Cognitive Impairment

Question 1

More sensitive assessment scales

Answer 1

MOCA (Montreal cognitive assessment)

SLUMS (St. Louis University Mental Status)

Question 2

Less sensitive assessment scales

Answer 2

Clock Drawing Test

Question 3

Assessment test sensitive vs specific

Answer 3

Can detect cognitive impairment, but cannot identify the cause

Question 4

Reversible Cognitive Impairment

Answer 4

• Delirium/acute confusional states
• Pseudo-dementia of depression
• Drug induced

Question 5

Irreversible Cognitive Impairment

Answer 5

• Mild cognitive impairment

- Dementia

Question 6

Cortical dementia

Answer 6

Alzheimer’s Disease
Frontal- Temporal
Pick’s Disease

Question 7

Sub-cortical dementia

Answer 7

Parkinson's Disease
Huntington's 
Normal pressure hydrocephalus
Progressive supranuclear 
AIDS

Question 8

Cortical presentations

Answer 8

Outer layers of the brain

Question 9

Define Amnesia

Answer 9

The acquistion (learning) and storage (memory) of new information

Question 10

Define Executive Function Deficits

Answer 10

Ability to employ insight, judgement, problem solving or abstract thought

Question 11

Define Apraxia

Answer 11

Ability to perform skilled acts or use tools

Question 12

Define Aphasia

Answer 12

Speech and language

Question 13

Define Agnosia

Answer 13

Ability to recognize/naming objects or people

Question 14

Sub-cortical presentations

Answer 14

Refer to deep structures within the brain

• higher level executive function, language skills, and memory
• Motor function, voice function, slowed cognitive processing, control of bowel/bladder, autonomic symptoms
• Behavioral/psychotic symptoms!!

Question 15

Anticholinergic Drugs as Primary offenders for drug induced CI

Answer 15

o	Atropine, benztropine
o	Antihistamines
o	TCAs, paxil, olanzapine
o	Cyclobenzaprine
o	Ditropan
o	Hyoscamine
o	Benzodiazepines, barbiturates, opiate, antipsychotics/depressants, AntiPD, corticosteroids, NSAIDs, FQ,
o	Clonidine, digoxin, amiodarone

Question 16

Define Primary Offender

Answer 16

Drug with a MOA that is directly related to the potential for cognitive impairment

Question 17

Define Secondary Offender

Answer 17

Drug without a mechanisms BUT

1) Interact with or in a way to enhance side effect potential of drug in primary category OR
2) Drug for which inappropriate use, dose, or disease state interactions compromise stability

Question 18

Define Pseudo-dementia

Answer 18

Changes in cognitive functions are part of the cluster of symptoms that can present with depression
- Always asses mood status with cognitive status

Question 19

Tip on dementia vs depressed patients

Answer 19

Dementia patients will typical deny forgetfulness and compensate for the deficient but depressed patients will complain about it

Question 20

Delirium is…

Answer 20

NOT a disease state, it is a disease presentation!!

Question 21

Define Delirium

Answer 21

Cluster of symptoms that are caused by an underlying illness that the patient cannot articulate experiencing
• EITHER altered level of consciousness or LOC (hyper or hypo)
• OR disorganized thinking PLUS inattention, acute changes in mental status, fluctuating course

Question 22

Define Inattention

Answer 22

Inability to focus, concentrate or appropriately respond to external stimuli

Question 23

ICU Delirium

Answer 23

Critically ill pts in ICU are at a high risk especially ventilated patients
Use of sedatives, analgesics, sepsis presentation, brain injury all contribute to this

Question 24

Risk Factors for Delirium

Answer 24

• Advanced age
• Hospitalization
• Surrogate markers of fraility (low body weight, malnutrition, dependence, etc)
• Underlying dementia
• Polypharmacy

Question 25

Precipitating Factors of Delirium

Answer 25

Infection, malignancy, pain, sleep deprivation, dementia, trauma Exacerbation of underlying illness (HF, COPD, renal failure, MI, stroke) Electrolyte/metabolic distrubances Hypo/hypernatremia/kalemia Alcohol or illicit/prescription drugs (ADR, indirect effect, withdrawal)

Question 26

Delirium is assessed through what test?

Answer 26

CAM | - Hand squezzing, nodding or blinking

Question 27

How do you treat delirium? NonPharm?

Answer 27

``` Temperature and noise control Orientation cues Reassuring presence Avoid sensory stripping No physical restraints ```

Question 28

How do you treat delirium? Pharm?

Answer 28

Withdrawal preciptating meds | Optimize comfort: Haldol 0.5-1 mg PO or buccal, other antipsychotics (olanzapine), or Lorazepam for alcohol wihtdrawal

Question 29

Pitfalls of Pharm treatment of Delirium

Answer 29

No cocktails No excessive dosage Inappropriate frequency Failure to d/c meds upon resolution