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88 Cards in this Set
- Front
- Back
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What four steps are part of the dementia evaluation? (bogus question?)
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assessment
congnitive screening tests etiologies of dementia treatment/referral |
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By the year 2030, approximantly how many elderly will reside in the US?
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70 million
(2x current) |
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What are the current prevalence rates of dementia in those > 65? > 80?
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> 65 6 to 8%
> 80 30% |
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What is dementia?
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an acquired syndrome consisting of a decline in memory and other cognitive functions
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What is the diagnosis of dementia?
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memory impairment and one of the following: aphasia, apraxia, agnosia, or impaired executive functioning
deficits cause significant impairment in social or occupational functioning |
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What are the characteristics of aphasia related to dementia?
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characterized by fluency
- able to initiate and maintain a conversation - impaired comprehension - intact grammar and syntax however the speech is vague with paraphasias, circumlocutions, tangentail and often using nonspecific phrases later language can be severely impaired with mutism, echolalia |
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What is apraxia?
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inability to carry out motor activities despite intact motor funciton
- contributes to loss of ADLs |
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What is agnosia?
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inability to recognize or identify objects depsite intact sensory function
can be visual or tactile |
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What does agnosia usually present in dementia?
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later
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What are some marks of impaired executive function?
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difficulty with planning, inititating, sequencing, monitoring or stopping complex behaviors
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When does impaired executive functioning usually occur in dementia?
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midcourse
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What are the two dementia subtypes?
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early onset: < 60 y/o
- less than 5% of all cases of AD, strong genetic link, tends to progress more rapidly late onset: > 60 y/o - represents the majority of cases |
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What are some of the features of dementia?
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agitation
aggression sleep disturbances apathy depression or anxiety personality changes behavioral disinhibition impaired insight hallucinations delusions (often paranoid or persecutory) |
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What are the steps in a dementia work up?
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history
phyical and neuro exam cognitive screening test rule out reversible causes neuroimaging consider the etiology treatment or referral |
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What are the important points of history taking in a person with suspected dementia?
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patient will 'forget' their memory problems
get history from caregiver or spouse if possible memory impairment may be evidenced by repetative questioning, list writing, lost objects, etc. ask about memory impairment ask about ADLS to assess functioning |
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What are instrumental activities of daily living?
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telephone
travel shopping meals housework medicine money |
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What are activities of daily living?
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bathing
dressing grooming toileting continence transferring |
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What is the importance of cognitive screening in the workup of dementia?
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establish a baseline level of funcitoning
allows for objective documentation of cognition |
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What are 5 possible screening tests for dementia?
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mini-mental state exam
clock drawing test mini-cog time and change 7 minute screen |
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What are the elements of a mini-mental status exam?
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orientation (10 pts)
registration (3 pts) attention and calculation (5 pts) recall (3 pts) language (8 pts) visuospatial 91 pt) if less than 25 consider dementia |
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What are the pros and cons of the mini-mental status exam?
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pro: widely used and standardized, quick
cons: FP due to little education, FN with high premorbid intellectual functioning, stressful |
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What instructions are given for the clock drawning test?
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'draw a large cicle on the (blank) page'
'put numbers on the circle' 'place hands to show 10 past 11' |
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What is part of the mini-cog screening test?
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clock drawning + three-item memory test
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What are the advantages of using the mini-cog screening test for demensia?
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more sensitive than CDT
same advantages of CDT not as commonly used as MMSE but fast involves visuospatial, exectutive and planning and memory functions |
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What consitutes a positive mini-cog screening test?
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2 word recall and/or abnormal clock
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What are some reversible causes that can mimick dementia?
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drug toxicity
metabolic disturbance normal pressure hydrocephalus mass lesion (tumor, chronic subdural) infectius process (meningitis, syphilis) collagen-vascular disease (SLE, sarcoid) endocrine disorder (thryoid, parathyroid) nutritional disease (B12, thiamine, folate) other (COPD, CHF, Liver Dz, apnea...) |
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What % of patients with dementia have potentially reversible causes?
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13%
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What labwork should you order for evaluation of a patient with suspected dementia?
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electrolytes
CBC liver enzymes TSH B12 level syphilis |
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What neuroimaging should you order to work up a possible dementia?
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CT is usually adequate
MRI if vascular dementia is suspected |
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What is the difficulty with neuroimaging to work up dementia?
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'small areas of white matter ischemic changes' commonly seen in normals
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What are the characteristics of Alzheimer's disease?
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insidious onset and gradual progression
presentaiton usually related to primary deficits in memory ultimate diangosis bassed on pathology of plaques and tangles |
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What is the age-related incidence of demensia?
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8% per year by 85
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What % of dementia cases are Alzheimer's?
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1/2 to 2/3
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What are the biochemical characteristics of Alzheimer's?
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deficiency of acetylcholine
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What parts of the brain are afffected in Alzheimer's?
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cerebral cortex
amygdala hippocampus basal nucleus of Meynert (basal forebrain) depleted of acetylcholine-containing neurons that project elsewhere |
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What chromosomes are implicated in genetically linked Alzheimer's dx?
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1, 14, 21
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What gene increases the risk of Alzheimer's dx?
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allele E4, especially if homozygous
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What is the increase in risk with a first degree relative with Alzheimer's dx?
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fourfould
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what is the course of AD?
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insidious onset and progressive course with typical loss of 3 points on MMSE each year and death occuring 8 to 12 years after dx
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What are the characterisitcs of mild Alzheimer's?
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MMSE 20 to 24
Usually the first 2 to 3 years after dx primarily memory and visual-spatial deficits mild difficulty with executive funcitoning |
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What are the characteristics of Alzheimer's disease?
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insidious onset and gradual progression
presentaiton usually related to primary deficits in memory ultimate diangosis bassed on pathology of plaques and tangles |
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What is the age-related incidence of demensia?
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8% per year by 85
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What % of dementia cases are Alzheimer's?
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1/2 to 2/3
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What are the biochemical characteristics of Alzheimer's?
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deficiency of acetylcholine
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What parts of the brain are afffected in Alzheimer's?
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cerebral cortex
amygdala hippocampus basal nucleus of Meynert (basal forebrain) depleted of acetylcholine-containing neurons that project elsewhere |
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What chromosomes are implicated in genetically linked Alzheimer's dx?
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1, 14, 21
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What gene increases the risk of Alzheimer's dx?
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allele E4, especially if homozygous
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What is the increase in risk with a first degree relative with Alzheimer's dx?
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fourfould
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what is the course of AD?
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insidious onset and progressive course with typical loss of 3 points on MMSE each year and death occuring 8 to 12 years after dx
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What are the characterisitcs of mild Alzheimer's?
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MMSE 20 to 24
Usually the first 2 to 3 years after dx primarily memory and visual-spatial deficits mild difficulty with executive funcitoning |
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What are the characteristics of moderate Alzheimer's dx?
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MMSE of 11 to 20
3 to 6 years following dx aphasia and apraxia become more pronounced loss of IADLS and increased assistance with ADLs beginning to exhibit some neuropsych symptoms particularly paranoia |
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What are the characterisitcs of severe Alzheimer's dx?
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usually 6 to 10 years following dx
severe language disturbances: mutism, echolalia, repetative vocalizations pronounced neuropsych manifestations including agitation, aggression very late in the course can see muscle rigidity, gait disturbances, incontinence, dysphagia |
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What are the characteristics of vascular dementia?
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one or more strokes, two or more cognitive functions affected
abrupt onset and stepwise course |
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What is the second most common form of dementia?
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vascular dementia
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What other names does vascular dementia go by?
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Binswanger's Dx
Lacunar State Multi-infarct Dementia |
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What % of dementia cases are vascular dementia?
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10 to 40%
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What % of Alzheimer's dx are mixed (i.e. mixed with vascular dementia)?
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10 to 15 %
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What are the risk factors for vascular dementia?
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smoking
atrial fibrillation diabetes hypertension |
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What is the incidence of dementia with lewy bodies?
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7 to 16%
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What is the progression in lewy body dementia?
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memory impairment may come after visual hallucinations, delirium, parkinsonsim
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Lewy body dementia is sensitive to what drugs?
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neuroleptics
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Compare and contrast lewy body dementia vs. Parkinson's dx:
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LBD, lewy bodies are cortical.
In PD, lewy bodies are in substantia nigra In PD, motor symptoms precede dementia for years. In LBD the motor symptoms more closely linked to memory problems |
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What is frontotemporal (pick's dx) characterized by?
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personality changes
disinhibition executive dysfunction memory impairment |
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What are the hallmarks of frontotemporal dementia on gross brain specimens?
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frontotemporal atrophy
'walnut brain' |
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When is the usual onset for frontotemporal dementia?
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50 to 60 y/o
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What characterisitcs should be exemplified during behavioral therapy in dementia? When should they be tried?
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reassurance, distraction, redirection, structure
don't argue: it makes things worse provide a safe place where dysfunctional behavior can occur w/o causing harm should be tried first |
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What behavioral resources are utilized in dementia?
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refer to adult day care
respite/adult family homes psychoeducation depression in caregiver SNF's before crisis |
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What is the Rx treatment stragety for dementia?
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treat symptoms:
agitation depression delusions aggression |
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What Rx are used in the treatment of dementia?
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antidepressants
neuroleptics anticonvulsants benzodiazepines psychostimulants cognitive enhancers |
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What Rx is good for psychosis in dementia?
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neuroleptics
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What Rx is good for lability in dementia?
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anticonvulsant/mood stabilizer
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What is the gold standard for neuroleptics in the Rx of dementia?
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none
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What SE do you get from high potency neuroleptics? low potency?
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high: parkinsonism
low: sedation, hypotension, anticholingeric |
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What is the typical dose of risperidone in the treatment of dementia? What are the concerns?
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0.25 to 0.5 mg
EPS (especially good for agitation) |
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What is the typical dose of olanzapine in the treatment of dementia? What are the concerns?
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2.5 to 5 mg
BS, anticholinergic |
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What is the typical dose of quetiapine in the treatment of dementia? What are the concerns?
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12.5 to 25 mg
orthostasis |
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What is the use of neuroleptics in the treatment of dementia?
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psychosis, agitation
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What are some SE of neuroleptics?
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tardive dyskinesia
extrapyramidal symptoms cognition increased risk of stroke (maybe?) |
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What antidepressant is best for agitaiton and aggression in dementia? What is the SE?
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trazodone (not good for depression)
alpha-2 blockade - orthostasis |
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What antidepressants are not used in patients with demensia and agitation?
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tricyclics
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What is the starting dose of citalopram in the demented?
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10 mg
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What is the starting dose of sertraline in the demented?
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25 mg
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What anticonvulsant is used in the treatment of demensia? What are the indications?
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divalproex
disinhibition (yelling) behavior in the absence of psychosis or depression |
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What are the SE of acetylcholine esterase inhibitors?
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GI upset
nausea diarrhea sleep expensive |
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What drugs are available for cognitive enhancers in the treatment of dementia?
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donepezil
rivastigmine glantamine |
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What is the role of memantine in the treatment of dementia?
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NMDA antagonist
indicated for moderate-to-severe AD possible theory that prevents glutamate overstimulation, excitoxicity and neuronal cell death NOT indicated for vascular demensia |
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What is the role of Vit E in the treatment of demensia?
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showed some effectiveness in delaying SNF-placement
2000 IU/d No longer advised |
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When should you refer a demensia patient to a specialist?
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early onset
presentation is atypical if severe parkinsonism, focal findings, or abnormal scan behaviors seeminly 'untreatable' to better document severity, consider neuropsychologist |
