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7 Geriatrics > L4 Dementia > Flashcards

L4 Dementia Flashcards

1
Q

What brain changes with aging are considered normal?

A

It’s not a clear cut from alzhemiers vs healthy aging

consider both structural and functional changes (both happen with aging and disease)

cognitive reserve generally decreases with age AND disease

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2
Q

Structural changes of brain

A
  • decrease in overall weight, 5-10%
  • neuronal number loss is minimal, but decrease in size
  • decreaed dendritic density, shorter branches
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3
Q

Functional changes of brain

A

All decreasing…
* cognitive planning
* personality
* social behavior
* decision making
* short term memory

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4
Q

Other changes within the brain

A
  • white matter changes
  • neurofibrillary tangles
  • senile plaques
  • changes in NT function (specific ones decreases with age, not all)
  • impacted hippocampus
  • reduced glucose metabolism
  • change in communication between neuronal cells
  • activated state of glial cells
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5
Q

Accumulation of genetic damage throughout life

A
  • damaged nuclear and mitochondrial DNA
  • decreased capacity for DNA repair during aging
  • Decreased functioning of proteins due to damage
  • mitochondrial impairment
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6
Q

Reduced Glucose Metabolism

A
  • found in many brain regions, lots in temporal/parietal/motor cortex
  • brain insulin resistance accelerates with aging
  • Maintaining brain insulin sensitivity delays aging
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7
Q

Change in communication between neuronal cells

A

decreased synaptic connections, increased inflammation, degenerated neurovascular units

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8
Q

Activated state of glial cells

A

causes long term and chronic inflammation, which leads to cognitive impairments

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9
Q

Dopamine

A

decreased within frontal cortex, hippocampus, basal ganglia

impacts body movement, motivation, mood, and memory

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10
Q

Serotonin

A

decreased in frontal cortex, basal ganglia

impacts mood/behavior, sleep, appetite, memory

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11
Q

Glutamate

A

decreased in motor cortex and basal ganglia

impacts learning and memory

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12
Q

Neuroprotection is achieved by

A

exercise
continued cognitive challenge
low alcohol intake

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13
Q

Risk factors for decreased brain function in older age

A

diabetes/insulin resistance
high cholesterol
HTN
stress
head trauma
sedentary activity

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14
Q

Mini Cog

A

Step 1 - Three word registration
Step 2 - Clock Drawing
Step 3 - Three word recall

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15
Q

Scoring for Mini-cog

A

one point for each word that is recalled without cueing

0 or 2 points –must draw clock correctly and place hands correctly for 11:10

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16
Q

Can the mini-cog be used a diagnosis?

A

No
used to refer patients

quick screening tool, designed for assessment in early stages of dementia

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17
Q

A mini-cog less than 3/5

A

validated for dementia screening

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18
Q

Mini-cog score of 4/5

A

recommended when greater sensitivity is desired, may indicate need for further eval of cognitive status

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19
Q

Anything less than ____ on mini-cog should be referred on

A

5

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20
Q

Dementia

A

a syndrome of global intellectual decline

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21
Q

DSM-4 Dementia

A

development of memory impairment with at least one of the following cognitive impairments: aphasia, apraxia, agnosia, disturbance of executive function. Deficits are severe enough to result in limitations of occupational or social function and represent a decline from prior level

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22
Q

DSM-5 Dementia

A

the presence of memory impairment is not required, as some diseases have initial symptoms in other domains

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23
Q

Alzheimer’s Disease pathology

A
  1. Global atrophy
  2. Inflammatory response
  3. Neurofibrillary tangles
  4. Senile plaques
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24
Q

Atrophy in AD

A

occurs in the cerebral cortex, amygdala, and hippocampus due to neuronal cell death

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25
Q

Inflammation in AD

A

becomes excessive

Microglia (immune cells) in the brain become overactive and overproduce substances that produce death

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26
Q

Neurofibrillary tangles in AD

A

occurs intracellular

  • tau protein helps provide structure that is necessary for cell function
  • tau protein in AD becomes altered, collapses, and forms tangles, which results in decreased cell function
  • earliest signs of disturbed nerve cell function are seen in synapses
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27
Q

Functions of tau protein

A

nerve sprouting which helps with self-repair

maintaining nutrient transport system essential for the cell to work and survive

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28
Q

Senile plaques

A

Happens extracellular

  • abnormal cluster of amyloid protein frgaments that build up between cells and forms plaques
  • can impact cell to cell communication
  • might trigger inflammatory response
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29
Q

Mild Cognitive impairment

A
  • cognitive impairment not severe enough to meet criteria for demenita
  • preserved ADLs
  • minimal impairment to complex IADLs
  • most common deficits are memory, language, executive function, visuospatial function
  • 10-15% will progress to alzhemiers each year
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30
Q

Onset of AD

A

typically insidious

  • becomes apparent to others after pt has experienced an episode of stress
  • early s/s: difficulty with intellectual tasks, forgetfulness, untidiness, confusion, errors in judgement
  • short term memory becomes impaired
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31
Q

progression of AD

A
  1. Short Term memory loss
  2. Cognitive abilities impaired
  3. Inability to perform IADLs
  4. Long term memory loss
  5. Communication loss
  6. Inability to perform all other ADLs

highly variable from patient to patient, just a general pattern

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32
Q

Characteristics of Dementia

A
  1. impairment in abstract thinking
  2. impairment in judgement
  3. personality change
  4. motor unrest
  5. gait disturbance
  6. motor planning
  7. reflex/tone changes
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33
Q

Impairment in abstract thinking

A

difficulty in defining words
inability to find similarities/differences

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34
Q

Impairment in judgement

A

unable to make plans

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35
Q

Personality changes

A

exaggeration of regular personality
paranoia/depression/anxiety
perseveration and confabulation

36
Q

Motor unrest

A

pacing
wandering
unable to sit

37
Q

Gait disturbance

A

balance problems
shuffling
freezing

38
Q

Motor planning changes

A

apraxia (poor motor motor initiation)
agnosia (object recognition)
ataxia (motor incorrodination)

39
Q

Reflex and tone changes

A

primitive reflex
myoclonic jerks

40
Q

Dementia end stage indicators

A

limited vocabulary (<6 words)
no affect
non-ambulatory
can’t sit up
swallowing difficulty
weight loss
bowel/bladder incontinence
recurrent infections
pressure wound development

41
Q

Behavioral changes in AD

A
  • repeating a word, question, activity
  • exhibiting aggressive behaviors verbally or physically
  • thinking suspicious thoughts
  • having anxious or agitated feelings
  • refusing help
  • difficulty recognizing familiar people, places, or things
  • wanting to leave
42
Q

Behavioral changes are often seen in response to

A

physical discomfort
over-stimulation
unfamiliar surroundings
attempting to perform complex tasks
frustrating interactions

42
Q

Screening…

A

used to determine if further testing is needed for a diagnosis

43
Q

Staging…

A

is determining the severity or progression in someone who already has a diagnosis

43
Q

Screening exams for AD

A
  • MMSE–mini mental status exam
  • SLUMS – saint louis university mental status
  • MoCA – montreal cognitive assessment
  • Clocks test
44
Q

Staging exams

A
  • FAST
  • MMSE
  • MoCA
  • Allen Cognitive LEvels
45
Q

Cut off score for alzheimers for MOCA

A

<26

46
Q

Tests on the MoCA

A
  1. Visuospatial/executive
  2. Naming
  3. Memory
  4. Attention
  5. Language
  6. Abstraction
  7. Delayed Recall
  8. Orientation
47
Q

Mini Mental State Exam (MMSE)

A
  • used as a screening tool to identify the presence of cognitive decline or to stage dementia severity in older adults
  • max score = 30
  • positive for screening <24
48
Q

Norms for staging with MMSE

A

< 24 = mild dementia
20-23 = mild dementia
10-19 = moderate dementia
0-9 = severe dementia

49
Q

SLUMS norms (with hs education)

A

27-30 = normal
21-26 = mild neurocognitive disorder
1-20 = dementia

50
Q

SLUMS norms (w/out hs education)

A

25-30 = normal
20-24 mild neurocognitive disorder
1-19 = dementia

51
Q

Allen Cognitive Levels

A
  • 6 main cognitive levels based on remaining abilities
  • assess cognition by observing function
  • allows for id of highest cognitive abilities to determine appropriate intervention strategies
  • multiple assessments, including leather lacing and placemat test
52
Q

Allen Cognitive Levels Names

A

Level 1 = automatic actions
Level 2 = postural actions
Level 3 = Manual actions
Level 4 = goal directed actions
Level 5 = Exploratory actions
Level 6 = Planned Actions

53
Q

treatment for AD

A
  • no treatment slows or stops the disease
  • medications can slow symptoms for 6-12 mo for about 50% of pts
  • also good to manage other medical processes
54
Q

Cholinesterase inhibtors

A
  • aricept, exelon, reminyl
  • these degus prevent cholinesterase from destroying the depleting levels of acetylcholine.
  • allows sufficient levels of ach to be present in NT junction
55
Q

Rivastigmine

A

been found to improve behavioral and psychiatric s/s of dementia

brand name in exelon

56
Q

Memantine hydrochloride

A
  • namenda is the brand name
  • excessive amounts of glutamate leaks out in the extracellular spaces, so glutamate tries to reuptake it. This becomes TOXIC
  • blocks glutamate receptors and prevents re-uptake of excessive glutamate
57
Q

Delirium

A
  • clinical syndrome of confusion that may appear with structural changes in imaging
  • has an abrupt onset but considered a temporary condition
  • often occurs during hospital or ICU stays, and a good portion are preventable (30-40%)
58
Q

Structural changes present with delirium

A

cortical atrophy
ventricular dilation
white matter lesions

s/s thought to be due to NT disturbances brought about elevated cortisol occurring with acute stress

59
Q

S/S of delirium

A

disturbance in consciousness
hallucinations
cognitive impairment
inattention
drowsiness
inability to sleep

60
Q

Criteria for delirium

A
  1. Attention disturbance
  2. Duration
  3. Change in an additional cognitive domain not caused by NCD
  4. Disturbances in 1/3 must not occur in context of a severely reduced level of arousal, like coma
61
Q

Attention disturbance

A

reduced ability to direct, focus, sustain, and shift attention and orientation to the environment

62
Q

Duration of delirium

A

hours to a few days

fluctuate in severity during course of a day, worse in evenings

63
Q

Change in cognitive domain

A

memory deficit
language disturbance
perceptual disturbance

64
Q

Delirium Causes

A
  1. Medication
  2. Surgery
  3. Infections
  4. Cardiac Illnesses
  5. Metabolic disturbances
  6. Neoplasms
  7. Trauma
  8. Substance abuse/withdrawal
  9. Location change
65
Q

Medication (causes of delirium)

A

alcohol
sedatives
anticonvulsants
antidepressants
antihypertensives
antiparkinsonism
corticosteroids
digitalis

66
Q

Infections (causes of delirium)

A

upper respiratory infections
pneumonia
UTI
sepsis

67
Q

Cardiac Illnesses ((causes of delirium)

A

atherosclerosis in neck and brain

CHF, MI, arrhythmias

68
Q

Metabolic disturbances (causes of delirium)

A

liver/renal failure
fluid/electrolyte disturbances
hypoxia

69
Q

Neoplasms (causes of delirium)

A

primary brain tumors
brain metastases

70
Q

Trauma (causes of delirium)

A

post-operative delirium
burns
fractures

71
Q

Predisposing factors for Delirium

A
  • vision impairment without glasses available
  • hearing impairment without hearing aids available
  • functional mobility impairment
  • cognitive impairment
  • history of delirium
  • multiple comorbid conditions
  • physical restraint use
72
Q

Prevention in hospital for delirium

A
  • early mobility
  • use of exercise
  • proper hydration
  • appropriate sensory stimulation (glasses, hearing aids)
  • dentures
  • sleep/wale cycle preservation
  • provide cognitive orientation (family, objects, etc)
  • hospital elder life program (prevention program)
73
Q

Three versions of clinical presentation of delirium

A

Hyperactive (20%)
Hypoactive (20%)
Mixed (60%)

74
Q

Hyperactive delirium

A

increased psychomotor activity, restlessness, rapid speech

75
Q

Hypoactive Delirium

A

lethargy, slowed speech, apathy, decreased alertness

76
Q

Mixed Delirium

A

shifts between hyperactive and hypoactive

77
Q

Clinical Complications of delirium

A
  • longer length of stay with worse physical and cognitive recovery
  • continued dehydration/malnutrition
  • falls
  • aspiration pneumonia
  • pressure ulcers
  • joint cantractures
  • deconditioning
  • isolation
  • increased 1 year mortality rate
  • increased hospital readmission
  • accelerated cognitive decline
78
Q

Delirium vs dementia vs depression

A

Closely related

acute behavioral or mood change is suggestive of delirium

once medical contributors have been ruled out, depression can be ruled in if it is a more chronic low mood state. patients are less likely to self-report their cognitive problems

79
Q

Onset (Delirium vs dementia vs depression)

A

Delirium: hours to days
Dementia: months to years
Depression: weeks to months

80
Q

Mood Delirium vs dementia vs depression

A

Depression: low/apathetic
Delirium: fluctuates
Dementia: fluctuates

81
Q

Course Delirium vs dementia vs depression

A

Depression: chronic
Delirium: acute
Dementia: chronic with deterioration over time

82
Q

Self-awareness Delirium vs dementia vs depression

A

Depression: likely to be concerned about memory impairment
Delirium: may be aware of changes in cognition, fluctuates
Dementia: likely to hide or be unaware of cognitive deficits

83
Q

ADLs and Delirium vs dementia vs depression

A

Dep: may neglect basic self care
Del: May be intact or impaired
Dem: may be intact early, impaired as disease progresses

84
Q

IADLs Delirium vs dementia vs depression

A

Dep: may be intact or impaired
Del: may be intact or impaired
Dem: may be intact early, impaired before ADLs as disease progresses

7 Geriatrics (5 decks)

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