Lecture 10 Dementia Flashcards
1
Q
What is Delirium?
A
Acute confusional state
2
Q
what is Dementia?
A
Progressive loss of cognitive functions which interfere with work or usual social activities
3
Q
- Pt presents to ED with 2 days of confusion.
- No PMHx.
- Febrile.
- UTI on lab work
- That night would not stay in bed, accused nurses of trying to kill him
Is this delirium or dementia?
A
Delirium
4
Q
Delirium: onset over _____ period of time
A
Short
over hours
5
Q
Is delirium better or worse at night?
A
Worse at night
6
Q
What are some associated features of Delirium?
A
- Disrupted sleep wake cycle
- Disorganized thinking
- Inattention
- Drowsiness
- Restlessness/ agitation/ combativeness
- Delusions
- Hallucinations
7
Q
What is the most common thing that happens in neuro inpatient?
A
Delirium
occur in 15-50% of inpatients
8
Q
What are some options for treating Delirium?
A
- eliminate underlying cause
- frequent re-orientation
- Out of bed during day, blinds open, no naps
- Reduce noise at night minimize interruptions
9
Q
A
9
Q
- Pt presents with 2 years of progressive cognitive decline
- increasing problems remembering names of distant acquaintances
- started keeping detailed to-do list because he missed several appointments
- wife comments he has become more forgetful in previous 2 years
- he remains active in local community organizations
- fully independent with all IADLs
- PMHx: well controlled HTN
- takes meds for insomnia
Is this dementia?
A
No; He has normal ADLs/work life
This is normal aging
- decrease in attention span, ability to learn new information with age
- mild and do not affect normal IADLs
10
Q
- Pt presents with 3 years of progressive memory loss
- Husband reports she frequently misplaces personal items, forgets passwords, repeats questions
- Trouble with locating car in parking lot, tardiness with paying bills
- Difficulty completing tasks
- Less interest in previous hobbies but did not report low mood
- Husband has taken over with finances and paying bills and has to remind her of medications
Is this dementia?
A
Yes
- Progressive memory loss
- Difficulty completing tasks
- Less interest in previous hobbies but did not report low mood
11
Q
How can we define dementia? (4 criteria)
A
A. Presence of at least 2 of the following
- Impaired learning and short term memory
- Impaired handling of complex tasks
- Imapired reasoning ability (abstract thinking)
- Impaired spatial ability and orientation (constructional ability and agnosia)
- Impaired language (aphasia)
B. Significant impairment in social and occupational functioning due to impairments from A
C. Decline from PLOF
D. Not d/t delirium or major psychiatric illness
12
Q
Which cortical lobe does Learning and short term memory?
A
Temporal Lobe
13
Q
Which cortical lobe does handling of complex tasks?
A
Frontal Lobe
14
Q
Which cortical lobe does reasoning ability (abstract thinking)?
A
Frontal
15
Q
Which cortical lobe does spatial ability and orientation (constructional ability and agnosia)?
A
Parietal
16
Q
Which lobe does language (aphasia)?
A
Temporoparietal Lobe
17
Q
Dementia is not “more difficult,” its ____ ____ ___.
A
Can’t do it
Note: you have to have been able to do it before, for you to not have it anymore
18
Q
What are (7) reversable causes of Dementia?
A
- Depression
- Med side effects
- Poor sleep -?
- Hypothyroidism, B12 deficiency, Thiamine deficiency
- Neurosyphilis, other infections
- Autoimmune encephalitis
- Normal pressure hydrocephalus
19
Q
Is this atrophy or normal pressure hydrocephalus?
A
Normal pressure hydrocephalus
20
Q
Is this atrophy or normal pressure hydrocephalus?
A
Atrophy
21
Q
What is the triad of Normal Pressure Hydrocephalus?
A
- Memory problems
- Gait problems - magnetic
- Incontinence
22
Q
How do we dx NPH?
NPH = normal pressure hydrocephalus
A
Large volume lumbar puncture
23
Q
What test is this?
A
MMSE
Mini Mental Status Exam
Items include
* orientation of time and place
* repeat 3 object names
* count backwards from 100 by sevens
* remember 3 object names
* name 2 simple objects
* repeat phrases
* fold paper in half
* read what this says
* make up a sentence about anything
* copy this picture
24
What test is this?
**MOCA
Montreal Cognitive Assessment**
Items include:
* Visuospatial/Executive
* Naming
* Memory
* Attention
* Language
* Abstraction
* Delayed Recall
* Orientation
25
Which (MMSE or MOCA) is harder for illiterate/lower education levels?
MOCA
but this is the norm for education levels aka most "normal" educated people should be at this level
26
What test is this?
SLUMS
27
28
The Clock Drawing tests for which cognitive domains?
* Visuospatial
* Executive
* Attention
* Memory
29
What is the best way to evaluate for dementia? Name a test.
Neuropsychological testing
* 3 hours of cognitive testing
* Visual-Perceptual-Spatial Functioning
* Executive Functioning
30
What is Mild Cognitive Impairment?
* pre-dementia/prodromal dementia
* Impairment in 1 or > domain in absence of dementia or impairment in ADLs
31
* Pt presents with 3 years of progressive memory loss
* Husband reports she frequently misplaces personal items, forgets passwords, repeats questions
* Trouble with locating car in parking lot, tardiness with paying bills
* Difficulty completing tasks
* Less interest in previous hobbies but did not report low mood
* Husband has taken over with finances and paying bills and has to remind her of medications
**Is this MCI?**
**No, this is Alzheimer's Disease**
because it includes Cognitive, Functional, and Behavioral deficits
32
What is Alzheimer's Disease?
Progressive Cognitive, Functional, Behavioral deficits
33
What does AD look like **initially**?
| AD = Alzheimer's Disease
* Short term **memory** loss
* **word** finding difficulties
* mild **executive** dysfunction
* mild **visuospatial** deficits
34
What does AD look like later?
* All aspects of **memory** are impaired
* fluctuating **behavioral** changes
* disturbed **sleep** and **appetite**
* **hallucinations**
35
What does end stage AD look like?
* Mute
* aspiration risk
* bed bound
* incontinent
* *complications*: bed sores, DVT, infections, aspiration pneumonia, malnutrition
36
What is the most common neurodegenerative disorder?
Alzheimer's Disease
37
What are common risk factors for AD?
* family history & genetics (ApoE E4 gene)
* Lower education?
* gender (women)
* Head trauma
education & multi-language is protective for AD
38
What are modifiable risk factors for AD?
* HTN
* elevated BMI
* smoking
* cholesterol
* Diabetes mellitus
* hyperhomocysteinemia
* Metabolic syndrome
* Physical inactivity
* Obstructive sleep apnea
39
What are some things we see in AD pathology?
* Brain atrophy with neuron loss
* Neurofibrillary tangles - **tau protein**
* Senile plaques (abnormal nerve processes, glial processes, central amyloid core) **amyloid beta protein**
* Cerebrovascular amyloid
40
What pattern does AD follow?
1. Hippocampus/temporal lobes
2. Parietal
3. Frontal
4. Global
41
Pattern of AD
1. Hippocampus/temporal lobe deficits -->
2. Parietal lobe deficits -->
3. Frontal lobe deficits -->
4. Global deficits -->
1. Memory impairment and naming/language
2. Visuospatial function, calculations, orientation in space
3. Later in disease course - executive dysfunction
4. Global dysfunction
42
What kind of testing do we do for AD?
* **Labs**: to rule reversible causes of dementia (rule out B12 deficiency)
* Neuropsychological testing
* **CSF**: biomarkers: amyloid, tau
* **Imaging**: MRI brain, exclude structrual or reversible causes
- cortical atrophy is common (temporal/parietal lobes)
43
What are the 2 main types of Vascular Dementia?
* Multi-infarct dementia
* Diffuse white matter disease, subcortical leucoencephalopathy, Binswanger disease
44
What is multi-infarct Dementia?
* step-wise progression
* asymmetric focal weakness
45
What is Diffuse white matter disease, subcortical leucoencephalopathy, Binswanger disease?
* Chronic progressive
* diffuse global impairment
46
How does subcortical (vascular dementia) present?
* attention and concentration deficit with psychomotor slowing
47
On the MOCA, AD will struggle more with ________ and ______
Visuospatial and Delayed Recall
48
On the MOCA, VD will struggle with ____, ____, and _____
Visuospatial, **Attention**, and Delayed Recall
49
In your lab eval for dementia, you want to search for _____ _____.
Reversible causes:
* HIV
* thyroid, liver function
* kidney function
* B12, folate
* ANA
* paraneoplastic antibodies
* heavy metal screen
* thiamine levels
50
what is the main goal of treatment for AD?
Slow progression & maintain current level of function for longer
51
When treating AD pharmaceutically, we are focusing on ...
the **cholinergic deficiency** which results from degeneration of the **Nucleus Basalis of Meynert**
52
Name 3 cholinesterase inhibitors
1. Donepezil
2. Galantamine
3. Rivastigmine
53
What is **Aducanumab**?
new drug, Monoclonal antibodies that clear out *amyloid* in the brain
* NO CLINICAL DIFFERENCE
* significant side effect: causes bleeding in the brain
54
What is **Lecanemab**?
**Drug that showed clinical improvement**
* early stage Alzheimer slowed cognitive decline by 27% over 18 months on clinical dementia rating scale sum of boxes score
* IV medication
* $26,500/year - only in big research centers
55
AD management looks like...
* supervision needed
* caregivers trained in dealing with aggression --> caregiver burden
* quiet, familiar environment
* depression should be treated
* behavioral disturbances/hallucinations are common
56
* Pt presents with memory loss
* Forgets where he puts things and has other problems with *attention*
* Sometimes appears confused and sometimes seems to do well
* Worse at night than day
* At night, wife notes he acts out his dreams
* Sometimes talks about animals running around that are not in the house, but not bothered
* Exam showed: masked faces, stopped posture with en bloc turning. No tremor
* Impaired executive function, attention, visuospatial function, phonemic fluency
**What are we thinking this patient has?**
PD+: Lewy Body Dementia
aka no amyloid
57
# [](http://)
With Lewy Body Dementia, we have 2 or more of:
* **Fluctuations**
* Recurrent **visual hallucinations**
* Spontaneous parkinsonism
* REM sleep behavior disorder (acting out their dreams)
58
_____ ______ _______ develops before Parkinsonism or within one year of onset of Parkinsonism
Lewy Body Disorder
59
Severe neuroleptic sensitivity is a suggestive feature of what?
Lewy Body Disorder
60
On the MOCA, Lewy Body Disease struggle with _____ and ____.
* Visuospatial/Executive
* Attention
aka Parietal & Occipital lobes NOT TEMPORAL.
61
Compared with AD, Lewy body disease has fewer _____ issues.
Memory
62
With LBD, Rivastigmine helps with what?
| LBD = lewy body disease
* reducing hallucinations and fluctuation
63
With LBD, Levodopa-carbidopa helps with what?
To treat motor symptoms of parkinsonism
64
* Pt presents with wife with cc of "my husband is crazy"
* "Too honest, flippant, arrogant, aggressively egotistically, show-off"
* not interested in grandchildren anymore, credit cards suspended after spending spree
* 50 lb weight gain d/t profound love affair with chocolate
* hoarding behavior
* speech becoming emptier in meaning
* disregard of persla hygeine
* memory ok
**What are we thinking this patient has?**
Frontotemporal Lobe Degeneration (FTD)
65
T/F: we typically see Frontotemporal dementia in 45-65 year olds.
TRUE
FTD is 2nd most common cause of EARLY-onset dementia
66
If patients with AD are able to recognize their deficits causing them to socially "shrink," patients with FTD _________________.
Don't feel like anything is wrong with them
*note this difference*
67
What are the subtypes of FTD?
* behavioral variant (bvFTD)
* primary progressive aphasia
* FTD associated with motor neuron disease
68
Is there amyloid with bvFTD?
No
pathology with atrophy in frontal & temporal lobes
* protein inclusions of tau, TDP-43, ubiquitin
69
What are some gradual behavior changes we see with FTD?
* disinhibition
* loss of empathy
* apathy
* hyperorality
* perseverative or compulsive behaviors
* *newfound artistic talent - uninhibition*
70
What are ways to treat bvFTD?
* antidepressants
* antipsychotics
* cholinesterase inhibitors
* nonpharma: safety, driving, behavior mod, caregiver support
71
Movement disorders are generally due to pathology in where?
Basal ganglia
72
What is a movement disorder?
Neuro syndromes in which there is an **excess** of movement or a **paucity** of voluntary and autonomatic movement, *unrelated to weakness or spasticity*
73
What does the pyramidal system include?
Primary sensorimotor cortex through internal capsule, brainstem, medullary pyramids, CS tracts, anterior horn cells of SC
74
What makes up the extrapyramidal system?
* Basal ganglia (putamen, globus pallidus, caudate)
* substantia nigra
* red nucleus
* subthalamic nucleus
75
What is excessive movement called?
Hyperkinesia
76
What is abnormal movement called?
Dyskinesia
77
What is decreased amplitude of movement called?
Hypokinesia
78
What is slowness of movement called?
Bradykinesia
79
What is loss of movement called?
Akinesia
80
What is rhythmic oscillatory movement around an axis?
Tremor
81
What is ongoing random involuntary movements incorporated?
Chorea
82
What is involuntary sustained or intermittent contractions that cause twisting/repetitive movements or abnormal postures?
Dystonia
83
What are repeated non-rhythmic brief shock-like jerks?
Myoclonus
84
What is postural tremor vs. intention tremor?
**Postural tremor**: revealed by extending a limb against gravity
**Intention tremor**: evident by moving a limb to and from a target
84
What is movement with an urge that is suppressed with the movement?
Tic
85
Essential Tremor is during _____
PD tremor is during _____
| PD = Parkinson's Disease
* Essential tremor: action, posture
* PD: rest > posture (re-emergence)
86
Is essential tremor or PD faster?
Essential tremor is faster
87
# Direction of tremor:
Essential tremor vs PD
Essential tremor: flex/extend
PD: sup/pron
88
# Handwriting with:
Essential Tremor vs. PD
Essential Tremor: gets bigger
PD: gets smaller
89
Essential tremor: half of patients have ______ history and it is a ____ progression
Family history
Slow progression
*usually no other neuro deficits*
90
Essential tremor attacks ___ > _____ > _____
Hands > head > speech
91
Pharma treatment for Essential Tremor includes
* primidone
* propranolol
* topirimate
92
What is a progressive, neurodegenerative disorder with loss of dopaminergic cells within substantia nigra?
Parkinson's Disease (PD)
93
PD symptoms?
94
What are features of PD rest tremor? (what part of body does it affect? during rest or action?)
* distal extremities and lips
* "pill-rolling"
* stops with action of the limb
95
What does rigidity of PD look like?
* Increased resistance to passive movement
* equal in all directions
* "cog-wheeling"
96
What does bradykinesia in PD look like?
* masked facies
* decreased blink
* soft speech
* loss of inflection
* micrographia
* drooling
* shuffling gait
97
What does loss of postural reflexes look like in PD?
**Retropulsion**
a disorder of locomotion that causes a person to lean backward and lose their balance
98
What does freezing look like in PD?
* Motor blocks
* start-hesitation
* difficulty moving through doorways/halls
99
With parkinson's we see _____ posture of trunk, neck, limbs
Flexed
100
Off state of PD is ____
ON state of PD is ____
Off: freezing (not on medications)
On: on medication, normal, looks a lot better
101
What are indications for Levodopa (main drug for PD)?
* treats any motor symptoms of PD - early or late
* replaces brain dopamine
102
What drug do you add to Levodopa to make it last longer?
COMT inhibitor
* prevents breakdown of Levodopa
* advanced PD - only in combo with Levodopa
103
What is Peak Dose Dyskinesias with PD?
chorea-type movement AKA too much dopamine,
but sometimes we prefer that over not enough cuz at least they're not freezing and we can do things with them but they may feel like their tremor is worse
104
Who is Deep Brain Stimulation for?
Advanced PD patients
105
What is Deep Brain stimulation?
Implant high frequency electrodes in VIM nucleus of thalamus, Sub thalamic nucleus, or GPi
106
What does a Thalamotomy do?
improves **CL tremor, rigidity** (not bradykinesia)
Note: in contrast to palliotomy that improves bradykinesa
107
What does a Pallidotomy do? when is it indicated?
improves **tremor, bradykinesia, and rigidity** on CL side of lesion
indicated: when STN and GPi are overactive in PD
108
What are 4 atypical parkinsonism disorders?
1. Lewy body
2. progressive supranuclear palsy (PSP)
3. corticobasal denegeration (CBD)
4. multisystem atrophy (MSA)
109
What does progressive supranuclear palsy present with?
* inability to look up or down (supranuclear)
* axial rigidity
* early falls (because you can't look up or down at feel = fall)
110
What does Corticobasal degeneration present with?
Alien limb/apraxia
111
What does multisystem atrophy look like?
Orthostatic hypotension
Hypereflexia
112
What 2-3cognitive domains do each of these affect on the MOCA:
Alzheimer’s
Lewy body
Vascular
Alzheimer’s- visuospatial/executive + **short term memory**
Lewybody- **attention** + visuospatial/executive
Vascular dementia- **short term memory + attention** + visuospatial/executive
113
What kind of dementia is associated with Parkinsons?
Lewy body
114
how does vascular/lower body parkinsonism present
freezing. gait disturbances, normal upper extremity
115
Parkinsons patients have what kind of tremor?
resting tremor
116
How is huntington disease inhereted?
what chromosome
Autosomal dominant
chromosome 4
note: mean onset 35-42, avg time till death 17 years
117
what structures does huntington disease primarily affect
neuron loss in caudate and putamen
118
What are the symptoms of huntingtons
Personality changes, dementia
CHOREA- rapid jerky movements of extremities that can be incorporated into regular movement
ATHETOSIS- slow continous writing movements of LE
119
what medication treats huntington
tetrabenazine, depletes dopamine
120
Wilsons disease is due to a disorder of __________ metabolism
copper
caused ataxia, chorea, abonromal movements
can be mistaken for huntington but it's more rare
121
What is dystonia
sustained contractions that cause abnormal repetitive movements
initiated or worsened by voluntary movement
sensory tricks can relieve dystonia
122
What are tic disorders
repetitive stereotyped movements that change overtime
urge or desire is relieved when they do it
123
How do you classify a patient as having tourette syndrome
1+ motor tic
1 vocal tic
fluctuating course
over 1 year
onset before 21
124
what is the main thing to know about functional neurological disorders
they are real neurological dysfunctions, not caused by damage
they improve w/ distraction
can treat with PT!
