delirium, dementia, concussions Flashcards Preview

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Flashcards in delirium, dementia, concussions Deck (56):
1

Confusional state

a more profound deficit that includes disorientation, bewilderment, and difficulty following commands.

2

Lethargy

consists of severe drowsiness in which the patient can be aroused by moderate stimuli and then drift back to sleep.

3

Obtundation

a state similar to lethargy in which the patient has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states.

4

Stupor

means that only vigorous and repeated stimuli will arouse the individual, and when left undisturbed, the patient will immediately lapse back to the unresponsive state

5

Coma

state of unarousable unresponsiveness

6

Response to motor examination in comatose patients

reaction to noxious stimuli
Localizing responses, such as moving the examiner's hand away from the body, are not consistent with coma
Flexion and extension responses to painful stimuli are consistent with coma, and some patients have no response at all

7

determining coma:

-reactivity tom voice and physical stimulation
-cranial nerves, vestibule-ocular reflex
-motor exam

8

coma mimics:

locked-in
catatonic states
severe abulia

9

Locked-in syndrome

a form of paralysis from injury to the anterior brainstem with sparing of the RAS, leaving the patient awake and aware but with limited ability to communicate.

10

Catatonic states and severe abulia

syndromes that inhibit the patient from responding appropriately due to limited, not global, impairment of the brain.

11

A few clinical signs suggest the diagnosis of a locked-in syndrome, abulia, and catatonic states.

In locked-in syndrome, most patients have spared vertical gaze (particularly upward gaze) allowing them to follow commands.
Abulic patients will have occasional spontaneous purposeful movements.
Catatonic patients often have limb position postures that are not typical of coma.

12

what percent of elderly hospitalized its experience delirium?

30%

13

what type of drugs can cause delirium?

anticholinergics

14

delirium. conical presentation:

Altered cognition
Altered consciousness
Elderly
Hours to days
Other findings:
psychomotor agitation
sleep-wake reversals
irritability, anxiety
emotional lability

15

what test detects delirium?

Confusion assessment method (CAM)

16

delirium management:

Treat the underlying condition
Supportive care

Agitation
Reassurance, reorientation, limit aggravating factors
Constant observation
Pharmacologic? Antipsychotics with limited evidence

17

Dementia:

Mild cognitive impairment
Alzheimer’s
Lewy Body
Parkinson’s
Frontotemporal
Rapidly progressive
Normal pressure hydrocephalus

18

dementia laboratory eval:

B12
Thyroid function
Blood count
Metabolic panel
Additional tests depending on history:
RPR/T.pallidum, HIV, autoimmune testing
Lumbar puncture

19

dementia imaging:

MRI preferred over CT
Better resolution
Old infarcts
Atrophy
Ventricular size

20

alzheimers dementia clinical features:

Memory impairment
Executive dysfunction
Neuropsychiatric symptoms
Sleep disturbance
Also noted:
Olfactory changes
Seizures
Apraxia

21

alzheimers imaginign:

MRI:
Generalized and focal atrophy
Reduced hippocampal volume
Atrophic medial temporal lobe

-Functional brain imaging with [18F] FDG-PET, functional MRI (fMRI), perfusion MRI, or SPECT reveals distinct regions of low metabolism (PET) and hypoperfusion (SPECT, fMRI)
hippocampus, the precuneus (mesial parietal lobes), the lateral parietal and posterior temporal cortex

22

how do you measure Alzheimers progression?

-measured with MMSE, MoCA, and the clinical dementia rating scale

23

what is the most common type of dementia?

alzheimers

24

what is the second most common type of dementia?

dementia with Lewy bodies

25

pathologic hallmark of dementia with lewy bodies?

Lewy Body
abnormal aggregates of protein in the cytoplasm

26

features of Lewy body D?

Dementia
Other features
Fluctuating cognition
Visual hallucinations
Parkinsonism

27

differentiating dementia with lewy bodies and Parkinson's:

In DLB, dementia should occur before or concurrently with onset of parkinsonism
-in parkinsons, Parkinson's comes first, then dementia

28

DLB prognosis:

Similar to slightly faster rate of cognitive decline than AD
Shorter survival time than AD

29

DLB Tx:

same as AD, but neuroleptics with care
~30 - 50% have severe sensitivity to neuroleptics
Worsening parkinsonism

30

Parkinsons:

Neurodegenerative disease
Mostly motor symptoms
Pathophysiology:
Death of cells in the substantia nigra
Alpha-synuclein aggregates

31

parkinsons motor symptoms:

Tremor
Rigidity
Akinesia
Postural instability (walking/gait difficulty)

32

parkinsons dementia:

Cognitive decline usually later
~30% of PD patients
Risk factors:
Older age
Age of onset of PD >=60
Increased severity of parkinsonism

33

cardinal features of Parkinson's dementia:

executive dysfunction
impaired visuospatial function
less prominent memory deficits
relatively preserved language function

34

parkinsons dementia tx:

Symptomatic
No therapies have been shown to modify the course of the disease or influence prognosis

35

Frontotemporal dementias:

Changes in behavior, personality, language
Behavioral variant (bvFTD)
Primary progressive aphasias:
-Nonfluent
-Semantic

36

behavioral changes of frontemporal dementia:

Disinhibition
Compulsive behaviors
Hyper-orality

37

FTD diagnosis:

Diagnosis may be difficult
Rule out psychosis
Differential includes Lewy body disease, AD

38

primary progressive aphasia:

-insidious onset and gradual progression of a language impairment (ie, aphasia) manifested by deficits in word finding, word usage, word comprehension, or sentence construction
-Nonfluent vs. Semantic

39

most common form of prion disease:

creutzfeldt-jakob disease

40

neuropathology CJD features:

neuronal loss
proliferation of glial cells
absence of an inflammatory response
presence of small vacuoles within the neuropil, which produces a spongiform appearance

41

CJD clinical features:

Rapidly progressive cognitive decline
Myoclonus (startle)

42

CJD MRI abnormalities:

T2 hyperintensities in the putamen and head of the caudate
Cortical ribbon

43

CJD diagnosis:

exclusion

44

Vascular (multi-infarct) dementia:

Multiple brain insults accumulated over time (step wise decline)

45

vascular dementia risk factors:

Cardiovascular risk factors
Uncontrolled hypertension, hyperlipidemia, type 2 diabetes, heart disease

46

Normal pressure hydrocephalus (NPH):

large ventricle size with normal opening pressures

47

NPH features:

Wet
Wacky
Wobbly
Temporal course:
Gait difficulty and urinary urgency/incontinence first, then cognitive changes

48

NPH tx:

Lumbar puncture to aid in diagnosis
Ventriculoperitoneal shunt

49

NPH prognosis:

Shunt placement can lead to improvement in symptoms

50

most common form of sports-related TBI:

concussion

51

concussion clinical presentation:

Headache*
nausea
dizziness
confusion
memory impairment
incoordination
attention problems
behavioral changes

52

Post-concussion syndrome:

When patients report persistent neurobehavioral impairments after concussion
Chronic Post-concussion Syndrome when symptoms present >1year after injury

53

post-concussion syndrome assessment :

Comprehensive neurological examination
Personal and family history of migraine/sleep disturbance/mood disorders

54

concussion eval on field:

ABCs
Seizure? Prolonged loss of consciousness?
Evidence of cervical spine disease?

Emergency medical services!

55

concussion diagnosis:

SCAT3

56

concussion Tx:

Remove from participation
Direct observation
At least four hours
Distraction free environment
Limited utility of neuroimaging
Symptomatic management
Arrange follow up with comprehensive neuro exam within 24 hours