Neurocognitive Disorders

Question 1

Cognitive Function

Answer 1

• Decline is seen with age
• 50 to 75% of people 65+ notice subjective memory issues
• Cognitive effects have an effect on client and care
• Cognitive impairment have a direct burden on the client, caregivers, and society.

Question 2

What is Delirium?

Answer 2

It is an ACUTE, fluctuating syndrome involving disorganized thinking, altered attention and awareness, and variable levels of consciousness.

It is more common in hospitalized older adults or residents in long-term care facilities but can be seen in younger clients and primary care settings as well.

Symptoms are more worse later in the day, and sleep wake disturbances increase the incidence of symptoms

Delirium is a physiological consequence of a medical condition, medication use or withdrawal.

Question 3

What is Dementia

Answer 3

Insidious onset with a progressive decline
Associated with degenerative or vascular causes.
Other causes can include infections, inflammatory processes, neoplasms, toxic influences, metabolic disorders, and trauma

Question 4

Mini-Cog

Answer 4

Recall Score
Drawing Clock Score

Question 5

MMSE

Answer 5

Mini Mental State Exam

Question 6

This is the most common type of Dementia:

Answer 6

Alzheimer’s Disease

Question 7

This medication is used for moderate to severe dementia. It is classified as an NMDA. This drug selectively blocks the effects of abnormal glutamate release, an excitatory neurotransmitter.

Answer 7

Memantine aka Namenda

Question 8

These medication are used for mild, moderate, or severe dementia. It is classified as cholinesterase inhibitor.

Answer 8

Donepezil, Rivastigmine, and galantamine

Question 9

Aducanumab

Answer 9

helps with cognitive decline; has been used with clients with mild dementia in clinical trials. The drug acts by binding to and reducing amyloid-beta plaque in the brain.

Question 10

A phenotype model that describes a clinical syndrome of domains based on a biological framework thas manifested outwardly with these signs and symptoms: unintentional weight loss, self-reported exhaustion, weakness, slow walking speed, low physical activity.

Answer 10

Frailty

Question 11

Types of Cerebral Vascular Events

Answer 11

Ischemic Stroke
Hemorrhagic Stroke
TIA

Question 12

Signs of CVA

Answer 12

Sudden headache
dysarthria
balance problems
facial droop

Question 13

Risk for CVA

Answer 13

HTN, DM, Smoking, hx TIA, high blood cholesterol and lipids.

Question 14

CVA:Reduction of Risk Include:

Answer 14

Anti-HTN medications
Anti-Coagulants
Anti-Platelets
Anti-Aggregates / Statins
Smoking cessation
Weight loss and dietary changes

Question 15

Diagnostics to determine CVA

Answer 15

CT Scan

Question 16

This is a common progressive disease in older adults. Cardinal signs are tremors, bradykinesia, rigidity, and postural instability.

Answer 16

Parkinson’s Disease

Question 17

PD: Craniofacial Motor Symptoms

Answer 17

Hypomimia (masked facial expressions)
Decreased spontaneous eye blink
Speech impairment (dysarthria, hypophonia)
Dysphagia

Question 18

PD: Visual Motor Symptoms

Answer 18

Blurred Vision
Impaired upward gaze and convergence
Eyelid opening apraxia

Question 19

PD: Musculoskeletal Motor Symptoms

Answer 19

Dystonia
Myoclonus
Stooped Posture
Kyphosis

Question 20

PD: Gait

Answer 20

Shuffling
Freezing

Question 21

PD: Non-motor Symptoms

Answer 21

Cognitive dysfunction and dementia
Psychosis and Hallucinations
Mood disorders (anxiety, depression, apathy)
Sleep disturbances
Fatigue
Autonomic dysfunction
Olfactory dysfunction
Gastrointestinal dysfunction
Pain and Sensory disturbances
Dermatologic issues

Question 22

Treatment for tremors that impact ADLs

Answer 22

Levodopa - S/E: dyskenesia for the first 5 years of treatment

Dopamine Agonist - S/E: impulse control disorders, daytime fatigue, and hallucinations.

Monoamine Oxidase Inhibitors - S/E: dyskinesia and insomnia

Question 23

Referrals for PD include:

Answer 23

Speech Pathology
Occupational Therapy
Physical Therapy
Dietitian Consult

Question 24

Labs for PD:

Answer 24

CBC, CMP - electrolyte imbalances and weight loss

Question 25

Signs and Symptoms of Dizziness

Answer 25

Imbalance, vertigo, syncope, presyncope

Question 26

Causes of dizziness:

Answer 26

Anxiety
Depression
Impaired Balance
Past myocardial infarction
Postural hypotension
Polypharmacy
Impaired hearing

Question 27

1. The US Advisory Committee on Immunization Practices and the Centers for Disease Control currently recommend which one of the following?

a. All older adults be immunized against influenza annually and that they receive at least one pneumococcal vaccination.
b. All high-risk older adults should receive an additional pneumococcal vaccination 5 years or more after their first immunization.
c. Older adults should receive a one-time revaccination for pneumonia if they were initially vaccinated more than 5 years previously and were less than 65 years of age at the time of the initial vaccination.
d. All of these are recommended.

Answer 27

d. All of these are recommended.

Question 28

2. Healthcare providers should recommend that older adults engage in which one of the following?

a. 150 minutes of moderate intensity physical activity weekly
b. 20 minutes of moderate intensity physical activity 3 days per week
c. 10 minutes of vigorous physical activity most days of the week
d. 30 minutes of vigorous physical activity 3 days per week

Answer 28

a. 150 minutes of moderate intensity physical activity weekly

Question 29

3. Guidelines for the primary prevention of stroke recommend that aspirin be used in which one of the following?

a. Individuals whose risk is high enough for the benefits to outweigh the risks
b. Individuals regardless of risk level
c. Males regardless of risk level
d. Females who are also taking antihypertensives

Answer 29

a. Individuals whose risk is high enough for the benefits to outweigh the risks

Question 30

4. Even though older adults are less likely to get counseled for smoking cessation, they have which one of the following?

a. The same quit rates as younger individuals
b. Approximately 50% better quit rates than younger individuals
c. Approximately 25% better quit rates than younger individuals
d. Much lower quit rates than younger individuals

Answer 30

a. The same quit rates as younger individuals

Question 31

A 67-year-old female with a history of congestive heart failure and myocardial infarction is admitted to the hospital because of increasing altered mental status and decreased arousal over the last week. Physical examination reveals a confused woman with right lower lobe crackles and a pulse oximetry of 86% on room air. While you are interviewing the patient, she is irritable, paranoid, and inattentive, which her family tells you is out of character. You notice waxing and waning in her alertness and impaired short-term memory during your examination. Which one of the following features present in this patient best distinguishes delirium from depression or dementia?

a. Irritability
b. Inattentiveness
c. Paranoia
d. Aggressiveness

Answer 31

b. Inattentiveness

Question 32

A 72-year-old man with colonic diverticulosis was admitted to the hospital with gastrointestinal bleeding and abdominal pain. He underwent colonoscopy under conscious sedation using fentanyl and midazolam. The following day, the patient was positive on the Confusion Assessment Method performed by the geriatric consultation services. Presence of delirium in this patient predisposes him to all of the following except:

a. Higher risk of institutionalization
b. Increased risk of dementia
c. Shorter length of stay in the hospital
d. Increased mortality

Answer 32

c. Shorter length of stay in the hospital

Question 33

A 78-year-old male who resides at a nursing home has Lewy Body dementia, frequent falls, visual hallucinations, and sleep disturbances. He is transferred to your hospital with poor oral intake and confusion of 3 days duration. Physical examination reveals a thin man with dry mucous membranes, tachypnea, tachycardia, and confusion. To reliably identify delirium in this patient in a time-efficient manner (<5 minutes), what will be your instrument of choice?

a. Folstein Mini-Mental State Examination (MMSE)
b. Confusion Assessment Method (CAM)
c. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V)
d. Glasgow Coma Scale (GCS)
e. Delirium Rating Scale - Revised 1998 (DSR-R98)

Answer 33

b. Confusion Assessment Method (CAM)

Question 34

4. An 84-year-old woman complains of nausea and vomiting for the past 3 days. She has a history of multiple abdominal surgeries, adhesions, and recurrent hospitalizations for partial small bowel obstruction. She has visual and hearing impairment and is currently taking oxybutynin for neurogenic bladder. You recognize she is high risk for development of delirium. Interventions that may prevent the onset of delirium among older adult hospitalized patients include all of the following except:

a. Early mobilization
b. Ensuring 6 hours of uninterrupted sleep per night
c. Treating volume depletion
d. Treating anxiety with lorazepam
e. Ensuring access to hearing and visual aids

Answer 34

d. Treating anxiety with lorazepam

Question 35

5. A 78-year-old man with multiinfarct dementia, chronic kidney disease, congestive heart failure, and uncontrolled hypertension was hospitalized with a heart failure exacerbation. He was initially treated with diuretics and salt restriction and his condition stabilized. On day 3 of his hospital stay, he developed confusion, restlessness, and combativeness. Utilization of sitter, redirection, calming music, and reassurance are unsuccessful. When safety of the patient and staff are in jeopardy and nonpharmacologic approaches have failed, which of the pharmacologic agents would be the best choice for treating the agitation associated with his delirium?

a. Melatonin
b. Haloperidol
c. Diazepam
d. Gabapentin
e. Diphenhydramine

Answer 35

b. Haloperidol

Question 36

. A 69-year-old female presents to your office for routine primary care. Her elder sister was recently diagnosed with Alzheimer disease, and she wonders what steps she can take to reduce her own risk of developing dementia. Which of the following statements about the prevention of dementia is true?

a. There is moderate quality evidence to support daily use of vitamin B12 and fish oil to prevent risk of cognitive decline.
b. Risk of dementia is modulated by nonmodifiable risk factors, such as genetics, family history, and educational attainment, and there are no behavioral interventions that can be taken to reduce risk of developing dementia.
c. There is moderate quality evidence to suggest control of cardiovascular and metabolic risk factors, such as blood pressure, weight, and blood sugar, may reduce risk of dementia.
d. There is moderate to low quality evidence supporting cannabinoids may reduce rates of progression from mild cognitive impairment to dementia.

Answer 36

c. There is moderate quality evidence to suggest control of cardiovascular and metabolic risk factors, such as blood pressure, weight, and blood sugar, may reduce risk of dementia.

Question 37

2. A 78-year-old male was recently diagnosed with Alzheimer disease. He scored 23/30 on his Montreal Cognitive Assessment (MoCA) and his clinical presentation is consistent with mild disease. He returns to clinic with his family to discuss possible initiation of pharmacotherapy. You consider beginning donepezil 5 mg daily for 4 weeks, with a plan to increase to 10 mg daily if he tolerates the lower dose. Which of the following is not a common side effect of donepezil?

a. Thrombocytopenia
b. Bradycardia
c. Vivid dreams
d. Gastrointestinal distress

Answer 37

a. Thrombocytopenia

Question 38

1. The remission rate of depressed patients who are 65 years and older to initial antidepressant treatment is:

a. 30%
b. 40%
c. 70%
d. 80%

Answer 38

a. 30%

Question 39

2. Which of the following groups has the highest rate of suicide in older adults?

a. Asian males
b. Hispanic males
c. White males
d. Black males

Answer 39

c. White males

Question 40

3. Which of the following is not a risk factor for late-life depression?

a. Family history of depression
b. Disability
c. History of stroke
d. History of a myocardial infarction
e. Loss of a loved one

Answer 40

a. Family history of depression

Question 41

4. Which of the following is not a side effect of selective serotonin reuptake inhibitors in older adults?

a. Extrapyramidal symptoms
b. Gastrointestinal bleeding
c. Gastrointestinal irritation
d. Hyponatremia
e. Increase in suicidal ideation

Answer 41

e. Increase in suicidal ideation

Question 42

5. You want to start pharmacologic treatment for depression in an older patient who is taking numerous medications. You are concerned about drug–drug interactions. Which of the following antidepressants is the least likely to cause such an interaction?

a. Citalopram
b. Fluoxetine
c. Paroxetine
d. Venlafaxine
e. Bupropion

Answer 42

a. Citalopram

Question 43

1. Randall Johnson, an 80-year-old man with a history of high blood pressure and hypothyroidism, presents to your office with ongoing dizziness. He feels it has worsened since the summer months began. He states it is worst when he gets up from his chair on his front porch to stand or when he is working in his garden. If he stands still for a few minutes, the dizziness typically resolves on its own. If he tries to move too quickly, he has felt like he may pass out, but has not yet done so. He denies changes in vision or hearing. He has had no recent changes in his medication. On examination today, he is a frail-appearing older man in no acute distress. Vitals show a blood pressure of
   118/71 mmHg with a pulse of 55 beats per minute. Heart and lung exams are benign. What is the most likely cause of his dizziness?

a. Orthostatic hypotension
b. Benign positional paroxysmal vertigo

c. Overcontrol of thyroid
d. Ménière disease

Answer 43

a. Orthostatic hypotension

Question 44

2. Joyce Mitchell is a 73-year-old frail female with a history of frequent falls, who presents with rapid onset of nausea, vomiting, sweating, and horizontal nystagmus. She also reports hearing loss in the right ear. After testing and further questioning, you diagnose the patient with vestibular neuritis. What is the best initial course of treatment?

a. Vestibular rehabilitation
b. Supportive care with antinausea and antivertigo medication
c. Fluids
d. Epley maneuver

Answer 44

b. Supportive care with antinausea and antivertigo medication

Question 45

3. Pedro Lopez is an 89-year-old male who presents to you with the complaint that he continuously experiences the feeling that a fall is imminent. He appears comfortable when seated, but is notably unsteady and imbalanced when erect, walking with a broad- based gait. Which of the following is not a standard treatment modality for this condition?

a. Assistive device, such as a cane
b. Physical therapy focusing on balance training
c. Meclizine
d. Hearing and vision amplification

Answer 45

c. Meclizine

Question 46

1. Which of these is true regarding the relationship of frailty with cognition?

a. Cognitive frailty is synonymous with dementia.
b. Patients with Alzheimer disease do not have higher rates of frailty.
c. Neither the frailty index or Fried frailty criteria include cognition assessment.
d. Currently, to be considered cognitively frailty it requires a MMSE score over 26.

Answer 46

d. Currently, to be considered cognitively frailty it requires a MMSE score over 26.

Question 47

2. Which of these clinical vignettes are not part of the Fried frailty paradigms?

a. Mrs. P has a caregiver comb her hair now because of inability to hold her arm up long enough to brush it herself.
b. Mr. J has just been diagnosed with congestive heart failure after a recent admission to the hospital for a myocardial infarction.
c. Mr. K has been losing weight for the last year despite family support of bringing food and negative workup for more insidious cause.
d. Mrs. T tells you she spends the majority of her time in her chair and only walks to the bathroom now because she gets too fatigued for minor home care tasks.

Answer 47

b. Mr. J has just been diagnosed with congestive heart failure after a recent admission to the hospital for a myocardial infarction.

Question 48

3. Which of these statements about frailty are false?

a. Neither prominent frailty model currently uses age as a component for defining frailty
b. Individuals who are prefrail have a higher likelihood of becoming robust than those with frailty.
c. Clinical diagnosis of anxiety or depression do not have any effect on frailty rates.
d. Frailty diagnosis has proved valuable in preoperative assessment of patients likely to do well with surgical interventions.

Answer 48

c. Clinical diagnosis of anxiety or depression do not have any effect on frailty rates.

Question 49

4. John P. is an 81-year-old male with extensive cardiac history, including three vessel coronary artery bypass graft when he was in his 60s, hypertension, diabetes mellitus, osteoarthritis, sciatica, and progressive macular degeneration. His vitals today are blood pressure 146/86 mmHg, heart rate 67 beats per minute, respiratory rate 21 breaths/min, and temperature 98.7° F. He is here with his only son and has been living in an assisted living since his wife died 3 years ago. His Montreal cognitive assessment (MoCA) 1 month ago was 23/30. He has no advance directive in the chart. He tells you he’s “been slowing down” a lot lately. He does not go down to the dining room because it is too taxing, he has been slowly losing weight because food does not taste good, he has fallen four times in the last year. He has no specific concerns to discuss today. What is the most important thing that can be addressed at today’s visit?

a. His elevated blood pressure noted on today’s vitals.
b. Repeating his MoCA testing to assess for cognitive change.
c. Suggest completion of an advance directive at visit with his goals of care in mind for moving forward in his care.
d. Review his last colonoscopy report and discuss further screening procedures.

Answer 49

c. Suggest completion of an advance directive at visit with his goals of care in mind for moving forward in his care.

Question 50

You have recently assumed directorship of a nursing home that has a 30-bed dementia unit. The nursing home does not have an onsite pharmacist. You go to the dementia unit for patient observation and chart review. Immediately, you notice that although it is 9:00 AM, and most of the patients have been taken out of their rooms and placed in the dayroom, they are dozing in their wheelchairs. The window blinds block about half of the sunlight, and without the overhead fluorescent lighting, the room would be considered dimly lit. The nurses have just finished administering the morning medications. You begin focused chart review, concentrating on patient medications, cognitive/functional status, and comorbidities. When you are finished, you note that of the 28 patients currently living in this facility, seven of them are receiving a low- moderate dose of an atypical antipsychotic (quetiapine, olanzapine, risperidone, etc.) before bedtime, but only one of these patients has any history of recurrent visual hallucinations and delusions. All of these individuals have either moderate-to-severe dementia from Alzheimer disease or vascular/Alzheimer overlay listed among their problems. You ask the charge nurse why these patients are receiving these medications, and he replies that his counterpart on the night shift stated that many of these patients did not sleep through the night, cried out from their rooms, woke other patients, and seriously disrupted the limited staff’s ability to manage the facility. The night nurse thus asked the previous attending to prescribe medications that would help these individuals sleep through the night.

1. What further diagnostic steps are required in the seven patients receiving atypical antipsychotics?

a. All patients should receive 1 week of actigraphy monitoring both on and off their current antipsychotic.
b. All patients should be immediately referred for cognitive behavioral therapy for insomnia (CBTI).
c. All patients should receive referral to both psychiatry and neurology, neuroimaging, and screening polysomnography to identify underlying sleep disorder.
d. Unless there is an underlying suspicion of obstructive sleep apnea (OSA) or other sleep disorder, these patients already meet criteria for irregular sleep-wake phase disorder, and no further diagnostic steps are required.

Answer 50

d. Unless there is an underlying suspicion of obstructive sleep apnea (OSA) or other sleep disorder, these patients already meet criteria for irregular sleep-wake phase disorder, and no further diagnostic steps are required.

Question 51

2. What is an appropriate step in the initial management of the seven patients receiving atypical antipsychotics?

a. No action is necessary, because one potential indication for atypical antipsychotic use is refractory behavioral disturbance in persons with significant dementia.
b. Taper to discontinue the atypical antipsychotic; after a 2-week washout, begin therapy with zolpidem.
c. Taper to discontinue the atypical antipsychotic, and create day programs that allow patients to develop a sleep deficit/need through the morning/afternoon/early evening.
d. Start modafinil or a similar short-acting stimulant to minimize daytime sleepiness.

Answer 51

c. Taper to discontinue the atypical antipsychotic, and create day programs that allow patients to develop a sleep deficit/need through the morning/afternoon/early evening.

Question 52

3. What aspects of sleep hygiene may make your facility more conducive for nighttime sleep?

a. Bright lights to illuminate pathways to bathrooms.
b. Judicious restraint use to ensure patients remain in bed overnight.
c. Allow patients with greater degree of dementia an opportunity for an afternoon nap to improve their cognitive status.
d. Neutralizing antiseptic smells, minimize movement of equipment through halls, maintain quiet hours where staff can speak in areas away from residents, avoid using overhead announcement systems.

Answer 52

d. Neutralizing antiseptic smells, minimize movement of equipment through halls, maintain quiet hours where staff can speak in areas away from residents, avoid using overhead announcement systems.

Question 53

4. Which of the following statements regarding programs to increase daytime engagement in persons with dementia is true?

a. Daytime exercise programs are contraindicated in this population because of high risk of fall and fracture.
b. Daytime programs are designed to maintain client wakefulness, and as such can cover a broad range of topics, including music, art, exercise, dance, and cognitive tasks (puzzles, etc.), and should be designed with patient cognitive and physical status, cultural beliefs, social support, and available staffing in mind.
c. Daytime programs that lack a physical exertion component do not contribute to physiologic need for sleep, and are thus less effective than programs that require client physical exertion.
d. Daytime programs must include moderate to rigorous intensity physical exercise (3–6 mets) to generate an appropriate sleep deficit in nursing home residents

Answer 53

b. Daytime programs are designed to maintain client wakefulness, and as such can cover a broad range of topics, including music, art, exercise, dance, and cognitive tasks (puzzles, etc.), and should be designed with patient cognitive and physical status, cultural beliefs, social support, and available staffing in mind.

Question 54

1. An 85-year-old man with newly diagnosed nonvalvular atrial fibrillation comes to the office for a follow-up. He has a history of essential hypertension, type 2 diabetes mellitus, hyperlipidemia, and stage 3B chronic kidney disease. He takes lisinopril, atorvastatin, metformin, and aspirin. He lives in an assisted living facility and uses a walker for ambulation. He has fallen twice in the past year. On physical examination, his heart rate is normal but his rhythm is irregularly irregular. His blood pressure is 135/70 mmHg.

Which medication change would be most appropriate for reducing his stroke risk?

a. Current medications are appropriate.
b. Continue aspirin and start warfarin with international normalized ratio goal 2–3.
c. Stop aspirin and begin apixaban 5 mg twice a day.
d. Continue aspirin and start apixaban 5 mg twice a day.

Answer 54

c. Stop aspirin and begin apixaban 5 mg twice a day.

Question 55

2. A 79-year-old woman was admitted to the hospital a month ago with an acute left middle cerebral artery ischemic stroke. On examination, she had right hemiparesis, mild motor aphasia, and dysphagia. After discharge, she was transferred to a skilled nursing facility where she has been working with physical, occupational, and speech therapy. Despite initial progress, in the last 2 weeks, she has lost her appetite, and complains of insomnia and difficulty concentrating.

Which would be the next best step in management?

a. Start escitalopram 5 mg orally daily.
b. Start eszopiclone 1 mg orally at bedtime.
c. Start a high calorie supplement twice a day.
d. Change the time at which she gets physical therapy.

Answer 55

a. Start escitalopram 5 mg orally daily.

Question 56

3. An 82-year-old woman with a past medical history of essential hypertension and type 2 diabetes mellitus, and who currently smokes, was brought to the hospital after collapsing at home. The onset of her symptoms was 1 hour before arrival to the emergency room. On examination, she is awake, alert, and oriented to person, place, and time. She has moderate dysarthria, right gaze preference, left hemineglect, and left face, arm, and leg weakness. Her blood pressure is 190/90 mmHg and her glucose is 110 mg/dL.
   What diagnostic test should be done first?

a. Complete blood count and basic metabolic panel
b. A STAT noncontrast head computed tomography (CT)
c. A two-dimensional echocardiogram
d. Urinalysis

Answer 56

b. A STAT noncontrast head computed tomography (CT)

Question 57

A clinical prodrome of nonspecific symptoms of Parkinson disease (PD) include all the following except:

a. Hyposmia
b. Bradykinesia
c. Constipation
d. Fatigue

Answer 57

b. Bradykinesia

Question 58

2. The National Institute of Neurologic Disorders and Stroke (NINDS) criteria require a confirmatory autopsy for PD to be described as “definitive” but would rate as “probable” if three of the four primary clinical features were present for at least 3 years. Which of the following lists three primary clinical features of PD? (Choose one)

a. Fatigue, postural instability, gait dysfunction
b. Rigidity, resting tremor, urinary urgency

c. Rigidity, bradykinesia, resting tremor
d. Freezing, sleep disturbance, arthralgias

Answer 58

c. Rigidity, bradykinesia, resting tremor

Question 59

Imaging plays a limited role in diagnoses of PD but is central in making diagnosis of:

a. Multiple system atrophy (MSA)
b. Progressive supranuclear palsy
c. Dementia of Lewy body type
d. Normal pressure hydrocephalus

Answer 59

d. Normal pressure hydrocephalus

Question 60

Key neurotransmitter-based therapeutic strategies for PD include all the following except:

a. Increase glutamatergic stimulation
b. Decrease cholinergic stimulation
c. Increase dopaminergic stimulation
d. Decrease glutamatergic stimulation

Answer 60

a. Increase glutamatergic stimulation

Question 61

Treatment for early PD in an otherwise healthy older patient without significant functional impairment should begin with:

a. Catechol-o-methyl transferase (COMT) inhibitors
b. Dopamine agonist
c. Levodopa
d. Careful observation

Answer 61

d. Careful observation