Week 6 - Neurocognitive and Psychiatric Disorders Flashcards
Mild cognitive impairment
cognitive changes beyond what is expected from normal aging but with preserved function – family members may report symptoms
Dementia
Cognitive dysfunction across multiple domains with impaired functioning.
Dementia Clinical tools
- Clinical dementia rating scale (CDR)
- MMSE
- Montreal cognitive assessment instrument (MOCA)
- SLUMS
- AD8 <5min
- Mini-cog
Mild dementia
CDR score 1
MMSE 20-26
Poor memory, forgetting key events, repetitive questioning, misplacing familiar objects, maintain ADLs, and some iADLs, live independently
Moderate dementia
CDR =2
MMSE 12-19
Worsening memory loss, difficulty using language, problems reading/writing, impulsive behavior, difficulties with multistep tasks like dressing/bathing, gradual dependence on others for ADS and iAdls, emergence of paranoia, delusions, hallucinations
Severe dementia
CDR=3
MMSE<12
inability to communicate verbally, sleep dysregulation, lose motor function, dysphagia, weight loss, lose desire to eat/drink, dysmobility - bedridden
- incontinence
Non-modifiable risk factors for dementia
- Age
- genetics
- family history
- low level of educational attainment
- CKD
- AF
- Depression
Potentially modifiable risk factors for dementia
- HTN
- CVD
- Obesity
- Social isolation
- Alcohol/smoking
- Medications
- Diabetes
- Sedentary lifestyle
- Sleep disorders
- Hearing impairment
- Brain trauma
- Environmental pollutants
Cognitive impairment screening recommendations
Not currently recommended by the USPSTF
Labs to check with cognitive impairment
- CBC
- CMP
- LFT
- TSH
- Vitamin B12
- HIV & Syphyllis
- neuroimaging (falls, abnormalities with exam, anticoagulants, atypical features–> CT or MRI)
Treatment for cognitive impairment
- Cholinesterase inhibitors (donepexil, galantamine, rivastigmine)
- GI distress
- Weight loss
- Urinary urgency
- Bradycardia
- Syncope
- Sleep disturbances - N-methyl-D-aspartate receptor inhibitor – memantine (can help with behavioral symptoms)
Frontotemporal neurocognitive disorder symptoms
Behavioral disturbances such as:
- impulsivity
- socially inappropriate behavior
- hoarding
- apathy
- personality changes
- decline in language abilities
Memory is typically intact.
Neurocognitive disorder with Lewy Bodies symptoms
Memory loss, difficulty in executive function, depressed mood, and cardiovascular risk factors
Risk factors for delirium
- Cognitive impairment
- Depression
- Alcohol abuse
- Hearing loss
- Vision loss
- Assistance with 2 ADLs
- Anticholinergics
- Oxybutynin
- Diphenhydramine
- Atenolol
- Meclizine
- Ranitidine
- scopalamine - CV – HTn CHF, DM, CVA, AF
Precipitating factors for delirium
- Physical restraints
- Malnutrition
- Three new meds
- Catheterization
- Surgery
How is delirium different from dementia?
inattentiveness, altered level of arousal, fluctuation of symptoms
Symptoms of delirium
- Acute change in mental status
- Fluctuating course
- Attention disturbance
- Memory disturbance
- Orientation disturbance
- Perceptual disturbance
- Thought disturbance
- Sleep disturbance
- Consciousness disturbance
- Speech disturbance
- Psychomotor activity disturbance
Assessment tools for delirium
- The confusion assessment method severity (CAM)
- Acute onset and fluctuating through the day
- Inattendtion
- Disorganized thingking
- Altered LOC - Confusion state examination
- Delirium-o-meter
- delirium observation scale
- delirium rating scale
- memorial delirium assessment scale
Delirium diagnosis
Delirium is diagnosed if a patient has an acute change in mental status with inattention accompanied by disorganized thinking or a change in alertness.
Prevention strategies for delirium
- Orientation activities
- Early mobilization
- Minimize use of psychoactive drugs
- Use of glasses/hearing aids
- Treating volume depletion
Treatment for delirium
Rispiradone
Modifiable risk factors for stroke
- HTN
- DM
- HLD
- AF
- OSA
- Tobacco
- Alcohol
- Physical inactivity
Ischemic stroke
Sudden unilateral weakness of the face, arm, and leg; sudden unilateral sensory loss; sudden speech difficulties (producing or understanding speech); sudden slurring of speech; sudden loss of vision or double vision; sudden loss of balance, vertigo, or clumsiness; and sudden onset of severe headache
Clinical assessment for stroke
- Accurate history
- Onset of symptoms
- Chornololgoy
- PMH
- Stroke hx
- Recent surgery
- Bleeding disorder
- Use of anticoagulants
Neurological exam for stroke
- Conscious
- Speech
- Paralyzed
- Gaze deviation
- Pupil size
- Facial weakness
- Motor tone
- Spontaneous movements
- VSS
- Capillary glucose
What stroke tool is used to gauge stroke severity?
National Institutes of Health Stroke Scale (NIHSS) is a systematic, quantitative assessment tool to measure stroke-related neurological deficit.
Labs to check if stroke is suspected
- CBC
- CMP
- BUN/creatinine
- Troponin
- Glucose
- INR (if on warfarin)
- Noncontrast head CT
Management of acute stroke
- 0-3 hours – alteplase/mechanical thrombectomy
- 3-4.5 hours – alteplase, mechanical thrombectomy
- 4.5-6 hours – mechanical thrombectomy
- 6-24 hours – mechanical thrombectomy
- Wake up stroke – MRI brain
- Thrombolysis if abnormal DWWI and no signal change in FLAIR
BP goals after
acute ischemic stroke
- Not a candidate for thrombolysis: <220/120 mmHg
- Candidate for thrombolysis: <185/110 mmHg
- After thrombolysis: <180/105 mmHg
- After revascularization: <140/80 mmHg
Options for HTN treatment after acute ischemic stroke and acute reperfusion therapy
- Labetalol
- Hydralazine/enalaprilat
- Nicardipine
- Clevidipine
TIA
transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, without evidence of CNS infarction. Most patients have symptoms for 15 to 20 minutes with complete recovery