Neurocognitive Disorders I Flashcards Preview

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Flashcards in Neurocognitive Disorders I Deck (25)
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describe delirium 

acute confusional state, acute brain syndrome

  • delirium involves:
    1. a disturbance in awareness and attention
      • awareness is assessed by one's orientation to the environment
      • attention is assessed by one's ability to direct, focus, sustain and shift attention
    2. an additional disturbance in a cognitive domain
      • memory, language, thoughts (delusion) and perceptions (hallucinations)
    3. sudden onset of symptoms (over hrs to a few days) that typically fluctuate during the day
    4. evidence for a direct physiological cause
      • medical condition, drug intox/withdrawal


describe the confusional assessment method chart for delirium


describe contrast delirium with dementia

  • dementia = cognitive impairment but with full consciousness
  • delirium = reduced level of consciousness


describe the pathology of delirium

  • multiple etiologies (e.g. fever, dehydration)
  • widespread brain regions affected
  • core deficits in central cholinergic functioning
  • deficits in the RAS and its ascending connections
    • important for attention and arousal


describe risk factors for delirium

  • non-modifiable: poor health, older age, male gender
  • modifiable: immobilization, poor sleep, use of benzos in an ICU


describe the course of delirum

  • symptoms persist until cause is reversed
  • resolution typically occurs within 3-7 days
  • amnesia for events during delirium is common
  • delirium is a poor prognostic sign for long-term survival and results in longer ICU stays


describe the treatment for delirium

  • treat underlying medical condition
  • manage associated symptoms (agitation, psychosis)
    • use antipsychotics to treat associated symptoms (agitation, psychosis) of most delirium
    • use benzodiazepines to treat delirium caused by alcohol withdrawal


describe non-pharmacological treatment for delirium

  • utilize environmental supportive measures
    • regulate amount of environmental stimulation
    • provide orienting stimuli
      • lighting, personal effects, sensory aids
    • provide for safety needs 
      • attendant, bedrails and possibly restraints


describe amnesia

  • significant acquired memory deficit
  • caused by a medical condition or the effect of a substance (not from dissociation)
  • NOT diagnosed if it occurs in the context of general cognitive decline (i.e. a dementia)
  • typically caused by damage to the hippocampus


describe a typical profile of amnesia

  • intact short-term (working) memory 
  • short-duration retrograde amnesia
  • if lengthy retrograde amnesia, there is often a temporal gradient to the memory loss with recent long-term memories (LTMs) more impaired than remote LTMs
  • prominent anterograde amnesia


describe the treatment of amnesia

  • treat underling cause
    • B1 deficiency in Korsakoff's to stop amnesia progression
  • cognitive rehabilitation
    • restoration of function: memory exercises to strengthen memory through repetition
    • compensation (e.g. using mnemonics):
      • external strategies (non-mental activities such as using lists, calendars, other person)
      • internal strategies (mental activities such as acronyms and acrostics)


describe dementia

  • refers to multiple and severe cognitive impairment without impaired consciousness
  • is usually progressive and irreversible 
  • most commonly occurs in the elderly
  • note: mild cognitive impairment (MCI) refers to cognitive decline that doesn't cause impairment in activities of daily living


describe Alzheimer's dementia (AD)

  • significant memory impairment plus impairment in at least 1 other cognitive domain
    • a gradual onset with steadily progressive decline
    • exclusion of other causes of the symptoms (stroke)


describe the general course of AD

  • typically onset in late 70s with 10+ year progression:
    • early stages: memory deficits (rapid forgetting) and anomia (aka word finding struggle)
    • middle stages:
      • further memory and language decline
      • visuospaital deficits
      • agnosias
        • anosognosia = unaware of mental condition
        • prosopagnosia = unable to recognize familiar faces 
      • mood changes, personality changes
      • psychosis
    • late stages: global aphasia, motor dysfunction, death from opportunistic infxns


describe neuropatholgy and neurochemical changes in AD

  • neuroanatomical: 
    • cortical atrophy
    • hippocampal atrophy
    • enlarged ventricles
  • neurochemical:
    • multiple neurotransmitter deficiencies 
    • focus has been on loss of cholinergic (ACh) neurons in the nucleus basalis of Meynert due to its role in memory formation


describe neurofunctional and histopathological changes seen in AD

  • neurofunctional: posterior hypometabolism (parietal/temporal)
  • histopathological: B-amyloid plaques and neurofibrillary tangles
    • in vivo biomarkers of AD:
      • CSF amyloid and tau levels
      • PET imaging of amyloid plaques
    • definitive AD diagnosis still depends on post-mortem histopathological confirmation


describe the 4 FDA approved drugs for treating AD

  • 3 cholinesterase inhibitors, approved for mild-moderate AD
    • donepezil (Aricept)
    • galantamine (Razadyne)
    • rivastigmine (Exelon)
  • 1 NMDA receptor blocker, approved for moderate-severe AD
    • memantine (Namenda)


describe the effectiveness and side-effects of AD treatment

  • AD trugs are considered ineffective
  • side effects (e.g. hypotension, GI disruptions) have notable consequences for the elderly (e.g. risk of falls)
  • research efforts are on decreased production and increased clearance of B-amyloid through antibody drugs


delirium requires problem with consciousness and problems with paying attention, therefore no, because she is alert and attentive


reduced level of consciousness, confused, inattentive = delirium

antipsychotics = first choice, unless alcohol withdrawl


clicker 3

dementia = close, but severe cognitive impairment

amnesia = only if memory problems and severe

delirium = pt is alert, so can't be delirium

MCI = testing is lower than expected, but able to perform normal activities, so she has MCI


clicker 4

misplacing objects and difficulty coming up with familiar words (anomia) = seen from beginning

seizures, motor weakness, vision loss = end stages

middle stages = change in personality, therefore social reclusiveness



describe other interventions for AD

  • treatment of neuropsychiatric symptoms (e.g. aggression, agitation)
  • non-pharm methods: music therapy
  • antipsychotics
    • used off-label for demented patients
    • FDA black box warning of increased mortality risk if used with this population
  • anticonvulsants and antidepressants 
  • rule out non-dementia causes of behavioral problems (e.g. pain) in AD patients


describe psychosocial consideration in treating AD

  • use of external mnemonics in early AD stages
  • assessment and restriction of driving
  • "Safe Return Program" for wanderers


describe support for AD patients' caregivers 

  • risk of "Care Giver Syndrome" from psychological, social and financial sequelae of caregiving
  • resources through AD association/AD foundation
    • support groups
    • caregiver tips (e.g. how to respond to psychosis)
    • long-term care options
    • legal and financial planning