Dementia Flashcards
1
Q
_________ is a MEDICAL EMERGENCY.
A
Delirium
2
Q
What are the 3 steps in the Cognitive Continuum?
A
- Preclinical [Normal Cognitive function]
- Minor neurocognitive disorder [Mild Cognitive Impairment]
- Major neurocognitive disorder [Dementia]
3
Q
What are Instrumental Activities of Daily Living?
A
- Cooking
- House cleaning
- Laundry
- Management of medications
- Management of the telephone
- Management of personal accounts
- Shopping
- Use of transportation
4
Q
What are Activities of Daily Living (ADLs)?
A
DEATH
- Dressing
- Eating
- Ambulating
- Toileting
- Hygiene (Bathing)
5
Q
What is the Mini-Cog Exam?
What are the 3 steps?
A
- Ask patient to remember 3 unrelated words
- Banana, Sunrise, Chair
- Village, Kitchen, Baby
- Leader, Season, Table
- Ask patient to draw the face of a clock. After the numbers are on the clock, ask patient to draw hands to read 10 min after 11:00
- Ask patient to recall the 3 words
6
Q
How is the Mini-Cog exam scored?
A
- 3 recalled words
- Negative for cognitive impairment
- 1-2 recalled words + normal clock
- Negative for cognitive impairment
- 1-2 recalled words + abnormal clock
- Positive for cognitive impairment
- 0 recalled words
- Positive for cognitive impairment
7
Q
What is the laboratory work up for all patients?
A
- CBC
- Electrolytes
- Creatinine
- Glucose
- TSH
- Vitamin B12
8
Q
What is the laboratory work up for selected cases?
A
- HIV serology
- RPR
- Heavy metal screening
- LFTs
- MMA
9
Q
What is a normal score for the Montreal Cognitive Assessment test? (MOCA)
A
> 26/30
10
Q
How are Neurocognitive Disorders defined according to DSM-V?
A
- Delirium
- Neurocognitive disorders [not delirium]
- Minor
- Major
- Further subdivision based on etiology
11
Q
What is the Dementia/Major Neurocognitive Disorder Diagnostic Criteria for DSM-5?
A
- Evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains based on:
- Concern of the individual, knowledgeable informant, or the clinician that there has been a significant decline in cognitive function AND
- A substantial impairment in cognitive performance (documented)
- The cognitive defects interfere w/ independence in everyday activities
- The cognitive defects do not occur exclusively in the context of a delirium
- The cognitive defects are not better explained by another mental disorder
12
Q
What are the 6 cognitive domains?
A
- Complex attention
- Executive function
- Learning & memory
- Language
- Perceptual-motor
- Social cognition
13
Q
What are the 4 components of a dementia diagnosis?
A
- >2 cognitive domains affected
- Impaired occupational function
- Evidence of progression
- No alternative diagnosis
14
Q
Mild Cognitive Impairment (MCI)
- Onset
- Domain
- Motor
- Progression
- Imaging
A
- Onset: Gradual
- Domain: >Memory
- Motor: Rare
- Progression: 12%/yr to Alzheimer’s
- Imaging: Normal or Alzheimer’s pattern
15
Q
Alzheimer’s Disease
- Onset
- Domain
- Motor
- Progression
- Imaging
A
- Onset: Gradual
- Domain: Memory, Language, Visuospatial
- Motor: Late
- Progression: Gradual (8-10 yrs)
- Imaging: Atrophy, small hippocampal volume
16
Q
Vascular Dementia
- Onset
- Domain
- Motor
- Progression
- Imaging
A
- Onset: Sudden & gradual
- Domain: Depends on location
- Motor: Depends on location
- Progression: Depends on ischemia pattern
- Imaging: Cortical or subcortical MRI changes
17
Q
Lewy Body Dementia
- Onset
- Domain
- Motor
- Progression
- Imaging
A
- Onset: Gradual
- Domain: Memory, visuospatial, hallucinations, fluctuating
- Motor: Parkinsonism
- Progression: Gradual & cognitive fluctuations
- Imaging: Atrophy
18
Q
What is the prevalence of dementia by age?
- 65-75
- >75
- >85
A
- 65-75
- Outpatient: 2.1%
- Inpatient: 6.4%
- >75
- Outpatient: 11.7%
- Inpatient: 13.0%
- >85
- Outpatient: -
- Inpatient: 31.2%
19
Q
What are the typical pathologic findings of Alzheimer’s disease?
A
- Decreased brain weight
- Atrophy of gyri & widening of sulci
-
Senile Plaques (amyloid)
- Diffuse: EC accumulation of Aß protein
- Neuritic: EC accumulation of Aß protein & tau containing neurites
-
Neurofibrillary Tangles
- Intraneuronal accumulation of abnormally phosphorylated tau (normal MT associated protein)
- Not unique to AD, found in other degenerative diseases
20
Q
What is the typical prognosis of Alzheimer’s disease?
A
- Estimates of median survival: 5-9 yrs
- 3 yrs (2.7-4 yrs)
21
Q
Dementia can lead to impairments in…..
A
“Make safety a priority before it’s a problem!”
- Judgment
- Orientation
- Behavior
- Physical ability
22
Q
What are some safety issues in dementia?
A
- Home environment
- Medications
- Firearms
- Wandering & getting lost
- Driving
23
Q
What is the second most common type of dementia?
What is the second most common type of degenerative dementia?
A
Vascular dementia
Lewy body dementia
24
Q
Lewy Body Dementia
- Prevalence
- Sex & Age
- Inheritance
A
- 10-20% of dementias
- M > W
- Mean age of onset = 75 yrs
- Most cases sporadic
- Autosomal dominant inherited form
- alpha-synuclein gene
25
What are the clinical features of Lewy Body Dementia?
* Gradual cognitive decline; Dementia often presenting symptom
* Early in course: attention, visuospatial & executive function, poor job performance getting lost
* Later in a course memory is impaired
26
What are the 3 core clinical features of DLB?
* **Fluctuation in alertness**
* Seconds to days
* In btwn episodes functioning may be normal
* **Vivid visual hallucinations**
* Simple or complex
* Early sign, often precedes motor symptoms
* **Parkinsonism**
* Bradykinesia & rididity
* Tremor is less common than PD
* Motor symptoms develop later in a course of illness or in concordance w/ dementia
* If motor symptoms present \>1 yr before dementia, think PD dementia
27
What are some suggestive features of DLB?
* **Repeat** **falls**
* **Neuroleptic sensitivity** resulting in severe pakinsonism, typical more than atypical, not dose related
* **REM sleep disorder** - vivid dreams in REM sleep w/o muscle atonia, patients act out their dreams
* **Syncope or LOC**
* **Orthostasis** - associated w/ carotid sinus sensitivity
* **Autonomic dysfunction** - urinary incontinence or retention, constipation, impotence
* **Auditory hallucinations & delusions**
* **Depression** - 40% will have MDD
28
In DLB, what does MRI show?
What does SPECT/PET show?
* MRI - generalized _atrophy_
* SPECT/PET scan - _decreased perfusion_ in _occipital_ lobes
29
What is the neuropathology of Lewy Body Dementia?
Lewy bodies
Alpha-synuclein
30
What are Lewy Bodies?
round, eosinophilic, intracytoplasmic inclusions in the nuclei of neurons
31
What is alpha-synuclein?
Where is it found?
* Major component of Lewy bodies
* Deep cortical areas throughout the brain
* Anterior, frontal & temporal lobes
* Cingulate gyrus & insula
32
\_\_\_\_\_\_\_\_\_ are often present but NFTs are rare in DLB.
\_\_\_\_\_\_\_\_\_\_\_\_ are sparse or absent.
Amyloid plaques
NFTs
33
Neuronal loss in DLB is greater in \_\_\_\_\_\_\_\_\_\_, \_\_\_\_\_\_\_\_\_\_\_\_, __________ and \_\_\_\_\_.
* Frontal lobes
* Nucleus basalis of Meynert
* Substantia nigra
* LC
34
In DLB, there are decreased cortical levels of \_\_\_\_\_\_\_\_\_\_\_\_\_.
choline acetyl transferase
35
What is the prognosis of DLB?
What are some non-pharmacologic treatments?
* **Prognosis is very poor**
* No therapies are known to alter the natural progression of the underlying neurodegeneration or time of death
* Average survival is similar to that of AD, about 8 years
* **Non-pharmacologic treatments is emphasized**: addressing environmental, medical, psychologic & social factors; caregiver education & support
36
What is the pharmacological management of DLB?
* Pharmacological treatment is _symptomatic_, no FDA approved medications
* **Acetylcholinesterase inhibitors** can offer benefit in realms of apathy, confusion, hallucination & somnolence
* When antipsychotics are needed, atypical agents are preferred (**Olanzapaine, Quetiapine**) w/ the goal to avoid long-term usage
* Antiparkinsonian medications: **Levodopa-carbidopa** well tolerated, avoid anticholinergics
* REM sleep behavior disorder: low dose of **Clonazepam**; **Melatonin** might be helpful
37
What does DLB look like on brain imaging?
* MRI - generalized atrophy
* SPECT/PET scan - decreased perfusion in occipital lobes
38
What does AD look like on brain imaging?
* MRI
* generalized atrophy
* shrinkage of hippocampus
* enlarged ventricles
39
What does FTD look like on brain imaging?
* MRI - frontal & temporal atrophy
* PET scan - decreased metabolism in frontal & occipital lobes
40
What does vascular dementia look like on brain imaging?
* MRI - white matter lesions
41
Which 3 are the core features of DLB?
* Visual hallucinations
* Repeated falls
* Parkinsonism
* Cognitive fluctuations
* Visual hallucinations
* Parkinsonism
* Cognitive fluctuations
42
Which 3 are the supportive features of DLB?
* Neuroleptic sensitivity
* REM sleep disorder
* Delusions
* Non-REM sleep disorder
* Neuroleptic sensitivity
* REM sleep disorder
* Delusions
43
Alpha-synuclein is a major component of....
* NFTs
* Senile plaques
* Lewy bodies
* Amyloid-beta protein
**Lewy bodies**
44
65 YO male has been frustrated as he is forgetting phone numbers & misplaces his keys. Otherwise he is doing well & his daily functioning is not impaired. His father had Alzheimer's disease. On MMSE he scored 28/30, he lost 2 points on delayed recall. What is the most likely diagnosis?
* Vascular dementia
* Alzheimer's disease
* Mild cognitive impairment
* Lewy body dementia
**Mild cognitive impairment**
45
What is the second most common type of dementia?
* Parkinson's disease dementia
* Frontotemporal dementia
* Vascular dementia
* Alzheimer's disease
**Vascular dementia**
46
Mr. Smith is a 60 YO male who was brought by his son for evaluation. Son reported that 4 yrs ago his father become social inappropriate, making sexual comments to his female neighbors. Mr. Smith was evicted from his apartment due to poor environmental hygiene & complaints made by his neighbors as he was urinating in a hallway.
On neurophysiology testing Mr. Smith showed executive & visuospatial deficits along w/ deficits in attention & language. The memory is preserved however he is not able to work or live independently.
Labs were w/i normal limites. On physical exam he had no focal signs & didn't exhibit any signs of movement disorder. What is the most likely diagnosis?
* Alzheimer's disease
* Lewy body dementia
* Frontotemporal dementia (FTD)
* Vascular dementia
**Frontotemporal dementia (FTD)**
47
70 YO male came for evaluation due to memory problems that started a year ago. Physical exam was significant for bradykinesia, rigidity & pill-rolling tremor. You found in his history that he has parkinsonian features for the past 5 yrs & has been taking sinemet. Neurophysiology testing was done & showed deficits in executive function along w/ visuospatial, memory & language impairment. He has no Hx of stroke. What is the most likely diagnosis?
* Frontotemporal dementia
* Lewy body dementia
* Parkinson's disease dementia (PDD)
* Vascular dementia
**Parkinson's disease dementia (PDD)**
