2 - Altered Mental Status Flashcards
(78 cards)
1
Q
HPI questions?
A
Time (course of change)
Changes in personality
Changes in mood
Changes in memory
2
Q
Mental status exam categories?
A
General behavior and appearance Stream of talk Mood and affective response Content of thought Sensorium Folstein mini mental status exam
3
Q
Folstein mini mental status exam score of <24/30 gets what?
A
Additional testing
4
Q
Topics covered by a formal mental status exam?
A
Consciousness Orientation Speech/language Fund of information Insight/judgment Abstract thought Calculations
5
Q
LOC assessment?
A
Normal: you know
Impaired: sleepiness -> obtunded
6
Q
Attention/calculation assessment?
A
Serial 7’s
Identify a letter in a series w/o error
7
Q
Language and speech assessment?
A
Elements (fluency, naming etc)
Dysarthria (arriculation)
Aphasia (produce and comprehend)
8
Q
Examples of aphasia?
A
Broca’s Wernicke’s Global Conduction Transcortal motor Transcortal sensory Subcortal
9
Q
Global aphasia?
A
Impairment: - Fluency - repetition - comprehension may have associated severe right hemiparesis cause by large lesion in the L hemisphere
10
Q
Conduction aphasia?
A
Preserved:
- Fluency
- Comprehension
Impaired:
- repetition
- naming
- writing
11
Q
Transcortical motor aphasia?
A
Fluency impaired
Preserved:
- comprehension
- repetition
May have an associated R hemiparesis caused by lesion in broca’s area
12
Q
Transcortal sensory aphasia?
A
Preserved:
- fluency
- repetition
Impaired:
- comprehension
Lesion in the wernicke’s area
13
Q
Subcortical aphasia?
A
Variable:
- Fluency
- comprehension
Preserved:
- repetition
May have hypophonia caused by a lesion in the L basal ganglia or thalamus
14
Q
Types of amnesia?
A
Psychogenic - forget emotional shit
Organic - forget objective facts
Retrograde - events prior to injury
Anterograde - inability to store, retain and recall new knowledge
15
Q
How is Memory tested?
A
Immediate: 3 easy to ID objects
Short term: repeat 3 obj 5-15 min later
Remote: mothers maiden name, school attended, past presidents etc
16
Q
Evaluate integrative sensory function?
A
Asterogenosis
Agraphesia
2 point discrimination
17
Q
How is spacial thought evaluated?
A
“Construction”
Can they draw clock or intersecting shapes?
Evaluates parietal lobe function
18
Q
Red flags in the HX?
A
Progressive declining LOC PUPILLARY ASYMMETRY Seizures Repeated vomiting Double vision Worsening HA Cant recognize (faces, places) Confused/irritable Slurred speech Unsteady on feet Weakness/numbness in extremeties
19
Q
Causes of delirium and dementia?
“I watch death”
A
I - infection
W - withdrawl (ETOH/drugs) A - acute metabolic T - trauma C - CNS pathology H - hypoxia
D - deficiencies (b12, folate, etc) E - endocrinopathies A - acute vascular T - toxins H - heavy metals
20
Q
3 types of memory?
A
- Working memory
- Episodic memory
- Lasting memory
21
Q
Working memory?
A
<30 sec
Rule of 7
RAS, prefrontal cortex and parietal lobe
22
Q
Episodic memory?
A
Minutes - years
What, where and when
“Lay down” memories and tag to experiences
Hippocampus, dorsomedial nucleus of thalamus
23
Q
Lasting memory?
A
Lifelong - protein synthesis and creation of new synapse
Anterior temporal lobe
Frontal lobe
24
Q
How to test working and episodic memory?
A
Working: “repeat after me”
Episodic: trivial events of the day “what did you eat for breakfast?”
25
Causes of amnestic syndromes?
Acute:
- head trauma
- hypoxia/ischemia
- bilat cerebral artery occlusion
- alcoholic blackouts
- wernicke encephalopathy
- dissociative (psychogenic) amnesia
Chronic:
- alcoholic korsakoff
- postencephalitic amnesia
- brain tumor
- paraneoplastic encephalitis
26
What is the difference between acute and dementia related amnesia?
Acute: impaired attention and cant learn new material
Demented: normal attention span, recent memory loss
27
What is executive function?
Central organizing function of the brain
- Planning
- Initiating and regulating behavior
28
Delirium vs dementia
Delirium: acute onset bad LOC
- reversible
Dementia: chronic, normal LOC but confused
- irreversible
29
Hallmark of delirium?
Described as waxing and waning levels of consciousness
30
Key features of delirium?
- Attention impairment
- memory impairment
- agitation
- apathy/withdrawal
- sleep disturbance
- emotional lability
- perceptual disturbances (hallucination)
- neurologic signs
31
Causes of delirium?
- Stroke
- ETOH/drugs
- endocrine disturbances
- electrolyte disturbances
- nutritional disorders
- organ system failure
- psychiatric diagnosis
- infectious disorders
- hypertensive encephalopathy
- concussion
32
Does the alcohol level predict the level of impairment?
Nope
33
Stages of alcohol withdrawal?
5-10 hrs “dry”
- Tremulousness, tachycardia, HTN
2 days
- seizures
3-5 days
- agitation, tremulousness, hallucinations, CV collapse
34
Meds to help with alcohol withdrawl?
Benzo’s
Fluid, electrolyte, glucose balance
B-blocker (adrenergic response)
35
What is the key to understanding alcohol withdrawal?
Socks apparently
36
What is a common nutritional disorders that acutely confused pts may have?
B-12 (pernicious anemia)
Wernicke’s encephalopathy (thiamine)
37
Classical triad of wernicke’s encephalopathy?
Ophthalmoplegia/nystagmus
Gait ataxia
Global confusion
38
What do all patients with undiagnosed altered mental status, oculomotor disorders or ataxia get?
Parenteral thiamine (wernicke’s encephalopathy)
39
What is korsakoff’s psychosis?
Deficits in learning and memory following wernicke’s encephalopathy
Gaps in memory
Confabulation
Disordered temporal sequencing
40
What is dementia?
Disorder involving impairment of learning and memory and impairment one or more of the following:
- complex tasks
- reasoning ability
- spatial orientation
- language
41
Prevalence of dementia in the west?
1. Alzheimers (50%)
2. Vascular (10-20%)
3. Parkinson’s
4. Chronic intoxication
42
3 most common reversible causes of dementia?
Depression
Hydrocephalus
Alcohol dependence
43
Reversible vs irreversible causes of dementia?
19% reversible
81% irreversible
44
Biggest risk factor for dementia?
Increasing age (over 50)
45
Levels of cognitive impairment?
Normal: No affect on daily life (age causes)
Mild cognitive impairment (MCI): affects daily life
46
Mild cognitive impairment (MCI) often turns into’?
Frank dementia
- Usually Alzheimer’s
47
Risk factors for Alzheimers?
Memory deficit >1.5 SD from normal
Presence of apolipoprotein e4 allele (epsilon?)
Small hippocampal volume
48
Types of dementia?
1. Alzheimers: AB42 protein
2. Frontal temporal dementia: tau protein
3. Lewd body dementia (DLB): a-synuclein protein
4. Prion disorders: creutzfeldt-jakob disease
49
MC cause of dementia in US?
Alzheimers
50
Alzheimer’s disease macro and microscopic changes?
Macroscopically: diffuse cortical atrophy
Microscopically:
- neurotic plaques of AB42 amyloid
- silver-staining neurofibrillary tangles in neural cytoplasm
- accumulation of AB42 amyloid in arterial wall of cerebral blood vessels
51
What is alzheimer’s disease?
Progressive neurological disorder that results in:
- memory loss
- language deficit
- visual spatial deficit
- anosognosia
52
What is anosognosia?
Lack of awareness of cognitive deficits
| Sometimes seen in alzheimer’s disease
53
Etiology of alzheimer’s disease?
Female:male 2:1
Family hx common
Lower eduction
Head trauma/concussions
54
Where are neuritic plaques and neurofibrillary tangles usually found with alzheimer’s disease?
Hippocampus
Lateral temporal cortex
Lateral septum (nucleus basalis of mynert)
55
What does an MRI show for Alzheimers?
Nothing until they become severe then it MAY show cortical atrophy leading to compensatory dilation of the ventricles
So, nothing...
56
Early signs of alzheimer’s?
Non-focal neurologic exam
- short term memory abnormal
- speech hesitant
- 24-27 score on MMSE
57
Later signs of alzheimer’s?
- Paranoia, hallucinations, delusions
- primitive reflexes emerge
- mute, bedbound, incontinent
58
Diagnostic studies for alzheimers?
No labs
MRI, CT (only effective later)
```
Neurophychiatric testing (memory, verbal, executive function)
Apo episilon genetic testing
```
59
Meds for alzheimers?
Meds to target CNS levels of ACh
Cholinesterase inhibitors
- donepezil
- rivastigmine
- galantamine
N-Methyl-D-asparte (NMDA) receptor antagonist
- memantine
60
Do meds cure alzheimers?
No they are aimed at slowing the progression of cognitive decline
61
Types of vascular dementia?
Multi-infarct dementia
Diffuse white matter disease
62
What is vascular dementia?
Vascular insult/CVD leading to dementia
No uniform set of criteria
63
Findings that suggest vascular dementia?
Cognitive deficit onset post stroke
Abrupt onset w stepwise deterioration
Focal findings on neuro exam c/w CVA
Infarcts on imaging
64
Vascular dementia’s effect on alzheimer’s?
CVD may affect severity of alzheimer’s symptoms
65
What is frontotemporal dementia FTD?
50-70 yrs old
Associated with atrophy of temporal and frontal lobes
66
Microscopic findings with FTD?
Tau protein accumulation with neurons
67
What is associated with dementia with lewy bodies?
```
Hallucinations
Parkinsonism
Fluctuating alertness
Falling
REM sleep disorder
```
68
Reversible causes of dementia?
- Depression
- Normal pressure hydrocephalus
- Metabolic disorders
- Medication induced
- ETOH
- Malignancy
69
What condition is MC mistaken for dementia?
Depression
- mental slowness, apathy, self-neglect, irritability, difficulty with memory
70
What is Pseudodementia: psychological disease
Depression that mimics dementia
71
Differentiating dementia and depression?
Dementia:
- unaware of deficits
- not vegetative
- worse at night
- abnl neuro exam
- abnl labs
Depression:
The opposite
72
Tx for pseudodementia: depression?
Treat the depression SSRI, SNRI, CPT, etc
73
Normal pressure hydrocephalus triad?
Cognitive decline (dementia)
Urinary incontinence/urgency
Gait difficulty
74
Treatment for normal pressure hydrocphalus?
Shunt
75
Dementia puglistica?
Recurrent head trauma
76
altered mental status without obvious cause?
Full workup:
- LP
- Blood Cx
- Imaging
- Broad diagnostic blood work
77
Management of delirium?
Treat the underlying medical cause
78
Hallmark of delirium?
Waxing and waning mental status
