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Psych Week 2 > ICL 9.2: Neurocognitive Disorders > Flashcards

ICL 9.2: Neurocognitive Disorders Flashcards

1
Q

what is delirium?

A

an acute confusional state that’s a transient, reversible global dysfunction in cerebral metabolism

a disturbance in consciousness and a change in cognition with reduced ability to focus

it develops over a short period of time! usually over days which is what separates it from dementias

also called ICU psychosis, sundowning or syndrome of cerebral insufficiency

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2
Q

what are the various causes of delirium?

A
  1. substance intoxication delirium
  2. substance withdrawal delirium
  3. medication-induced delirium
  4. delirium due to another medical condition
  5. delirium due to multiple etiologies
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3
Q

how prevalent is delirium?

A

highest among older hospitalized people

15-53% of older patients postoperatively

70-87% in intensive care units

40% recovering from hip fracture surgery

40% on ventilators

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4
Q

is delirium well diagnosed?

A

eh not really, 30-60% goes unrecognized which could be due to:

  1. lack of awareness especially with hypoactive delirium
  2. fluctuating nature – pt. could be delirious at one point and not at another like when you go in to see them vs. the attending
  3. overlap other neurocognitive disorder
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5
Q

what are the risk factors for developing delirium?

A
  1. increased age (>65)
  2. pre-existing brain damage: neurocognitive disorders like alzheimers, h/o delirium, tumor
  3. ETOH, other drug dependence, anticholinergics
  4. co-occurring medical illnesses – HIV, Cancer, renal or hepatic disease
  5. heart surgery
  6. sensory impairment; someone without their hearing aids or glasses
  7. malnutrition and dehydration
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6
Q

what changes happen in the neurobiology of someone with delirium?

A
  1. changes in neuronal membrane function which leads to multiple neurotransmitter aberrations
  2. the NTs thought to be involved are acetylcholine and dopamine

drugs with anticholinergic properties can cause delirium

drugs that increase dopamine induce delirium – stimulants, amphetamines, cocaine, burpropion

dopamine blocking drugs used to treat delirium

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7
Q

what is the clinical presentation of the prodromal phase of delirium?

A

nonspecific symptoms; hard to realize at the time and often written off

  1. sleep disturbances; backwards sleep schedule
  2. anxiety
  3. irritability
  4. night time disorientation
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8
Q

what are the clinical features of the delirium phase?

A
  1. disturbance of awareness or attention w/ a baseline change in cognition
  2. overall confusion
  3. disorientation; usually to time and place, they usually know who they are
  4. distractibility
  5. short-term memory deficits
  6. hallucinations; visual and tactile esp. (schizophrenia is usually auditory)
  7. fluctuating level of consciousness**

symptoms tend to be worse at night (sundowning) and appear over hours to days (vs. dementia which is slower onset)

symptoms vary in severity and usually last less than a month

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9
Q

what are the clinical features of hyperactive delirium?

A
  1. restlessness
  2. anger/irritability
  3. combative
  4. uncooperative

5, wander

  1. risks: falls, injuries (self-inflicted too)
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10
Q

what are the clinical features of hypoactive delirium?

A
  1. lethargy
  2. decreased alertness
  3. apathy
  4. slow speech
  5. decreased movement
  6. often mistaken for depression!
  7. risks: deconditioning, decubitus ulcers
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11
Q

what are the various causes of delirium?

A

WHIMP

ⓦithdrawal of BZD or Wernicke’s encephalopathy (confusion, ataxia, ophthalmoplegia)

Ⓗypoxemia, hypertensive encephalopathy, hypoglycemia, hypoperfusion

Ⓘntracranial bleeding or Infection (UTI)

Ⓜeningitis or encephalitis

℗oisons or medications, Pain

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12
Q

what types of drugs can cause delirium?

A
  1. antibiotics
  2. analgesics (opiates!)
  3. anti-inflammatory (corticosteroids)
  4. anticholinergic agents
  5. cardiac
  6. drug intoxication/withdrawal
  7. gastrointestinal agents
  8. sedative-hypnotics

SO MANY!!

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13
Q

when you suspect delirium and do a mental status exam, what are you checking?

A
  1. level of consciousness; alert vs. drowsy vs. stuporous
  2. mood and affect
  3. motoric behavior
  4. perceptual disturbances; hallucinations
  5. delusions
  6. memory
  7. attention/concentration
  8. orientation
  9. name objects
  10. read, write and calculate
  11. insight
  12. judgement
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14
Q

what labs would you want to get if you suspect delirium?

A
  1. electrolytes (low Na is often a cause)
  2. BUN (kidney)
  3. thyroid functions
  4. CBC (complete blood count)
  5. UA (urinalysis for UTI)
  6. ABG (arterial blood gas to check oxygenation levels)

LP, EKG and EEG can also be done if necessary

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15
Q

what is the prognosis for delirium?

A

high incidence of morbidity and mortality if untreated

22-76% mortality in hospitalized patients and a 35-40% one-year mortality rate

longer delirium implies longer recovery period; if low Na has been developing over several weeks, even if their Na is fixed over a few days they may still be delirious for a little longer even though sodium is back to normal

older patients usually take longer to recover

40% recover while 40% of delirious patients never return to baseline functioning

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16
Q

what is the treatment for delirium?

A

determine the underlying etiology and reverse the cause!!! like for an infection, hypoxic, etc. treat with antibiotics or oxygen

then you can do environmental support like patient protection from self-injurious behavior, sensory stimulation, familiar person in room, hearing aids, eye glasses

stop the medications causing the delirium, give medications if necessary to help with delirium

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17
Q

what other neurocognitive disorders should be considered in the differential when someone is delirious?

A
  1. dementia
  2. schizophrenia
  3. depression
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18
Q

what is the definition of a neurocognitive disorder?

A

dvidence of cognitive decline, representing a change from the previous level of functioning, in >/=1 cognitive domains:

  1. complex attention
  2. executive function
  3. learning and memory
  4. language
  5. perceptual motor
  6. social cognition
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19
Q

what are the various etiologies that could cause neurocognitive disorder?

A
  1. Alzheimer’s disease 60-70%*
  2. Frontotemporal degeneration 12-25%*
  3. Vascular disease 10-20% *
  4. Lewy Body Dementia 5-10%
  5. traumatic brain injury
  6. substance/medication use
  7. HIV infection
  8. Parkinson’s disease*
  9. Huntington’s
  10. Normal pressure hydrocephalus*
  11. neurosyphilis
  12. hyper or hypothyroidism
20
Q

what are the characteristics of a major neurocognitive disorder?

A
  1. evidence of significant cognitive decline from previous level of functioning
  2. substantial impairment in cognitive performance on clinical assessment or neuropsychological testing
  3. cognitive deficits interfere with independence in daily activities, e.g. managing meds, paying bills, balancing checkbook, meal planning
21
Q

what are the characteristics of a mild neurocognitive disorder?

A
  1. similar to Mild Cognitive Impairment
  2. modest cognitive decline from previous level of functioning in one or more cognitive domains
  3. modest impairment in cognitive performance on clinical assessment or neuropsychological testing
  4. cognitive deficits do not interfere with ability to carry out daily activities!! this is what differentiates it from major neurocognitive disorders
  5. patients likely to describe tasks as being more difficult or requiring extra time
  6. pts. use compensatory strategies
  7. neuropsych testing critical at this phase; results are usually 1-2 SDs below where expected
22
Q

how prevalent are neurocnogitive disorders?

A

1-2% > 65, up to 30% > 85 have dementia/major NCD

2-10% at age 65, 5-25% at age 85 with mild cognitive impairment (similar to mild NCD)

23
Q

what is the clinical presentation of major neurocognitive disorder due to alzheimer’s?

A
  1. criteria met for major or mild NCD
  2. insidious onset and gradual progression of impairment in >/= 1 cognitive domains
  3. clear evidence of decline in memory and learning and at least 1 other cognitive domain
  4. steadily progressive and gradual decline in cognition w/o extended plateaus
  5. no evidence of mixed etiology
  6. behavioral and psychological symptoms common – 80%: depression, apathy, irritability, agitation, psychotic symptoms, wandering –> these symptoms can be more distressing than the memory issues and are often the reason medical help is obtained
24
Q

how long do alzheimer’s patients survive?

A

mean survival duration from dx is 10 years

can live as long as 20 years

25
Q

how prevalent is alzheimer’s?

A

60 - 90% with NCD have Alzheimer’s type

50% nursing home patients

26
Q

what are the risk factors for developing alzheimers?

A
  1. age – strongest risk factor
  2. genetics
    apolipoprotein E4

Presenilin-1: most common cause of early onset

Presenilin-2: cause of early onset disease

  1. history of traumatic brain injury
  2. Down’s Syndrome
  3. small changes in blood vessels in eyes
  4. female gender
27
Q

what are the early symptoms of Alzheimer’s?

A
  1. short-term memory deficits/forgetfulness
  2. depression
  3. mild disorganization
  4. mild word-finding difficulty
  5. may have mild problems getting lost when driving to somewhere very familiar to them
28
Q

what are the symptoms of alzheimer’s 3-5 years after symptom onset?

A
  1. behavioral disturbances; agitation
  2. agnosia, apraxia, aphasia
  3. significant memory deficits
  4. paranoia
  5. need for assistance with ADL’s
29
Q

what are the symptoms of alzheimer’s 7-9 years after symptom onset?

A
  1. global memory deficits
  2. aphasia progressing to mutism
  3. disorientation
  4. incontinence of bowel/bladder
  5. complete dependence for ADL’s
30
Q

what are the symptoms of alzheimer’s 10 years after symptom onset?

A
  1. nonambulatory
  2. noncommunicative
  3. compromised nutritional status; don’t know how to chew or swallow
  4. frail
31
Q

what are the definitive diagnostic features at autopsy of a person who had alzheimers?

A
  1. neuritic plaques of amyloid beta
  2. neurofibrillary tangles
  3. neuronal loss
  4. diffuse atrophy
  5. parietal-temporal distribution of pathology of tangles and plaques**
32
Q

which medications are used to treat alzheimers?

A
  1. donepezil
  2. galantamine
  3. rivastigmine
  4. tacrine

  1. memantine = NMDA receptor antagonist
33
Q

what are the supportive treatments that can be done for Alzheimer’s?

A
  1. maintain physical health
  2. memory cues
  3. advance directives
  4. driving test
34
Q

how can you prevent alzheimers?

A
  1. exercise/physical activity
  2. waist size
  3. decrease risk of heart disease
  4. healthy blood pressure
  5. treat high lipids, cholesterol
  6. caffeine
  7. get adequate sleep
  8. brain aerobics (sudoku, word puzzles)
  9. gingko biloba
  10. vitamin D
  11. omega-3 fatty acids
35
Q

what is the criteria for frontotemporal neurocognitive disorder?

A
  1. criteria met for major or mild NCD
  2. insidious onset & gradual progression of behavioral and personality change and/or language impairment
  3. dementia due to Pick’s Disease
  4. atrophy in frontotemporal regions
  5. cognitive decline less prominent; relative sparing of learning, memory, motor function

can be difficult to distinguish from NCD due to Alzheimer’s disease

36
Q

what age group does frontotemporal dementia effect?

A

it’s a common cause of NCD in those < 65 yo

often presents in 50’s ):

survival 6-11 years after symptom onset, 3-4 years after dx so the decline is faster than Alzheimer’s disease

37
Q

what is vascular neurocognitive disorder?

A
  1. criteria met for major or mild NCD
  2. evidence of vascular disease must be present
  3. history, physical or neuroimaging
  4. range from large vessel stroke to microvascular disease
  5. onset of cognitive deficits temporally related to 1 or more cerebrovascular events
38
Q

what is the clinical presentation of someone with vascular neurocognitive disorder?

A
  1. evidence for decline is prominent in complex attention and frontal executive function
  2. personality changes
  3. mood changes; depression
  4. emotional lability

acute stepwise decline in cognition with plateaus of stability; slowly progressive disease

39
Q

how can you differentiate between alzheimers and vascular disease?

A

vascular dementia is stepwise decline with plataus

alzheimers is a slow consistent progression

40
Q

what causes vascular neurocognitive disorder?

A

small vessel disease of white matter, basal ganglia and thalamus most commonly

deficits due to disruption of cortical-subcortical circuits

41
Q

how prevalent is vascular dementia?

A

10-20% of all NCDs

second most common cause of NCDs

increases greatly after age 65

men > women

42
Q

what are the risk factors for vascular dementia?

A
  1. increasing age
2. risks for cerebrovascular diseas:
Hypertension
Diabetes mellitus
Obesity
Smoking
Hyperlipidemia
  1. atrial fibrillation = heart arrhythmia that can cause blood clots that can go out to the brain
43
Q

how do you treat vascular dementia?

A

same as alzheimer’s

also treat CVD like HTP, obesity, DM2, smoking etc. which will help improves cerebral perfusion and thus cognitive function

44
Q

what is parkinson’s disease?

A

degeneration of dopamine-containing neurons in substantia nigra (basal ganglia) which causes motor deficits

depression, anxiety, delusions, personality changes common

75% will have major NCD; develops in late life

25% will have mild NCD; develops early in Parkinson’s

45
Q

what is normal pressure hydrocephalus?

A
  1. wet, wobbly and wacky
    urinary incontinence, dementia, and ataxia
  2. large cerebral ventricles, mild atrophy
  3. due to defective CSF drainage/reabsorption

treat with ventricular shunting (may/not help) so this dementia can be reversible!

46
Q

what are the differences between delirium and dementia?

A

DELIRIUM
acute, fluctuating course, impaired awareness, disturbed attention, poor working memory and immediate recall, often short-lived or changing delusions, fragmented sleep

DEMENTIA
insidious onset, gradual deterioration, often clear awareness until advanced stages, often good attention until advanced stages, poor short-term memory, more fixed delusions, sleep-wake reversal

Psych Week 2 (18 decks)

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