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Psychiatry > Cognitive impairment > Flashcards

Cognitive impairment Flashcards

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1
Q

Definition of dementia

A

Acquired progressive generalised impairment in cognition that interferes with social functioning but without clouding of consciousness

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2
Q

Cardinal clinical features of dementia

A
  • Memory impairment (short term > long term)
  • Behaviour: Restless, repetitive/purposeless, rigid routine
  • Speech: Dysphasia, mutism
  • Mood: Irritable, depressed
  • Peronsality: Disinhibition, aggression
  • Lack of insight
  • Psychosis (esp visual hallucinations) in 50% of cases
  • Progressive
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3
Q

Differentials for dementia

A
  • Deafness/dysphasia: Check they can hear
  • Depression: Important and reversible
  • Delirium: Associated with organic pathology
  • Drugs: esp anticholinergics
  • Epilepsy: Post-ictal state, ongoing complex partial seizures (temporal lobe epilepsy)
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4
Q

Distinguishing dementia from depression (pseudodementia)

A
  • Did low mood (or other features of old age depression) precede memory impairment
  • Is failure to answer Qs due to lack of ability or lack of motivation? (I don’t know/it’s too hard vs incorrect answer)
  • Neurological deficits suggest organic cause (e.g. dementia)
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5
Q

Prominent features of depression in older adults (> than low mood)

A

Apathy

Anxiety

Forgetfulness

Irritability

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6
Q

Broad categories of dementia aetiologies

A

Common dementias

Degenerative disorders

Metabolic disorders

Infections

Neurological disorders

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7
Q

Most common causes of dementia

A

Alzheimer’s: 50-60% of cases

Vascular dementia: 20-25%

Dementia with Lewy bodies: 10-15%

Everything else: 10%

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8
Q

Degenerative disorders causing dementias (in the 10%)

A

Frontotemporal degeneration

Huntington’s

Parkinson’s plus syndromes

Prion disease (e.g. CJD)

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9
Q

Metabolic/endocrine abnormalities causing cognitive impairment

A

Hypothyroidism

Hyperparathyroidism

Hypercalcaemia

B12/folate deficiency

Alcohol-associated dementia

Cushing’s

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10
Q

Infections causing dementia

A

HIV

Syphilis

Meningitis/encephalitis may present as cognitive impairment (more commonly delirium)

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11
Q

Neurological causes of dementia

A

Head injury

Subdural haematoma

Intracranial tumour/mets

Normal pressure hydrocephalus

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12
Q

Dementia suggested by past history of fall

A

Subdural haematoma

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13
Q

Dementia suggested by repeated falls

A

Lewy body dementia

Progressive supranuclear palsy

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14
Q

Dementia suggested by carotid bruits/hypertension

A

Vascular dementia

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15
Q

Dementia suggested by incontinence

A

Normal pressure hydrocephalus

Delirium

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16
Q

Dementia suggested by prominent behavioural change/apathy early in illness

A

Vascular dementia

FTD

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17
Q

Dementia suggested by prominent aphasia early in illness

A

Vascular dementia

FTD

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18
Q

Dementia suggested by progressive gait disorder

A

PD-assoc dementia

normal pressure hydrocephalus

Vascular dementia

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19
Q

Dementia suggested by prominent fluctuations

A

Lewy body

Delirium

Medication SEs

Obstructive sleep apnoea syndrome

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20
Q

Dementia suggested by hallucinations or delusions

A

Delirium

Medication SEs

Late-onset schizophrenia (paraphrenia)

Dementia with Lewy bodies

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21
Q

Dementia suggested by eye movement abnormalities

A

PD-assoc dementia

Wernicke’s encephalopathy

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22
Q

Formal assessment tools for cognition

A

MMSE

MOCA

CLOX

Addenbrookes Cognitive Examination

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23
Q

Prominent symptoms and signs of Alzheimer’s dementia

A

Memory loss

Dyspraxia

Dysphasia

Apathy

Psychosis

Loss of executive f(x): disorganisation, disorientation, lack of reasoning

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24
Q

Prominent symptoms and signs of vascular dementia

A

Gait disturbance (Parkinsonian, small-step)

Urinary urgency/frequency appears early

Preserved insight

Labile mood, personality changes (occur earlier than AD, before memory)

Sudden-onset, step-wise progression

Hx/risk factors for vascular disease

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25
Prominent signs and symptoms of LB/Parkinsonian dementia
Parkinsonism Visual hallucinations (usually not scary) Flucctuating dementia Delirium-like phases Poor REM sleep Visuospatial impairment
26
Prominent signs and symptoms of frontotemporal dementia
Early onset (40-60) Insidious, gradual progression (lacks insight) Memory initially preserved Early primitive reflexes + stereotyped behaviours Peronsality change Emotional blunting Expressive dysphasia: echolalia, perseveration, reduced speech
27
Prominent features of Huntington's disease
Family Hx Early onset (20s-40s) Choreiform movements Irritability/depression Schizophrenia-like psychosis
28
Prominent features of normal pressure hydrocephalus
Urinary incontinence Gait apraxia Mental slowing, apathy, inattention Onset 50-70s
29
Clinical features of prion disease
Onset \<50 Myoclonic jerks Seizures Cerebellar ataxia
30
Problems with antipsychotics in dementia
More rapid cognitive decline (esp LBD) Increased risk of stroke Increased risk of sudden death
31
Poor prognostic factors for dementia
Prion disease (\<1y) Young age of onset Focal neurological signs Psychotic symptoms
32
Initial assessment + workup of dementia
* Baseline bloods --\> treat reversible causes * Corroborative Hx * MOCA/MMSE * CT scan before referral to 2ry care * Treatment of exacerbating factors * Infection, dehydration, constipation (esp if sudden deterioration) * DVLA + driving advice (alone not ban on driving) * Establish formal multidisciplinary care plan
33
Long-term management of dementia components
* Psychoeducation * Social support * Optimising environment * Psychological treatments * Pharmacological interventions (employ later) * Medico-legal aspects * Carer support
34
Social support services in dementia
Support for carers *and* patients e.g. meals-on-wheels, day care, respite admissions
35
Optimising environment in dementia
Calm, familiar, well-lit Regular toileting schedule to treat incontinence, other routines Visible clocks
36
Psychological treatments in dementia
Aromatherapy Reminiscence therapy Music/art therapy Structured group cognitive stimulation programme
37
Medico-legal aspects in dementia
DOLS MCA Advance directives LPA
38
Histopathology of Alzheimer's
Neurofibrillary tangles (Tau protein) Beta-amyloid plaques Cerebral atrophy, esp loss of cholinergic neurons in basal forebrain
39
Genetic risk factors for Alzheimer's
ApoE4 allele APP/PSEN mutations (rare) Down's syndrome
40
Environmental protective factors for Alzheimers
High educational attainment Regular physical/mental exercise
41
Medical risk factors for Alzheimer's
Homocysteinemia Obesity/diabetes in middle age Hypertension Hx of depression Head injury
42
Pharmacological treatment of mild-mod Alzheimer's
Chlolinesterase inhibitors (e.g. donepezil, rivastigmine, galantamine)
43
Contraindications to donepezil
Baseline bradycardia Cardiac conduction abnormalities (e.g. sick sinus) Peptic ulcer Hepatic impairment COPD/asthma Caution w/ beta blockers/Ca channel blockers
44
Pharmacological treatment of mod-severe Alzheimer's
Memantine (NMDA antagonist)
45
Effect of pharmacological treatments of Alzheimer's
Delay entr into residential care (6-9 months)
46
Risk of developing dementia after stroke
10%
47
Risk of developing dementia after two strokes
30%
48
Management of vascular dementia
Manage cardiovascular risk factors No evidence for aspirin
49
Histopathology of Lewy body dementia
Alpha-synuclein intracellular inclusions in cerebral cortex
50
Distinction between Parkinson's associated dementia and Lewy body dementia
PDD occurs \>12mo after onset of Parkinsonism
51
Pharmacological treatment of LBD/PDD
Cholinesterase inhibitors (rivastigmine) ***NOT*** antipsychotics
52
Risk of PDD after onset of PD
1/3
53
Treatment of normal pressure hydrocephalus
Ventricular shunting
54
Prognosis of normal pressure hydrocephalus dementia
50% respond well to ventricular shunting
55
Management of Huntington's dementia
Symptomatic treatment of depression/psychosis Genetic counselling for family
56
Neuropathology in normal pressure hydrocephalus
Disproportionate enlargement of ventricles on CT/MRI
57
Neuropathology in Huntington's
Accumulation of huntingtin --\> neurotoxic Atrophy of caudate nucleus --\> frontal lobe
58
Time criterion for dementia
6 months
59
Presentation of neurosyphilis
* Argyll-Robrtson (aka prostitute's) pupil: accommodate but don't react * Hypomania * Memory issues * 15-20y post-infection
60
Common misidentifying delusions in Alzheimer's
Capgras Mirror sign Phantom boarder
61
Distinction between MCI and dementia
MCI: AoDL intact + still possesses insight (complaint of memory loss)
62
Chance of developing dementia from MCI
10%
63
Classical progression of vascular dementia
Stepwise deterioration
64
MMSE score for mild-moderate Alzheimer's
10-26
65
MMSE score for severe AD
\<10/30
66
Temporal sequence of symptoms in vascular dementia
Labile affect + personality changes often precede cognitive deficitys
67
Distinction between anhedonia and apathy
Apathy --\> will not seek out enjoyment but will report enjoyment of things if they happen to them Anhedonia --\> reports nothing is enjoyable
68
Side effects of cholinesterase inhibitors
Anorexia Nausea + Vomiting Diarrhoea Syncope Urinary incontinence
69
Side effects of memantine
Dizziness Headache Ataxia Dyspnoea Constipation Hypertension
70
Managing agitation/behavioural disturbance in dementia
Risperidone, haloperidol Increased stroke risk, use with caution
71
Prognosis of AD
Death within 3-10 years Irreversible
72
Prognosis for LBD
Death within 4-10 years Worse functional impairment due to parkinsonism, more need residential care
73
Prognosis for VD
3-5 year life expectancy, death from stroke/IHD

Psychiatry (20 decks)

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