thus likely and thus likely to harbor pathology.
noncontrast heat CT
Screening for depression recommended in dementia because ____________ is a common treatable comorbidity.
Presence of one or two ApoE epsilon 4 alleles indicates increased risk of __________ disease.
Mild Cognitive Impairment have more ___________ into memory problems than dementia patients.
Presence of new memory complaint --> objective evidence of impaired memory --> normal general cognitive functions --> no substantial interference with work, ADLs or social activities --> no dementia
clinical manifestations of MCI:
-Have more insight than dementia patients
-Forget recent events or conversations
- Have difficulty ___________.
-Mental status testing
Treatment of Mild Cognitive Impairment:
-randomized trial showed
-increased physical activity
- transdermal nicotine improves cognitive test performance
Types of major dementia syndromes (5)
-Dementia with Lewy Bodies
Cortical dementias arise from a disorder affecting the cerebral cortex, the outer layers of the brain that play a critical role in cognitive processes, such as _______ and _________. Examples are ______________ and ____________.
Subcortical dementias from dysfunction in the parts of the brain beneath in the cortex. Tend to show changes in their ____________ and _________ and slowed _________.
AIDS dementia complex
What is the most common neurodegenerative dementia?
What is the most important risk factor for AD?
What is another important risk factor?
The brains of individuals with AD:
-Neuritic plaque: ______________
-Intracellular neurofibrillary tangles: ______________
- loss of neurons
-in a low power microscopic section of frontal temporal or parietal areas.....
-extracellular amyloid beta-protein
- Tau protein
- 6 neuritic plaques and neurofibrillary tangles should be visible to make diagnosis of Alzheimer's
Alzheimer's Disease has a deficit in ___________ transmission.
What is the gene that causes Alzheimer's
APOE 4 gene
Early manifestations of Alzheimer's (3)
-traveling to unknown places can cause confusion
What is their appearance?
_____ and ________ memory loss produce disorientation
Patient's have little insight.
_________ restlessness and agitation.
Sensori-motor abnormalities (present/ absent)
Social amenities are preserved until late in the disease
Clinical presentation of alzheimers-
AD does not have any curative disease modifying medications.
Exercise for 45 mins a day is recommended to reduce functional decline & to increase mental stimulation.
Medications for symptomatic benefits (2)
NMDA receptor antagonists
Cholinesterase inhibitors in AD..
Most common side effect of Cholinesterase inhibitors
NMDA Antagonists in AD
What are some symptomatic treatment options in AD?
Vitamin E may delay functional decline; must be prescribed with caution in those with bleeding diathesis
SSRIs help with depression and sleep disturbances. Avoid paroxetine
Atypical antipsychotics to trreat behavioral disturbances. However BBW for death
3 complications in AD
-death (from pneumonia or sepsis)
Vascular dementia involves cognitive decline consisting of impairment of memory + _____ cognitive domains.
Vascular dementia has more problems with _______________ than ______________ or ____________.
Appearance of vascular dementia
Patients with severe vascular dementia are expected to have..
severe cardiovascular disease
Tx for vascular dementia focuses on reduction of modifiable risk factors for CVA like...
HTN, hyperlipidemia, hyperglycemia
Approximately equal to Alzheimer's disease as cause of dementia in patients under 60 y.o
Frontotemporal familial cases result from mutations in genes for _____ or ____.
3 variants of FTD
frontal variant-behavioral variant
progressive non-fluent aphasia
temporal variant- semantic dementia
FTD/ Picks disease is characterized by focal atrophy of the _____ and ____ lobes.
In contrast to AD, FTD presents at a somewhat earlier age and is rare after the age of 75
Behavioral variant have deficits in (4)
Behavioral variant FTD have behavior that is disinhibited (3)
crave sweet, salty food
In behavioral variant FTD, behavioral changes are prominent early in the disease course, unlike in____
Semantic dementia is deficit in word finding
object and categodry knowledge
Tx of frontotemporal dementia:
Symptomatic for agitation, anxiety, and insomnia.
Three drugs that have been used with some sucess
What should not be routinely used?
second MC form of neurodegenerative disease
Dementia with Lewy bodies
Dementia is histologically indistinguishable from
Dementia with Lewy bodies have cognitive dysfunction, ___________ motor deficits, and poor tolerance to __________ meds
psychoactive (neuroleptics, dopaminergics)
Dementia with Lew Bodies
-repeated falls, syncope
-sensitivity to neuroleptics
-REM sleep behavior disorders
Does lewy body dementia have a faster progression than AD?
What are the 5 core features of dementia with lewy bodies?
-Fluctuating cognition (pronounced variation in attention and alertness)
-recurrent visual hallucinations
-sensitivity to neuroleptics
Treatment of disease modifying agents available.
Motor symptoms may improve with ________/_____ and __________ _________. But they can worsen with __________ features.
Typical neuroleptics are contraindicated for increased neuroleptics sensitivity and irriversible __________.
For REM sleep disorder...
carbidopa/levodopa, dopamine agonist
PDD is differentiated from DLB by the time course.
Dementia with Lew Bodies --> ________ dementia
Parkinson's disease ---> ..
What is the overlap in histopathology
late or no dementia
Both can have lewy bodies in cerebral cortex
Hydrocephalus that develops in patients without clear obstruction of CSF
normal pressure hydrocephalus
What is the classic triad for NPH
-gait disturbances (apraxia, magnetic gait)
What kind of gait do you see in normal pressure hydrocephalus?
What is the classic finding on neuroimaging in NPH?
ventriculomegaly out of proportion to brain atrophy
How do you confirm clinical diagnosis of NPH?
In NPH, a videotaped observation of patient before and after large volume (30 mL) lumbar tap should...
What should they be referred for?
document clear improvement
(this finding should be reproducible)
Is CJD cortical or subcortial dementia?
CJD has memory and concentration problems.
What behavioral abnormalities do they have?
What movement disorder do they have?
What visual disturbance do they have?
myoclonus (jerky movements)
cerebellar dysfunction and pyramidal or extra pyramidal involvement
What do you see in EEG of CJD?
patterns of periodic synchronus, sharp wave complexes (spikes)
What is the CSF pattern of CJD?
What confirms CJD dx?
histopathology- spongiform degeneration, neuronal loss, gilosis, + immune staining for prion proteins
Vit B12 deficiency
-slowed information processing
Dx of vit B12 deficiency
-low VB12 levels
-high homocysteine &/or methylmalonic acid levels
Tx of VB12 deficiency
B12 replacement for 2 weeks
Tx for HIV associated dementia
also HAART combined with agressive tx of affective sx
-Wing beating tremor
Autosomal recessive chromosome 13
What atrophies in Wilson's?
Brain findings in Wilsons
caudate atrophy and cystic putamen
Tx for Wilson's
May need liver transplant
Huntington's in an autosomal ____________ disease.
Gradual onset and progression of chorea and dementia or behavioral change
Huntington's Dz has degeneration of ________ and ________-ergic cells in _________.
It has relative excess ________.
cholinergic, GABA, basal ganglia
3 manifestations of Huntington's dz
-middle age onset
-violent outbursts, psychosis, withdrawals
Tx for Huntington's
What atrophies in Huntington's?
caudate nucelus and cerebral
How to dx Huntington's?
CT or MRI
Pseudodementia is in older people who exhibit Sx consistent w/ dementia. But the cause is _________ or another psychiatric illness.
In AD, two proteins _________ and ____________ are postulated to be involved
Tangles INSIDE neurons
Plaques between neurons
Centrally acting reversible cholinesterase inhibitors are used in Tx of AD, because they readily cross the...
Name 3 of these meds (brand and generic)
NMDA receptor antagonist prevent ______ actions.
Example of NMDA receptor antagonist
Approved to treat MILD TO MODERATE AD:
Approved to treat ALL stages of AD:
Approved to treat moderate to severe AD
Which one is available as a patch?
Dosing considerations of AD drugs
Start low and titrate up
Adverse effects of cholinesterase inhibitors
SLUDGE from cholinergic overstimulation
CI of cholinesterase inhibitors
-hypersensitivity to drug or class
-Dont give to people with GI probs already
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