Alzheimer's and other Dementias

Question 1

What is dementia?

Answer 1

Gradual decline of a previous high level of intellectual functioning of sufficient severity to interfere with social or occupational activities or both

Question 2

What are two conditions that may coexist with dementia or be difficult to distinguish from dementia?

Answer 2

• Depression

- Delerium

Question 3

Pathophysiology Facts of AD (4)

Answer 3

• Brain weight decreased 20%
• Significant cortical atrophy
• Neuronal loss and loss of synapses
• Senile (amyloid) plaques and neurofibrillary tangles

Question 4

AD Patterns on PET (5)

Answer 4

• Hypometablosim in posterior parietal lobe
• Extends to temporal and occipital lobes
• Seen in the frontal lobe if advanced
• PET can detect hypo metabolism before S/S even occur
• AD differs from other dementias on PET

Question 5

How does AD affect Hormones? (3)

Answer 5

• Decreases Ach
• Compromised cholinergic pathways in cerebral cortex and basal forebrain
• Imbalance in serotonin, GABA, substance P, NE & somatostatin

Question 6

Types of AD (4)

Answer 6

• Familial 5-10%, develops at an earlier age, 30-50
• Sporadic also seems to have genetic susceptibility
• Genetic testing is suggestive
• Do neuropsychological testing prior to genetic testing

Question 7

Assessment of AD (3)

Answer 7

• Progressive but symptoms can remain steady for years
• Progression varies d/t treatment, environment, other conditions
• Social skills are usually preserved

Question 8

Memory Mild/Moderate/Severe

Answer 8

Mild: forgets important events, difficulty focusing
Mod: recent/remote impairment, new material lost
Sev: Fragments of memory remain, untestable

Question 9

Language Mild/Moderate/Severe

Answer 9

Mild: Difficulty naming persons/objects
Mod: Impaired comprehensiveness of speech
Severe: repeats words with increased speed/volume

Question 10

Orientation Mild/Moderate/Severe

Answer 10

Mild: Lost in familiar places
Mod: disoriented to time and place
Severe: oriented to person only

Question 11

Judgement/Problem Solving Mil/Mod/Sev

Answer 11

Mild: Difficulty with complex problems and meanings
Mod: Social judgement impaired, difficulty with similarities and differences, not good with problems
Sev: Unable to attempt problem solving

Question 12

Behavior Mild/Mod/Sev

Answer 12

Mild: irritable, indifferent, hesitant
Mod: indifferent, delusional
Sev: agitated, difficulty participating in groups

Question 13

Personal Hygiene Mild/Mod/Sev

Answer 13

Mild: needs occasional prompting
Mod: requires assistance
Sev: requires much help, incontinent

Question 14

Gait Mild/Mod/Sev

Answer 14

Mild: normal
Mod: normal
Sev: flexed

Question 15

Abnormal Movements Mild/Mod/Sev

Answer 15

Mild: none
Mod: none
Sev: myoclonus

Question 16

Diagnostic Testing for Memory loss

Answer 16

Quantify and objectify with standardized tests

Question 17

Diagnostic Testing for Orientation

Answer 17

Memory-concentratio test (mini mental status test)

Question 18

Diagnostic Test for Time and Change

Answer 18

• Set clock to 11:10, respond in 60s, 2 tries
• Make change from 3 quarters, 7 dimes, 7 nickels, 120s to respond, 2 tries
• Incorrect responses on either or both indicate dementia

Question 19

Diagnostic Test Facts (3)

Answer 19

• No longer a diagnosis of exclusion
• There is criteria in the DSM IV
• Acquired, persistent impairment of intellectual functioning in memory and at least one of the following: language, visuospatial skills, emotion or personality, abstraction, calculation, judgement or problem solving

Question 20

Neuropsychological Testing for AD (5)

Answer 20

• identifies dementia
• monitors dz progression
• differentiates between different dementias
• administered at regular intervals
• Frontal release signs are often present in moderate to severe alzheimers

Question 21

Differential Diagnosis for AD (3)

Answer 21

• consider other causes for symptoms
• depression often coexists at early stages of AD
• Acute delirium can be a serious medical condition requiring referral and hospitalization

Question 22

Delerium Presentation (6)

Answer 22

• Difficulty concentrating
• Inattention
• Restlessness and irritability
• Poor appetite
• Insomnia
• Tremulousness

Question 23

Delerium Causes (3)

Answer 23

• Deficiency of metabolic substrate like glucose
• Disruption of internal environment, dehydration
• Presence of a toxin like uremia or ketosis

Question 24

Delerium Tx (3)

Answer 24

• Treat underlying condition swiftly
• CBC, lytes, ABG, ammonia, renal function, liver function, coags, drug & box screen, EKG, LP, UA
• HIV titer, syphilis serology, serum and urinary copper levels

Question 25

Depression Presentation (7)

Answer 25

- Sleep disturbances - Appetite/Wt. changes - Psychomotor retardation - Fatigue - Loss of libido - Guilt/low self esteem - Suicidal ideation

Question 26

Prevention Tx of AD (3)

Answer 26

- Reduced in postmenopausal women treated with hormone replacement therapy - Indomethacin and Vit. E used - Activities throughout life that challenge the mind

Question 27

Goals of Tx for AD (3)

Answer 27

- Arrest progression - Tx associated symptoms - Tx long term consequences of AD like anxiety, anger, frustration, etc.

Question 28

Pharmacological Therapy for AD (2)

Answer 28

- Tacrine (Tetrahydroaminoacridine): attempts to replace Ach that has been lost - Donepezil (Aricept): same mechanism, no liver tox

Question 29

Non-Pharmacological Therapy for AD (3)

Answer 29

- Enviornmental support - Sleep Hygiene practices - Wandering

Question 30

Tx of Agitated Dementia

Answer 30

- Tx with neuroleptics for: | Hallucinations, jealousy, paranoid ideation, etc..

Question 31

Lewy Body Dementia (5)

Answer 31

- Progressive * *Prominent Hallucinations!! - Movement disorders (parkinsonism) - Fluctuating attention - o/w looks like AD

Question 32

Frontal Lobe Dementia (4)

Answer 32

- Atrophy of frontal and temporal lobe - Personality changes: socially inappropriate, impulsive or emotionally withdrawn, early on! - Occurs at a younger age (40-70) - Often misdiagnosed

Question 33

Vascular Dementia (4)

Answer 33

- Cause: chronic decreased blood flow to the brain (stroke) - Usually from "silent strokes" - Slow or sudden onset - May have deficits related to stroke

Question 34

Vascular Dementia Diagnosis (3)

Answer 34

- Neurcognitive testing - Usually have another vascular dz - MRI showing vascular dz or stroke in the brain

Question 35

Subcortical Dementia (5)

Answer 35

- Affects the diencephalon - Affects motivation, mood, timing, arousal - Depression can be prominent - Clumsy, apathy or irritable - Diagnosis made by neuropsychiatric testing and imaging

Question 36

Subcortical Dementia Tx

Answer 36

- No medical cure - Tx symptoms - Control hypertension/hypotension

Question 37

Primary Progressive Aphasia (5)

Answer 37

- Rare, impairs language capabilities - Trouble expressing thoughts, finding words - Onset usually after 65 - slowly progressive - May become mute, unable to understand language

Question 38

What are the risk factors for primary progressive aphasia? (2)

Answer 38

- learning disabilities like dyslexia | - genetic

Question 39

Primary progressive aphasia Diagnosis/Cause/Tx

Answer 39

Cause: atrophy of frontal and temporal lobes, usually on the left side Diagnosis: neuropsych exam, genetic testing, MRI or PET Tx: no med available, SLP may help

Question 40

Caregiver Education (5)

Answer 40

- Formal/informal education - Support groups - Support system - Adult day care - Monitor for signs of abuse (both ways)

Question 41

Signs of Abuse

Answer 41

- Bruises on the face, shoulders, arms - Bruises in different stages of healing - Cigarette and rope burns - Lacerations or human bites - Fractures in different stages of healing - Cringing back when touched, nervous, fearful