Exam 2 -- MCM

Question 1

What is the differential diagnosis for confusion?

Answer 1

• Delirium
• Dementia
• Depression

Question 2

What is normal aging?

Answer 2

Slowed processing that DOES NOT interfere with function

Question 3

What are the domains of normal aging?

Answer 3

• Attention: Can they focus?
• Executive Function: Can they think clearly when it comes to higher level things?
• Memory: Do they forget things?
• Language: Word finding difficulties
• Visuospatial: Forgetting where they are in space
• Psychomotor: Changes in movement or speed of movement

Question 4

What are the basic activities of daily living?

Answer 4

• Dressing: Can they dress themselves? Can they pick out appropriate clothing for the season?
• Eating: Can they pick up the food , put it in their mouth, AND chew and swallow
• Ambulating: Can they get from point A to point B?
• Transferring: Can they move from the chair to the toilet and/or bed?
• Toileting: Can they do all steps of hygiene involved with toileting?
• Hygiene: Can they bathe themselves?

Question 5

What is the one basic ADL that an individual can need help with and still live independently?

Answer 5

Hygeiene

Question 6

What are the instrumental activities of daily living? (IADLs)

Answer 6

• Shopping
• Housekeeping
• Accounting
• Food preparation/medications
• Transportation
• Telephone

Question 7

What is delirium?

Answer 7

ACUTE disorder of attention and global cognitive function

Question 8

What is the diagnosis criteria for delirium?

Answer 8

CAM Criteria:

• Must have both acute onset and fluctuating course as well as inattention.
• Must have either disorganized thinking or altered consciousness.

Question 9

What are the types of Delirium?

Answer 9

• Hypoactive: Lower levels of agitation
  - Most commonly missed
• Hyperactive: High levels of agitation
  - Hardly ever missed
• Mixed: Fluctuate between hypoactive and hyperactive

Question 10

What is the etiology of delirium?

Answer 10

Dysfunction of multiple brain regions and neurotransmitter systems.
(exact cause is unknown, could be due to a possible cholinergic deficiency)

Question 11

Why are older adults more vulnerable to delirium?

Answer 11

Age related changes in central neurotransmission, stress management, hormonal regulation, immune response

Question 12

What are some of the known causes for the etiology of delirium?

Answer 12

Drugs – especially benzodiazepines & diphenhydramine
Eyes & Ears – lack of hearing aides and/or glasses
Low oxygen stats – due to MI, Stroke, PE
Infections – not just urinary
Retention – urinary retention or constipation
Ictal – post seizure
Undernutrition or under-hydration
Metabolic
Subdural – bleeding, etc

Question 13

What’s the treatment for delirium?

Answer 13

1. PREVENTION (key!!!)
2. Treat the underlying causes
3. Environmental modifications
4. Rarely use antipsychotics

Question 14

T/F: Delirium is irreversible.

Answer 14

False, it is reversible.

Question 15

What are the nonpharmacologic strategies to prevent delirium?

Answer 15

1. Reorientation
2. Involve family in care
3. Use of eye glasses and hearing aides
4. Sleep protocol (turn lights on during the day, off at night, quiet room, etc.)
5. Provide uninterrupted period for sleep
6. Avoid physical restraints and immobilization
7. Encourage mobility and self-care
8. Ensure adequate hydration.

Question 16

Why should antipsychotics be rarely used in treatment for delirium?

Answer 16

They mask the symptoms of delirium only and do not actually treat the underlying acute brain failure.

Question 17

When should antipsychotics be used in treatment of delirium?

Answer 17

Only if the patient is severely agitated and is at risk of interruption of essential medical care or is posing a safety hazard for themselves or others.

Question 18

What is dementia?

Answer 18

A progressive disease with a gradual onset with cognitive and behavioral symptoms that interfere with function, represent a decline in function, and cannot be explained by delirium or another psychiatric disorder

Question 19

With dementia, what are things the cognitive or behavioral symptoms must do?

Answer 19

Interfere with function, represent a decline in function, cannot be explained by delirium or another psychiatric disorder

Question 20

What are the domains of delirium?

Answer 20

Memory, attention, executive function, language, visuospatial function, motor function, and behavioral changes

Question 21

What are the types of dementia?

Answer 21

Alzheimer’s disease, Vascular dementia, Lewy body dementia, frontotemporal dementia, alcohol related dementia, normal pressure hydrocephalous dementia, psuedodementia

Question 22

What is Alzheimer’s disease?

Answer 22

The most common type of dementia. It has a slow, insidious onset and gets progressively worse over time. It is represented by amnesia and either language presentation, visuospatial presentation, or executive dysfunction.

Question 23

What is vascular dementia?

Answer 23

Dementia as a result of small vascular events happening in the Brain. Occurs in a stepwise fashion and often occurs in individuals with some sort of vascular risk factor.

Question 24

What is Lew body dementia?

Answer 24

Dementia with Parkinsonian features such as rigidity, gait, etc.

Question 25

What is frontotemporal dementia?

Answer 25

Dementia characterized by personality changes

Question 26

What is alcohol related dementia?

Answer 26

Dementia due to high alcohol consumption

Question 27

What is normal pressure hydrocephalous dementia?

Answer 27

Dementia due to changes in the pressure of the brain

Question 28

What is psuedodementia?

Answer 28

Other disorders such as severe depression that is affecting cognition that is being masked by dementia

Question 29

What are the risk factors for dementia?

Answer 29

Delirium in the last year, family history of dementia, substance abuse, age, co-morbidities (hypertension, hyperlipidemia, MI)

Question 30

What are the causes of cognitive dysfunction?

Answer 30

Psuedodementia (reversible), CVD, Nutritional Deficiency (B12 especially), DM 2, COPD, OSA (really common cause if left untreated), Thyroid dysfunction, Depression, Medication, or Delirium

Question 31

What are the big 3 that cause cognitive dysfunction?

Answer 31

Depression, Medication, or Delirium

Question 32

How is dementia evaluated?

Answer 32

1. Full neurological examination 2. Cognitive testing (Mini-Cog, MMSE, SLUMS, MoCA) 3. Neuroimaging

Question 33

What is the treatment for dementia?

Answer 33

It is a terminal disease, but there are some treatments that are available to slow the disease. (Ach esterase inhibitors, NMDA antagonist, focus on quality of life)

Question 34

Who does depression have a high prevalence in?

Answer 34

In older adults especially and it is under diagnosed

Question 35

What are the risk factors for depression?

Answer 35

Loss of social support, death of family and friends, changing social roles, physical limitations

Question 36

What is the evaluation for depression?

Answer 36

Geriatric Depression Scale, PSQ-9, or Cornell Scale for Depression in Dementia

Question 37

How does the Geriatric Depression Scale work?

Answer 37

Looks at how the patent has felt in the last week and asks hard questions that must be asked exactly how they are written and must be answered in a yes or no manner. A score of 4+ indicates depression

Question 38

What is the gold standard for depression treatment at all ages?

Answer 38

Medication and Cognitive Behavioral Therapy

Question 39

What is the diagnostic work up for the etiology of delirium?

Answer 39

Initially CBCD & CMP to look for infection

Question 40

What is the diagnostic work up for the etiology for dementia?

Answer 40

Cognitive testing, B-12 levels, thyroid function tests, and geriatric depression scale

Question 41

What is the diagnostic work up for the etiology for depression?

Answer 41

Geriatric Depression scale OR Cornell scale for depression and dementia.

Question 42

What is the sequence of events that occurs at a chemical synapse for synaptic transmission?

Answer 42

1. A signal action potential reaches the presynaptic terminal/end bulb. 2. Voltage gated Ca++ channels open and the presynaptic membrane depolarizes. 3. Ca++ flows inward, triggering the synaptic vesicles to fuse to the presynaptic membrane and the neurotransmitter is released. 4. The neurotransmitter cross the synaptic cleft & binds to ligand-gated receptors (The more neurotransmitter that is released the greater the change in potential of the postsynaptic cell) 5. Ion channels are opened (one-way information transfer)

Question 43

Describe the mechanisms that generate resting membrane potential in a neuron.

Answer 43

1. Steady-state condition with no net flow of ions across the membrane. (No net change in total distribution of ions) 2. Concentration gradient is maintained, ion channels are closed. (Voltage-gated Na+ and K+ channels closed.) 3. Electrical gradient is maintained by the Na/K ATPase pumps 4. Typically resting membrane potential is -70 mV. 5. Sodium and chloride are outside of the cell.(Making the outside of the cell positive) 6. Potassium and negatively charged anions are inside of the cell, making the inside of the cell negative.

Question 44

Describe the mechanisms that generate an action potential in a neuron

Answer 44

1. Threshold is reached at -55 mV by voltage-gated Na+ channels opening and Na+ entering the axon, beginning to depolarize the axon. 2. Depolarization happens because of the flow from ions through gated channels. The membrane potential becomes less negative and may even become positive and generates transmittable electrical signal, which is considered excitatory. (More voltage-gated Na+ channels open. Na+ rushing in depolarized the membrane. Na+ channels close about 1 msec after opening.) 3. Repolarization happens because of ions flowing through the gated channels. The membrane potential becomes more negative again. (Many voltage-gated K+ channels open, K+ exits, taking the positive charges out of the axon.) 4. Hyperpolarization happens when the membrane potential becomes even more negative, typically to -75mV. This decreases the ability to transmit an electrical signal and is considered inhibitory. (Voltage-gated K+ channels remain open. K+ continues to leave the axon restoring the polarized membrane potential.) 5. Action potentials occur on the axon (If the axon is myelinated, the potential will jump from one node of Ranvier to another and transmit the signal even quicker.)

Question 45

Describe the difference between gray matter and white matter.

Answer 45

White matter is axons and they look white because of the myelin around the axons. In the brain it is seen buried deep within the brain and in the spinal cord it is seen on the peripheral and it appears darker than gray matter. Gray matter is cell bodies and it appears gray because the cell bodies don't have myelin. In the brain it is found on the periphery and in the spinal cord it is found deep within the spinal cord and it appears brighter than white matter.

Question 46

List different cell types in the nervous system, and their morphological characteristics

Answer 46

1. Bipolar Neurons: Mostly primitive, Two processes connected to the cell body (Dendrite and the axon) - Very few cells have this type of neuron: Cranial Nerve I – olfactory nerve, Cranial Nerve II – optic nerve, Cranial nerve VIII – vestibular portion of the nerve 2. Pseudounipolar Neuron: Begins as bipolar, but the body becomes extended away from the neuron, single process connected to a cell body (Two kinds of axons) - Types of cells with this: Sensory neurons 3. Multipolar Neuron: More than two processes connected to a cell body (Most common) - Types of cells with these neurons: Motor Neurons & Most other types of neurons within the CNS