Delerium and Dementia

Question 1

What is the definition of dementia, and what is preserved

Answer 1

Progressive deterioration of intellectual function, with consciousness preserved

Question 2

What is the main risk factor for dementia

Answer 2

Age

Question 3

What are five main categories of causes of dementia

Answer 3

1.) Primary neurologic disorders2.) Infections3.) Metabolic disorders4.) Drugs and toxins5.) Pseudodementia

Question 4

What are the primary neurologic disorders causing dementia?

Answer 4

1.) Alzheimers disease - 66%2.) Vascular dementia - stepwise decline3.) Space occupying lesions - tumors/hematoma4.) Normal pressure hydrocephalus5.) Dementia with lewy bodies6.) Pick’s disease - like AD7.) Other diseases - Multiple sclerosis, hunt, parkinsons, wilsons

Question 5

What are some infectious causes of dementia

Answer 5

1.) HIV infection2.) Neurosyphilis3.) Cryptococcal infection4.) Creutzfeldt-Jakob disease5.) Progressive mulfifocal leukoencephalopathy

Question 6

What are some metabolic causes of dementia

Answer 6

1.) Thyroid disease2.) Vitamin B12 deficiency3.) Thiamine deficiency4.) Niacin deficiency

Question 7

What is pseudodementia

Answer 7

It’s actually depression so it would respond to antidepressants even though it looks like AD

Question 8

What three things must you do clinically when you suspect someone has dementia

Answer 8

1.) Patient history2.) Neurologic and mental status examination with gait analysis for Parkinsons, hydrocephalus, etc3.) Labs/imaging: CBC, chem panel, thyroid function, vitamin B12, folate, VDRL, HIV, CT/MRI of head

Question 9

What is a good stepwise manner to treat dementia

Answer 9

1.) Treat reversible causes2.) Monitor meds that could cause this3.) Treat comorbid med conditions causing this4.) Pharm therapy - vitamin E, tacrine, and donepezil

Question 10

What are the three main risk factors for alzheimers disease

Answer 10

1.) Age2.) Family onset - early alzheimers (chrom 21, 14, 19)3.) Down syndrome

Question 11

What are two things that would be seen on autopsy in alzheimers disease

Answer 11

1.) Senile plaques - torturous neuritic processes with beta-amyloid core2.) Neurofibrillatory tangles - Neurofilament bundles in cytoplasm denoting degeneration

Question 12

What is the average progression of alzheimers

Answer 12

5 to 10 years

Question 13

When do you see visuospatial disturbances in alzheimers

Answer 13

Intermediate stage

Question 14

When do you see major problems with recalling friends/famiy in alzheimers

Answer 14

Later stage

Question 15

When do you see incontinence in alzheimers disease

Answer 15

Advanced disease

Question 16

What do people die from in alzheimers

Answer 16

Infection or other complications of debiliated states

Question 17

What are three anticholinesterase inhibitors used in alzheimers disease

Answer 17

Donepezil, rivastigmine, galantamine

Question 18

What class of medications should you avoid in alzheimers disease

Answer 18

Anticholinergic medications

Question 19

What vitamin can you give to people with alzheimers

Answer 19

Megadoses of vitamin E - slows disease progression in severe alzheimers

Question 20

What is the effect of hormone replacing therapy on alzheimers

Answer 20

Lowers risk of developing alzheimers

Question 21

What is dementia with lewy bodies a mix of

Answer 21

Features of alzheimers and parkinsons with more rapid progression

Question 22

What symptoms predominate in early lewy body dementia

Answer 22

Visual hallucinations with fluctuating mental status and extrapyramidal features

Question 23

What exacerbates symptoms in lewy body dementia

Answer 23

Neuroleptic agents, but needed for hallucinations and psychotic features

Question 24

What antidepressant can slow down disease progression of lewy body dementia

Answer 24

Selegiline

Question 25

What are the only two dementias that you can use anticholinesterase inhibitors for

Answer 25

Alzheimers and Lewy body dementia

Question 26

What two things does consciousness depend on, and where in the brain is each one located

Answer 26

Arousal - RAS (brainstem)Cognition - cerebral cortex

Question 27

What is the mneunomic of delerium and what do they stand for

Answer 27

P DIMM WITP = PostoperativeD = dehydrationI = InfectionM = Medications - anticholinergics, tricyclic antidepressants, corticosteroids, hallucinogens, cocaineM = heavy metalsW = Withdrawal - alcohol, benzodiazepenesI = Inflammation, feverT = trauma

Question 28

What four things do you see clinically in delerium

Answer 28

1.) Rapid deterioration of mental status2.) Fluctuating level of awareness3.) Abnormal vital signs4.) Perception abnormalities - hallucinations

Question 29

What should you do on physical examination for delerium

Answer 29

Mini mental status exam

Question 30

What should you do for labs for delerium (two things)

Answer 30

1.) Labs - thiamine, B12 deficiency, chem panel2.) LP - if febrile, unless cerebral edema

Question 31

How do you treat the psychosis/agitation of delerium

Answer 31

Haloperidol

Question 32

What is the difference between consciousness and hallucinations in delerium and dementia

Answer 32

Delerium - altered consciousness, visual hallucinationsDementia - consciousness preserved, no hallucinations

Question 33

Where do you see sundowning

Answer 33

In delerium, worse at night

Question 34

What is the definition of coma

Answer 34

Depressed level of consciousness to point where patient is unresponsive to stimuli

Question 35

What are two general categories to put coma causes into

Answer 35

1.) Structural - bilateral2.) Global dysfunction - metabolic/systemic

Question 36

What is the initial thing you must do if someone presents with coma

Answer 36

Do ABC, measure vital signs, and stabilize cervical spine (assume trauma always), and use glasgow coma scale to assess level of consciousness

Question 37

How can you assess level of consciousness in coma

Answer 37

Glasgow coma scale - measures eye opening, motor response, and verbal response - pg 219

Question 38

What is the steps in diagnosing coma

Answer 38

1.) Rapid motor examination - start with this, if assymetric then probably smass lesion2.) Brainstem reflexes3.) Laboratories - CBC, electrolytes, calcium, BUN, creatinine, glucose, plasma osmoliarity, arterial blood gas, ECG4.) Toxicolic analysis of blood/urine5.) CT/MRI of brain6.) LP - if meningitis or SAH suspected

Question 39

What are the brainstem reflexes?

Answer 39

1.) Pupillary reflex - if equal, then midbrain intact (if anisocoria - possible uncal herniation affected CN 3)2.) Eye movements - dolls eye test - turning head to one side should move eyes to opposite side - brainstem intact

Question 40

How do you treat coma

Answer 40

1.) Correct reversible causes, control airway, give supplemental O2, naloxone if narcotics, dextrose if hypoglycemia, give thiamine before glucose load2.) Treat herniation by lowering ICP

Question 41

What is the mneumonic for causes of coma

Answer 41

SMASHEDS = structural (stroke, ICH, hematoma, herniation, abscess)M = meningitisA = Alcohol, acidosisS = seizuresH Metabolic disturbancesE = endocrine (addison crisis, thyrotoxicosis, hypothyroid), encephalitisD = Drugs (opiates, barbiturates, benzodiazepenes)

Question 42

In coma, what are the three kinds of pupils you can see and what are they associated with

Answer 42

Dilated pupils - severe anoxiaUnilateral fixed dilated pupil - herniation with CN3Pinpoint pupils - narcotics, ICH

Question 43

What is brain death?

Answer 43

Irreversible absence of brain and brainstem function - apnea despite adequate oxygentation and ventilation, no brainstem reflexesCore body > 32 degrees celsius to make diagnosisEEG shows isoelectric (no activity)

Question 44

What is a vegetative state

Answer 44

Unresponsive, but eyes open with random head/limb movements