Lecture 12: Dementia

Question 1

Dimentia: Essentials of Dx

Answer 1

• progressive intellectual decline
• not due to delirium or psychiatric dz
• age = main risk factor
• other risk factors = fam hx and vascular dz

Question 2

Dimentia: General Considerations

Answer 2

• progressive decline in intellectual fxn that is severe enough to compromise social and occupational fxn
• typically begins after 60 and prevalence doubles evert 5 yrs
• 85 and older: 50% with dementia
• most dementia is acquired or as result of another disorder (stroke)

Question 3

Risk Factors for Dimentia

Answer 3

• Fam hx
• DM
• other vascular dz risk factors
• significant head injury

Question 4

Delirium

Answer 4

• acute confusional state that often occurs in response to an identifiable trigger such as: drugs, intoxication, withdrawal, med side effects, infxn, met. disturbances, sleep deprivation or other neuro dz
• fluctuating levels of arousal
• improves after removal or tx of precipitating factor

Question 5

Signs/Sx’s of Dementia

Answer 5

• Short term memory loss
• word difficulty
• visual spatial dysfxn
• executive dysfxn
• apathy
• apraxia

Question 6

Short term memory Loss

Answer 6

• repeating questions/stories and diminished ability to recall details of recent convos or events
• sue to pathologic changes in hippocampus

Question 7

Word difficulty

Answer 7

• difficulty recalling names of ppl, places, or objects
• low frequency words first affected
• speech laden with pronouns and circumlocutions
• pathology at temporoparietal jxn of L hemisphere

Question 8

Visual spatial dysfxn

Answer 8

• poor navigation and getting lost in familiar places
• impaired recognition of previously familiar places
• trouble discerning objects against a background
• R parietal lobe is affected

Question 9

Executive Dysfxn

Answer 9

• easy distractibility
• impulsivity
• mental inflexibility, concrete thoughts
• slow processing speed
• poor planning, organization or impaired judgement -due to areas of frontal or subcortical areas

Question 10

Apathy

Answer 10

-indifference

Question 11

Apraxia

Answer 11

• loss of learned motor behaviors

- due to dysfxn of frontal or parietal lobes (especially L parietal)

Question 12

Hx questions : dementia

Answer 12

• establish risk factors
• document pt’s current capacity to perform basic ADLs and IADLs
• note extent go decline from premorbid level of fxn

Question 13

PE dementia

Answer 13

MMSE

Montreal Cognitive Assessment

Question 14

Montreal Cognitive Assessment

Answer 14

• takes longer but slightly more sensitive
• 26 and greater is normal: consider rechecking in 6 mnths-1 yr
• 25 and below: needs full cognitive eval

Question 15

Imaging: dementia

Answer 15

• indicated for a new progressive cognitive complaint
• exclude occult CV dx, tumor or other structural abnormalities
• MRI is preferred method

Question 16

Labs

Answer 16

• any pt with cog impairment: measure B12, T4, TSH

Question 17

Alzheimer’s Dz facts

Answer 17

• most common dementia 60+
• up to 50% have it in 80s
• not really genetic, more epidemic

Question 18

Alzheimer’s Risk Factors

Answer 18

• age
• low education
• uncontrolled DM
• fam hx
• APOE genotype
• mutations: APP gene on chrom 22; Presinillin 1 on chrome 14; Presinillin 2 on chrom 1

Question 19

AD Signs/Sx’s

Answer 19

• short term memory impairment
• 2 or more cognitive domains involved
• animal fluency worse than letter fluency
• some fxnl impairment in real life
• variable deficits of executive fxn, visuospatial fxn and lang

Question 20

AD Dx

Answer 20

• stage with MMSE, but don’t test unless symptomatic
• F/u every 6 mnths
• MRI shows atrophy in hippocampus

Question 21

Vascular Dementia: facts

Answer 21

• 2nd most common

- pathophysiology: multiple ischemic attacks

Question 22

VD signs/sx’s

Answer 22

• stepwise or progresive accumulation of cognitive deficits in association with repeated strokes
• sx’s depend on localization of stroke

Question 23

VD Risk Factors

Answer 23

• smoking
• DM
• HTN
• Hypercholesteremia

Question 24

VD: 2 types

Answer 24

• Multiple Infarct Dementia: medium large vessel; stepwise deterioration; strokes on MRI
• Subcortical Dementia: small vessel dz; gradual decline; no memory problem; letter fluency worse than animal; MoCA worse than MMSE; lacunas and other white matter changes on MRI

Question 25

VD tx

Answer 25

- prevent vascular events | - Afib: anticoags

Question 26

Frontotemporal Dementia: pathology

Answer 26

- defined by protein found in intraneural aggregates - Peak incidence in 6th decade - familial cases due to mutations in specific pros

Question 27

FTD types

Answer 27

1) Behavioral variant FTD 2) Semantic Dementia 3) Progressive Nonfluent Aphasia

Question 28

Behavioral Variant FTD

Answer 28

- deficits in empathy, social compartment insight, abstract thought and executive fxn - behavior is disinhibited, impulsive and ritualistic with prominent apathy - decrease/increase in sex or sweet/fatty foods - preservation of memory - Focal R frontal atrophy

Question 29

Semantic Dementia

Answer 29

- deficits in word finding, single word comprehension, object and category knowledge and face recognition - behaviors: rigid, ritualistic and may be similar to behavioral variant - focal asymmetric temporal pole atrophy

Question 30

Progressive nonfluent aphasia

Answer 30

- speech is effortful with dysarthria, phonemic errors, sound distortions and poor grammar - focal extrapyrimidal signs and apraxia of R arm and leg common - Focal L frontal atrophy

Question 31

Corticobasal Degeneration

Answer 31

- unilateral ideomotor apraxia, agraphthesia astereognosis - Alien hand syndrome - myoclonic jerks - Gait: preserved until late

Question 32

Lewy Body Dementia

Answer 32

- cog dysfxn with prominent visuospatial and executive deficits - psych disturbances with anxiety, hallucinations and fluctuating delirium - Parkinsonism motor deficits - less problems with memory

Question 33

Prion Disorders: pathophys

Answer 33

- rare - caused by infectious proteins called prions - induce conformation change of normal brain protein into abnormal isoform that causes neuronal vacuolation, reactive proliferation of astrocytes and microglia and deposition of B amyloid plaquea

Question 34

Prion Disorders: sx's

Answer 34

- myoclonic fasciculations, ataxia, visual disturbances, pyramidial and extrapyrimdial sx's - specific EEG: slow waves and high voltages

Question 35

Wernecke's Encephalopathy

Answer 35

- due to alcoholism, poor dietary intake of thiamine - anorexia, muscle cramps, parasthesis, irritability - hrt failure and peripheral nerve d/o - give Thiamine

Question 36

Vit. B12 Deficiency

Answer 36

- macrocytic anemia, megaloblastic blood smear, low serum Vit. B12 levels - anemia, mucosal cell changes, parasthesias of peripheral nerves - pale, icteric, sallow, decrease vibration and position sense, memory disturbance - give Vit. B12

Question 37

Pellegra (aka Nicotinic Acid deficiency)

Answer 37

- due to alcoholism and nutrient drug interactions - anorexia, weakness, irritability, mouth soreness, glossitis, stomatitis, wt loss - advanced: dermatitis, diarrhea, dementia - give oral niacin