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Neurology Module > Dementia > Flashcards

Flashcards in Dementia Deck (115):
1

Types of Dementia

Alzheimers
Multi-infarct dementia
Dementia with Lewy Bodies
Frontotemporal Lobar Degeneration
NPH
Medications
Vitamin B12 deficiency
Alcohol related dementia and Wenicke’s encephalopathy
Progressive supranuclear palsy
Other causes of dementia

2

Acutely disturbed state of mind that occurs in fever or intoxication or other disorders and is characterized by restlessness, delusions, and incoherence of speech and thought

Delirium

3

Chronic or persistent disorder of the mental process caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning.

Dementia

4

Onset of Delirium

Acute
Subacute

5

Onset of Dementia

Insidious

6

Duration of Delirium

Days-weeks

7

Duration of Dementia

Months-years

8

Course of Delirium

Fluctuating
Reversible

9

Course of Dementia

Progressive

10

Level of Consciousness in Delirium

Altered/variable

11

Level of Consciousness in Dementia

NL - Unless of Severe

12

Attention in Delirium

Impaired

13

Attention in Dementia

Initially Intact

14

Psychomotor in Delirium

Variable - usually slow

15

Psychomotor in Dementia

+/- Normal

16

Sleep in Delirium

Disrupted

17

Sleep in Dementia

Less disruption

18

Predominant Symptoms of Delirium

Hyperactivity- irritation, combativeness
Hypoactivity- sedation, lethargy (more common in the elderly)
Mixed

19

Causes/Risk Factors of Delirium

Age >60
Prior brain injury (vascular or traumatic)
Insomnia, sleep deprivation
Decreased visual and/or auditory function
Hospitalization
Polypharmacy
Poor nutritional status
Renal/hepatic failure
Alcoholism
Infection

Pneumonia, UTI, meningitis/encephalitis

CV: hypoxia, CHF, dehydration, MI

Metabolic: hypo/hyperthyroidism, hypercalcemia (or other electrolyte imbalances), thiamine deficiency (Wernicke’s encephalopathy)

Neuro: CVA, seizures

20

Drugs to be avoided in the elderly

The Beer’s List for Potentially Inappropriate Medication Use in Older Adults

21

Beers List - Sedating Antihistamines

diphenhydramine
promethazine

22

Beers List - Benzodiazepines for anxiety or insomnia

May be appropriate in some settings (Seizure)

23

Why are TCAs on the Beers list?

Hypotension
Sedation

24

Beers List antibiotics

Nitrofurantoin

Causes Pulmonary Toxicity

25

CV drugs on the Beer's List

Alpha blockers (doxazosin, terazosin, prazosin, clonidine)
Antiarrhythmics- amiodarone (rate control more beneficial than rhythm control)
Digoxin (toxicity)
Spironolactone (hyperkalemia)

26

Why are antipsychotics on the Beer's List?

Increased risk of stroke

27

Express caution with diabetic medications with:

SSI
Longer acting sulfonylureas - glyburide

28

Meoclopramide in elderly can cause

extrapyramidal effects

29

Long-term NSAIDs in elderly can have

increased risk of GI bleeding

30

Muscle relaxants in teh elderly?

Avoid

31

Most common type of dementia in the elderly

Alzheimer's Dementia

32

Presentation of Dementia

New information is difficult to learn and retain
Complex tasks difficult to perform
Unable to solve simple problems
Getting lost in familiar surroundings
Difficulty expressing oneself
Irritable or aggressive behavior

33

Prevalence of Dementia

Age >65 10%
Age > 90 50%

34

Types of Dementia

Cortical - Alzheimer's metabolic
Subcortical - vascular dementia
Mixed - Parkson's, Lewy body

35

Cortical (Alzheimer's metabolic) dementia has:

Short term memory loss

Aphasia

Apraxia- inability to perform purposeful movement; inabilit to use objects properly (not due to sensory/motor deficits)

36

Subcortical (Vascular Dementia) has

Motor slowing
Mood disturbances

37

Mixed Dementia includes:

Parkinson's Disease, Lewy Bodies

38

Risk factors for dementia

Age >65 yo
Female
Family hx
Low education level
Head trauma
Long standing htn/MI

39

Alzheimer's Genetic Link

Apolipoprotein E (ApoE)

40

How many subtypes of ApoE exist?

3 subtypes

41

What is associated with alzheimers?

E4

Mechanism?
Increased amyloid deposition?

42

Chromosome linkage for early onset dementia:

21
14
1

43

Abnormal cleavage of protein leads to formation of βamyloid protein which deposits in blood vessels and activates glutamate

Amyloid Plaques

44

Helical filaments (tau proteins) stabilizers in cells/neurons; when hyperphosphylated, form tangles; hippocampus, medial temporal lobe, frontal lobe, parietotemporal area

Neurofibrillary Tangles

45

Pathophysiology of Alzheimers

Amyloid Plaques
Neurofibrillary tangles

Death of cholinergic neurons – decreased Ach (involved with memory)
Death of serotoninergic neurons- decreased serotonin
Death of adrenergic neurons- decreased norepinephrine
+/- Inflammation

46

"Deaths" associated with Alzheimers

Death of cholinergic neurons – decreased Ach (involved with memory)

Death of serotoninergic neurons- decreased serotonin

Death of adrenergic neurons- decreased norepinephrine

+/- Inflammation

47

DMS Criteria for Alzheimers (294.1)

The development of multiple cognitive deficits manifested by both:

Memory impairment (impaired ability to learn new information or to recall previously learned information).

One (or more) of the following cognitive disturbances:
-Aphasia (language disturbance)
-Apraxia (impaired ability to carry out motor activities despite intact motor function)
-Agnosia (failure to recognize or identify objects despite intact sensory function)
-Disturbance in executive functioning (ie. Planning, organizing, sequencing, abstracting)

The cognitive deficits in A1 and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning

The course is characterized by gradual onset and continuing cognitive decline

48

Diagnosis of Alzheimers

Diagnosis of exclusion!

CT/MRI- cortical atrophy; volume loss medial temporal lobe

PET scans- hypometabolism

49

Treatment of Alzheimer's Disease

Cholinesterase Inhibitors
Donepezil (Aricept) 5mg daily x 4-6 weeks; 10mg daily
Rivastigmine (Exelon) - Pill or patch
Galantamine (Reminyl, Razadyne) - 4mg BID, titrate Q4 wks to 24mg daily

NMDA Receptor Antagonist
-N-methyl-d-aspartate
-Glutamate overstimulation of NMDA receptors allows increased calcium influx
-Memantine (Namenda) 10mg BID

50

Goal of pharmacotherapy in Alzheimer's

Slow progression of Disease

51

Cholinesterase Inhibitors and NMDA Receptor Antagonists have

Similar Efficacy
GI side effects

52

Prognosis for Alzheimers

11.8 years

53

Cholinesterase Inhibitors for Alzheimers

Donepezil (Aricept) 5mg daily x 4-6 weeks; 10mg daily

Rivastigmine (Exelon) - Pill or patch

Galantamine (Reminyl, Razadyne) - 4mg BID, titrate Q4 wks to 24mg daily

54

NMDA-Receptor Antagonists for Alzheimers

N-methyl-d-aspartate

Glutamate overstimulation of NMDA receptors allows increased calcium influx

Memantine (Namenda) 10mg BID

55

Risk factors for multi-infarct dementia

Diabetes
CAD
Htn
CVA
Smoking
Men>women

56

Treatment of multi infarct dementia

Manage risk factors
Alzheimers meds not effective

57

Pathonemonic for Dementia with Lewy Bodies

Visual Hallucinations!!

Can have auditory or olfactory

58

Characteristics of Dementia with Lewy Bodies

Shares characteristics of Alzheimers and Parkinson’s
Visual hallucinations (auditory, olfactory)
Fluctuations in alertness and attention
Periods of staring into space
Affects men more than women

59

Pathophysiology of Dementia with Lewy Bodies

Lewy bodies- protein deposits in nerve cells

Develop plaques and tangles (AD)

Movement disorders- Parkinsonian sxs

60

Treatment of Dementia with Lewy Bodies

Same meds as Alzheimers
Parkinsonian sxs- meds for Parkinson’s
+/- anti-psychotics

61

Prognosis for Dementia with Lewy Bodies

Death ~5-7 years after diagnosis

62

Frontotermporal Lobar Degeneration AKA

Pick's Disease

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Frontotermporal Lobar Degeneration onset

40-70

64

Frontotermporal Lobar Degeneration risk factors

Family History

65

What is found in structures of "Picks Disease"?

Named “Pick’s disease” for abnormal protein-filled structures found on pathology

66

Frontotermporal Lobar Degeneration presentation

Inappropriate behaviors and actions
Decreased empathy
Lack of judgement/inhibitions
Apathy
Repetitive compulsive behaviors
Lack of hygiene
Speech and language disorders
+/- Movement disorders
Lack of awareness of behavioral changes

67

Classifications of Frontotermporal Lobar Degeneration

Behavioral Variant FTD
Semantic Dementia
Progressive nonfluent aphasia

68

Behavioral variant FTD presents as

Decline in social skills, behaviors, emotional lability
Poor hygiene
Compulsive behaviors

69

Semantic Dementia presentation

Effortless speech that lacks meaning
Failure to recognize faces of famous people

70

Progressive nonfluent aphasia

Stuttering, poor grammar, difficulty with word finding, decreased comprehension

71

Treatment of Frontotemporal Lobar Degeneration

SSRIs- behavioral issues
+/- antipsychotics
+/- (experimental) Alzheimers meds- cholinesterase inhibitors

72

Prognosis for Frontotemproal Lobar Degeneration

8.7 years duration

73

Pathophysiology of NPH

Communicating hydropcephalus”

No obstructive mass

Decreased CSF absorption due to scarring/fibrosis of the arachnoid villae

Ventricles become distended and compress the preiventricular tissues/vessels- ischemia

74

Causes of NPH

Idiopathic
Contributing factors: head injury, SAH, meningitis

75

NPH Triad

Gait Instability
Urinary Incontinence
Dementia

Wobbly - Wet- Wacky

Can't think, can't walk, can't pee

76

Testing for NPH

MRI
Lumbar Puncture

77

NPH - MRI will show

Ventriculomegaly
Cerebral parenchyma preserved
Medial hippocampus and temporal regions preseverved

78

NPH - Lumbar Puncture Results

Pressure at upper limits of normal

Not needed for diagnosis but often will remove CSF and monitor response to see if shunting will be beneficial

79

NPH Treatment

Shunt system to drain spinal fluid from ventricles into abdomen.

80

Medications causing Dementia

Beer’s List (review)
Intoxication/Withdrawal
Opioids
Benzodiazepine
Corticosteroids
Metoclopramide (Reglan)
Antihistamines
TCAs

81

Vitamin B12 Deficiency is caused by

Pernicious anemia (lack of intrinsic factor)
Surgery
Crohn’s, celiac
Long term use of PPIs
Autoimmune conditions: Graves, SLE

82

Signs and Symptoms of Vitamin B12 deficiency

Weakness
Sore tongue
Easy bruising, bleeding gums
Pallor
Paresthesias
Mood changes
Dementia/memory loss

83

Short term memory loss
Lack of thiamine (B1)

Wernicke-Korsakoff Syndrome
"wet brain"

84

Impaired planning, apathy (mimics depression)

Alcohol related dementia

85

Other neuro effects caused by EtOH

peripheral neuropathy,
cerebellar ataxia,
depression,
psychosis

86

Questions to ask to determine severity of dementia:

When was the last time their thinking and memory was completely normal?
Is there any time you thought they may have had a stroke?
Do they repeat, misplace, forget names, rely more on calendars/notes?
Who is in charge of meds? Finances?
Word finding difficulty?
Get lost driving?
Do you feel comfortable leaving them home alone? Overnight? Weekend? Week?
Can they perform ADLs?
Are they depressed? Anxious? Agitated? Restless?
Do they have hallucinations?
Sleep? Incontinence?
Hx head trauma?

87

Important PMH for dementia diagnosis

Neuro: seizures, strokes, Down’s syndrome
CV: CAD, seizures
Endocrine: DM, thyroid
GI: hepatic disease
Renal: failure- dialysis
Psych: anxiety/depression
Oncology

88

Important Social History regarding dementia

EtOH
Ilicit Drug Use
Exposures - HIV, syphilis, TB

89

Important FH regarding dementia

Dementia
Psychiatric illness
Endocrine
Cancer
Cardiac

90

Dementia Physical Exam Findings

General appearance- facies, basic mental status, grooming

Cranial nerve exam: Pupillary response, EOMs, Symmetry

Presence/absence of dysarthria

Motor: Tremor, Lateralized weakness/spasticity, Cogwheeling/rigidity, Atrophy/fasiculations (ALS)
Sensory: Hyperreflexia- stroke/vascular dementia, Hypo- neuropathy

Gait/balance

91

Dementia Initial Labs

Mini-Mental Status Exam
Labs: CBC, CMP, B12, folate, TSH, UA
Imaging: CT or MRI (preferrable)

Second line labs or as indicated in history: ESR, Syphilis serology VDRL/RDR, Lyme titer, LP, EEG, heavy metal screening, ceruplasmin, HIV

92

Nutrition issues with Dementia

Avoid enteral nutrition if possible
Dysphagia diet
Strongly flavored foods
Liquid supplements
Easy access to food
Preferred treats
Swallowing ability

93

Wandering Issues with Dementia

Common reason for nursing home placement
Increase daytime activity
Sleep hygiene
Visual barriers/alarms
ID bracelets
Safe areas

94

What administration of medications are an issue with dementia?

Self-Administered
30% dementia patients still have active license

95

Driving in Dementia

Double risk for accident

96

Is depression an issue with dementia?

YES!!!

Depression may go away later on in dementia.

97

Symptoms worsening toward the evening

Sun Downing

98

Alcohol Related Dementia Ages

Age 50-70

Correlates to amount of alcohol/tiem period

99

Protection effect of alcohol related dementia

4 glasses daily may protect from dementia but more can increase risk

100

Diagnosis of Alcohol Related Dementia

Similar criteria to Alzheimers WITH
-Significant EtOH (35 d/wk for men; 28/wk female) x 5 years
-Onset of dementia within 3 yrs of cessation
More supportive: other end-organ damage, peripheral neuropathy, cerebellar degeneration

101

EtOH Dementia Treatment

EtOH cessation
Thiamine replacement
Experimental research- Alzheimers meds?

102

S/S Wernicke's Encephalopathy

Ataxia
Confusion
Opthalmoplegia
Vertical and horizontal nystagmus

103

Prognosis of Wernicke's Encephalopathy

Death occurs in 20% cases

Those that survive, 85% will develop Korsakoff’s disease

104

Short term memory loss
Confabulation

Korsakoff's Disease

105

Treatment Korsakoff's Disease

Improvement in 75% patients with treatment

Treatment:
-Thiamine 100-200mg IM or IV
-Maintenance 50 mg PO daily

106

Progressive Supranuclear Palsy

Rare

Related to Parkinsons and FTD

107

Risk Factors of Progressive Supranuclear Palsy

Age
Familial

108

Supranuclear Palsy Symptoms

Blurred vision
Loss of balance
Stiffness and bradykinesia similar to Parkinsons
Dysphagia
Dysarthria
Emotional labile
Apathy/depression

109

Progressive Supranuclear Palsy Symptoms

Masked facies
“Startled appearance”

Paralysis of vertical gaze

Overcome with vestibulaocular reflex (VOR)

Later stages- horizontal movements impaired

110

Progressive Supranuclear Palsy Treatment

Vision/speech- no treatment
Movement disorders- Parkinsons
SSRIs- mood
+/- Alzheimer’s meds

111

Infectious Diseases that cause Dementia

Syphilis (tertiary)

AIDS/HIV

Infection- toxoplasmosis, Lyme disease, PML, encephalitis

Prion disease- Jacob-Creuzfeldt

112

Infections that cause Dementia

Taxoplasmosis
Lyme Disease
PML
Encephalitis

113

Other Diseases that can cause dementia

Hyper/Hypothyroidism
Neoplasms
Parkinson's Disease
Depression

114

Rare causes of dementia

Wilson's Disease
Paraneoplastic Syndromes
Sarcoidosis
SLE
Whipple's Disease
MS
ALS-late

115

Evaulation of Dementia

Age

Source- patient vs. family member

Onset: acute, subacute, chronic, initiating event?

Pace: slow vs. rapid; plateaued, fluctuating

Cognitive domains involved: attention, memory, executive function, calculation

Behavior: irritability, lability, social w/drawal, disinhibition

Degree of disability/independence

Associated symptoms: weakness, HA, fever, incontinence, falls/ataxia, depression