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88 Cards in this Set
- Front
- Back
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What are the diagnostic criteria for dementia? |
Presence of an acquired impairment in memory, associated with impairment in one or more cognitive domains, including: - Executive function (e.g., abstract thinking, reasoning, judgment) - Language (expressive or receptive) - Praxis (learned motor sequences) - Gnosis (ability to recognize objects, faces, or other sensory information)
Impairments in cognition must be severe enough to interfere with work, usual social activities, or relationships with others |
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What does the term "praxis" mean? |
Learned motor sequences |
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What does the term "gnosis" mean? |
Ability to recognize objects, faces, or other sensory information |
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What is the role of diagnostic testing for dementia? |
Primarily to rule out treatable causes, which occur in <1% of cases of dementia |
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What comorbid condition is often present with dementia symptoms? |
Depression - widely recognized as a cause of "pseudo-dementia" |
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How can you screen for depression in a patient you think may have dementia? |
Geriatric Depression Scale (well-validated screening test for depression in older patients that may be used to rule out depression) |
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What tests are recommended in a patient you think may have dementia? |
- CBC - Basic chem - Calcium - Thyroid - Vitamin B12 deficiency - Folate deficiency (but so rare due to fortification of foods) - Syphilis (if clinical suspicion or local prevalence is high) |
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What is the role of neuroimaging in patients you think may have dementia? |
Either non-contrast CT or MRI has not been shown to be beneficial in the diagnosis, but it can rule out structural defects (e.g., tumors or normal pressure hydrocephalus) and vascular causes
If you have concern for one of these alternative diagnoses you can get imaging |
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What findings on brain MRI are common? |
Non-specific white matter changes - represent microvascular disease |
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What causes non-specific white matter changes? |
Microvascular disease - caused by HTN, smoking, obesity, or simply by aging
Commonly found in asymptomatic individuals and are often felt to be clinically irrelevant |
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What is the utility of the clinical dementia rating (CDR)? |
Developed for the evaluation of the severity of dementia, primarily for use in persons with dementia of the Alzheimer type; it can be used to stage dementia in other illnesses as well |
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What is evaluated in the clinical dementia rating (CDR)? Scores? |
Evaluated based on memory, orientation, judgment, community affairs, home and hobbies, and personal care 0 - no cognitive impairment 0.5 - very mild dementia 1 - mild dementia 2 - moderate dementia 3 - severe dementia |
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What are the most common causes of dementia? |
- Alzheimer's disease (60%) - Vascular dementia (15-20%) - Dementia with Lewy bodies (10-15%)
10% of patients with Alzheimer's disease have pathologic findings of vascular dementia - thus making it a mixed dementia |
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What are the other causes of dementia besides Alzheimer's, vascular, and Lewy body? |
- Parkinson's disease - Pick's disease - Huntington's disease - Creutzfeldt-Jakob disease |
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What are the three stages of Alzheimer's disease? |
1. Preclinical Alzheimer's disease 2. Mild cognitive impairment (MCI) d/t Alzheimer's disease 3. Dementia due to Alzheimer's disease |
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What causes vascular dementia? |
Multiple infarcts - usually associated with cardiovascular risk factors such as HTN and tobacco use
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Besides dementia, what other symptoms do patients with Dementia with Lewy Bodies (DLB) have? |
- Fluctuations in alertness and attention (delirium) - Visual hallucinations - Parkinsonian symptoms |
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What are the characteristics of dementia from Parkinson's disease? |
Parkinson's disease is a cause of dementia late in the course of the disease, with the prominent motor symptoms starting years before. |
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How do you distinguish dementia from Parkinson's disease from Lewy Body Dementia? |
- Parkinson's disease: motor symptoms start way before symptoms of dementia - Dementia from Lewy Body: Parkinsonian symptoms and dementia begin simultaneously |
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What type of dementia presents with changes in personality, demeanor, and behavior? |
Frontal temporal dementia (aka Pick's disease) |
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What are more rare forms of dementia? |
- Huntington's disease - Creutzfeldt-Jakob disease |
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What causes Huntington's disease? |
Autosomal dominant
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What is the initial presentation of Huntington's disease? |
Random, jerky, uncontrollable movements (choreiform movements) |
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What are the characteristics of Creutzfeldt-Jakob disease? |
- Extremely rare - Rapidly progressie infectious condition - Transmitted by a prion |
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What are the characteristics of dementia as compared to delirium and depression? |
- Dementia is an acquired syndrome of gradual progressive deterioration in global intellectual ability - Interferes with ability to function in social and occupational roles - Important elements of the definition include: acquired (i.e., not congenital), progressive (i.e., worse over time), global (i.e., not isolated to memory), and interfering with function |
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What are the characteristics of delirium as compared to dementia and depression? |
- Delirium causes a decline in cognition - Particularly notable for acute disturbances in attention (e.g., an inability to shift focus), alertness (e.g., impaired consciousness and sleep cycles), and perception (e.g., hallucinations) - Symptoms fluctuate over short periods of time, whereas in dementia the symptoms are slowly progressive |
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What are the characteristics of depression as compared to dementia and delirium? |
- Depression is an alteration in mood, which can be confused with dementia in older patients - Frequently causes a decline in ability to concentrate, which may worsen memory - Also leads to lack of interest and energy, which may appear similar to symptoms of dementia - Since depression is readily treatable, it is essential to diagnose this condition in patients who present with memory loss - In addition to representing the primary diagnosis, depression can be comorbid with dementia, and should be considered both because it may worsen symptoms related to dementia and because it can be reversible |
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Which bedside instrument for diagnosing delirium has the best support of evidence? |
Confusion Assessment Method (CAM) - takes 5 minutes to administer |
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Of the CAM, MMSE, MiniCog, and MOCA, which is the least useful for assessing delirium? |
MMSE - mini mental status exam |
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What are examples of ADLs? |
- Bathing - Dressing - Transferring - Continence - Toileting - Feeding |
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What are examples of IADLs? |
- Shopping - Preparing a meal - Using the telephone - Managing transportation needs - Managing medications - Managing finances |
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What are ADLs? When do you learn these? |
Most basic skills that patients need to stay independent and live at home. They represent one's basic personal care and physical ability.
They are usually acquired by the first time one leaves home (about 5-6 years old, or kindergarten age) |
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What are IADLs? When do you learn these? |
These don't have to be done on a daily basis, are not as severe a threat to independent living, and other people can be hired to do them. They typically require a cognitive component in addition to physical ability.
They are usually acquired by the second time one leaves home (about 16-17 years old, beginning college, or career) |
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How common are IADL deficits in patients over the age of 75? |
>50% of people over 75 years have at least 1 ADL deficit |
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On the MMSE, how many points do you get for orientation? How do you receive these points? |
10 points - City - State - County - Building - Floor - Day - Date - Month - Year - Season |
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On the MMSE, how many points do you get for registration? How do you receive these points? |
3 points - Immediately repeating 3 words (e.g., ball, tree, jacket) |
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On the MMSE, how many points do you get for attention and calculation? How do you receive these points? |
5 points - Ask all patients to perform serial 7's - Those who do not correctly complete this entire sequence should be asked to spell "WORLD" backwards - The scorer then uses the better of the two scores - Using the better performance accommodates for the fact that some people are naturally more gifted with literacy than numeracy, and vice versa |
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On the MMSE, how many points do you get for recall? How do you receive these points? |
3 points - Remembering the 3 words (e.g., ball, tree, jacket) |
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On the MMSE, how many points do you get for language? How do you receive these points? |
2 points - Have them name two objects (e.g., pen, watch) |
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On the MMSE, how many points do you get for repetition? How do you receive these points? |
1 point - Repeat the phrase completely correct "no ifs, ands, or buts" |
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On the MMSE, how many points do you get for complex commands? How do you receive these points? |
6 points (2 for each) - 3-stage command (take a piece of paper, fold it once, hand it back to you) - Follow a written command (e.g., write to pt to write another sentence and then check if what they write is a sentence) - Copy design (intersecting pentagons should have 5-sides and each figure should have only one corner within the other figure) |
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Mr. Marshall is a 72-year old man, with a history of HTN, COPD, and moderate dementia, who presents with 4 days of increased confusion, nighttime restlessness, visual hallucinations, and urinary incontinence. His physical exam is unremarkable except for tachypnea, a mildly enlarged prostate, inattentiveness, and a worsening of his MMSE score from a baseline of 18 to 12 today.
What are the top five diagnoses on differential? |
- Electrolyte disturbance - UTI - Respiratory infection - Urinary retention - Pain |
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What is the most common cause of delirium in older patients? |
UTI |
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Mr. Marshall is a 72-year old man, with a history of HTN, COPD, and moderate dementia, who presents with 4 days of increased confusion, nighttime restlessness, visual hallucinations, and urinary incontinence. His physical exam is unremarkable except for tachypnea, a mildly enlarged prostate, inattentiveness, and a worsening of his MMSE score from a baseline of 18 to 12 today.
What is the most likely diagnosis? Why? |
UTI - most common cause of delirium in older patients; these patients are seldom able to identify the common symptoms of UTIs; it may also exacerbate urinary incontinence
The presence of new onset of incontinence makes this the most likely diagnosis |
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Mr. Marshall is a 72-year old man, with a history of HTN, COPD, and moderate dementia, who presents with 4 days of increased confusion, nighttime restlessness, visual hallucinations, and urinary incontinence. His physical exam is unremarkable except for tachypnea, a mildly enlarged prostate, inattentiveness, and a worsening of his MMSE score from a baseline of 18 to 12 today.
What makes infection from pneumonia possible? |
His history of COPD and his tachypnea make this a possible diagnosis and cause of his delirium |
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What causes the high mortality rate in patients with advanced dementia? |
Infections such as pneumonia and urosepsis; aspiration pneumonia may also cause delirium |
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Mr. Marshall is a 72-year old man, with a history of HTN, COPD, and moderate dementia, who presents with 4 days of increased confusion, nighttime restlessness, visual hallucinations, and urinary incontinence. His physical exam is unremarkable except for tachypnea, a mildly enlarged prostate, inattentiveness, and a worsening of his MMSE score from a baseline of 18 to 12 today.
What could be causing an electrolyte disturbance in this patient to explain his delirium? |
He takes HCTZ for BP which may cause hypokalemia and hypercalcemia; metabolic acidosis leads to tachypnea (compensatory respiratory alkalosis) |
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What electrolyte disturbances may cause delirium? |
Wide range: - Hypo- or Hyper-natremia - Hypercalcemia - Hypokalemia - Metabolic acidosis |
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How does urinary retention cause delirium in a patient with dementia? |
Any condition that leads to discomfort may cause delirium
Acute urinary retention leads to complete inability to pass urine. Chronic urinary retention (most commonly d/t BPH) leads to incomplete emptying and distention of bladder, which further may lead to UTI and overflow incontinence. |
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What are the risk factors for urinary retention? |
- Male - Age >70 - BPH |
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How should you evaluate a patient with delirium for urinary retention? |
Postvoid residual should be measured (either by catheterization or U/S assessment of bladder volume after voiding)
Catheterization allows collection of a urine culture that is unlikely to be contaminated by skin flora.
When urinary retention is severe, bladder may be palpated in the suprapubic area. |
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Why is it difficult to treat pain that is causing delirium in patients with dementia? |
Treatment of pain with opiates can also cause delirium
Since patients in this condition are frequently unable to localize and report their symptoms, it is important to do a full physical exam looking for hidden sources of pain (abdominal tenderness, joint or bony injury) |
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Mr. Marshall is a 72-year old man, with a history of HTN, COPD, and moderate dementia, who presents with 4 days of increased confusion, nighttime restlessness, visual hallucinations, and urinary incontinence. His physical exam is unremarkable except for tachypnea, a mildly enlarged prostate, inattentiveness, and a worsening of his MMSE score from a baseline of 18 to 12 today.
What are less likely causes of his delirium? |
- Depression - Withdrawal - Acute cerebrovascular event - Adverse drug effect |
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Mr. Marshall is a 72-year old man, with a history of HTN, COPD, and moderate dementia, who presents with 4 days of increased confusion, nighttime restlessness, visual hallucinations, and urinary incontinence. His physical exam is unremarkable except for tachypnea, a mildly enlarged prostate, inattentiveness, and a worsening of his MMSE score from a baseline of 18 to 12 today.
Why is depression a less likely cause of his delirium? |
- Depression and other psychiatric condition can present with altered mental status in older patients; these usually present differently from delirium - Mental illnesses typically present more gradually - Profound depression may even present with psychotic features such as Mr. Marshall has - In mental illness, auditory hallucinations are more common than visual ones - Mr. Marshall presents with clinical features of delirium, in which visual hallucinations are more common |
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Mr. Marshall is a 72-year old man, with a history of HTN, COPD, and moderate dementia, who presents with 4 days of increased confusion, nighttime restlessness, visual hallucinations, and urinary incontinence. His physical exam is unremarkable except for tachypnea, a mildly enlarged prostate, inattentiveness, and a worsening of his MMSE score from a baseline of 18 to 12 today.
Why is withdrawal a less likely cause of his delirium? |
- Withdrawal from meds or other substances is a common cause of delirium - This reaction most frequently occurs from alcohol and benzos; in these cases, delirium may progress to a more severe form known as DTs - In this case, withdrawal is unlikely given he does not consume any meds or substances associated with withdrawal (keep in mind puts may underrepresent substance use) |
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What are the signs/symptoms of delirium tremons? |
- Tachycardia - HTN - Delirium with agitation - Visual hallucinations - Formication (sensation of insects crawling on patient) |
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Mr. Marshall is a 72-year old man, with a history of HTN, COPD, and moderate dementia, who presents with 4 days of increased confusion, nighttime restlessness, visual hallucinations, and urinary incontinence. His physical exam is unremarkable except for tachypnea, a mildly enlarged prostate, inattentiveness, and a worsening of his MMSE score from a baseline of 18 to 12 today.
Why is acute cerebrovascular event a less likely cause of his delirium? |
- Acute cerebrovascular events - i.e., ischemic stroke or intracranial bleeding - may present with acute change in mental status - More likely in a patient with vascular dementia who experiences a new ischemic event - Vascular event could be small enough to not cause an acute alteration in mental status - Large brain insults typically have associated near findings on exam (e.g., hemiplegia or UMN findings - hyperreflexia, clonus, positive Babinski's) - Prior MRI was not consistent w/ vascular dementia and his euro exam is normal (other than mental status); if his mental status remains the same over time despite treatment for delirium, this diagnosis should be considered more closely |
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Mr. Marshall is a 72-year old man, with a history of HTN, COPD, and moderate dementia, who presents with 4 days of increased confusion, nighttime restlessness, visual hallucinations, and urinary incontinence. His physical exam is unremarkable except for tachypnea, a mildly enlarged prostate, inattentiveness, and a worsening of his MMSE score from a baseline of 18 to 12 today.
Why is an adverse drug event a less likely cause of his delirium? |
- As a group, adverse drug effects represent one of the most common causes of delirium in older patients - Pts with dementia in particular are sensitive to meds w/ sedating effects - Meds w/ anti-cholinergic effects (opiates, bentos, sedating antihistamines, TCAs, antipsychotics, and some anti-nausea meds) are most likely to cause delirium - Other potential offenders are certain antibiotics (e.g., fluoroquinolones), beta-blockers, and H2-blockers - While adverse drug effects are common causes of delirium, Mr. Marshall has had no recent changes to his med list and doesn't take meds commonly associated with delirium |
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Mr. Marshall is a 72-year old man, with a history of HTN, COPD, and moderate dementia, who presents with 4 days of increased confusion, nighttime restlessness, visual hallucinations, and urinary incontinence. His physical exam is unremarkable except for tachypnea, a mildly enlarged prostate, inattentiveness, and a worsening of his MMSE score from a baseline of 18 to 12 today.
What labs/studies would you like to get? |
- CBC - Basic chem - Post-void residual - Urinalysis / urine culture - CXR |
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What is a normal post-void residual? |
<100 mL is normal |
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How do you diagnose a pneumonia on CXR? |
- Typically appears as a density in one of the lung fields - When a consolidated pneumonia rests up against solid tissue, such as the diaphragm, you lose the ability to distinguish the border of that tissue from the lung tissue - Sometimes air bronchograms (linear lucencies) are visible in the infiltrate - these represent air within a bronchus surrounded by consolidated lung tissue |
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When might you not see a pneumonia on CXR? |
- Older patients - Patients with atypical pneumonia such as Legionella - Patients early in their illness |
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What should you do if you have a high clinical suspicion of pneumonia and the CXR does not show a clear cut finding of pneumonia? |
Start treatment for pneumonia and repeat a CXR in 24-48 hours |
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How can you treat UTI in a patient being admitted to the hospital? |
IV ceftriaxone - make sure you have a urine sample sent for gram stain and culture |
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How can you treat delirium? |
- Short course of haloperidol - Atypical anti-psychotics, eg, olanzapine or quetiapine |
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What are the benefits of haloperidol for delirium? |
- Aids sleep - Diminishes agitation - Clears hallucinations |
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What are the side effects of haloperidol? |
- Sedating - Can cause constipation - Tardive dyskinesia - involuntary spasms of the neck, tongue, and lips (generally seen in patients on higher doses for a long time, >1 year) - QT prolongation (rare) |
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What are the pros/cons of atypical antipsychotics vs haloperidol? |
- For symptoms such as psychosis, mood alterations, and aggression associated with dementia in elderly, small but significant benefits have been observed with aripiprazole, olanzapine, and risperidone - These agents can prolong QT interval and don't have the long track record of haloperidol |
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How does caregiver stress impact the caregiver? |
- Risk factor for morbidity and mortality - Older spousal caregivers who report emotional strain have a relative risk of mortality of 1.63 over 4 years, compared to non-caregivers - Depression, anxiety, and use of psychotropic meds are more common in caregivers |
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How can you assess for caregiver stress? |
- Formal tools have not been developed for the primary care setting - Direct questioning of the caregiver is recommended to identify the level of burden - Screen for anxiety and major depression - Identify level and type of external support caregiver is receiving (e.g., family member or home health aid visits) |
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What resources can you offer to help a caregiver under extreme stress? |
- Respite care (either family member or paid professional) - Adult day program - Caregiver support groups - Family Caregiver Alliance - www.eldercare.gov |
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What are some hospital interventions that can prevent or minimize delirium? |
- Frequent reorientation and redirection by a familiar provider (one-to-one sitter) - Avoid medications that can lead to delirium - Provide early mobility and range of motion exercises - Minimize unnecessary lines, cables, and catheters - Provide increased stimulation |
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What medications can worsen delirium? |
- Sedating meds - Meds w/ anticholinergic side effects (e.g., narcotics, benzodiazepines, and tricyclic antidepressants) - See Beers criteria for meds that should be avoided when possible |
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What interventions can help bedridden patients be less delirious? |
Provide early mobility and ROM exercises; these exercises provide physical touch, cognitive and sensory stimulation, and can prevent decubitus ulcers |
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Why is it important to minimize unnecessary lines, cables, and catheters in patients with delirium? |
- Foley fathers, while preventing urinary incontinence in bed, can be uncomfortable and provide noxious stimuli that can augment delirium - These lines and wires can lead to preventable falls - Oxygen tubing, IV lines, telemetry monitors, and physical restraints should be used when no alternative but should be discontinued as soon as safely possible |
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What stimulating measures can be done to help patients with delirium? What things should be avoided? |
- Increase stimulation - maintain adequate lighting, windows, large clocks, calendars (keep them calm and oriented) - Keep patient close to the activity of the nursing station is also helpful - Visual and hearing disturbances can contribute to delirium - avoid dim lighting, ambient noise, and removal of hearing/visual aids |
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What pharmacologic and non-pharmacologic measures that have roles in the treatment of Alzheimer's dementia and its symptoms? |
- Cholinesterase inhibitors - Vitamin E - Memantine - Respite care - Atypical antipsychotics
(Cognitive rehabilitation therapy has not been demonstrated to be helpful in slowing the progression of Alzheimer's) |
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What are the types of cholinesterase inhibitors for Alzheimer's disease? |
- Donepezil - Rivastigmine - Tacrine - Galantamine |
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Who benefits from cholinesterase inhibitors (donepezil, rivastigmine, tacrine, galantamine)? |
Patients with mild to moderate dementia - Statistically significant, though clinically small benefits - Improvements in MMSE, ADLs, and IADLs - Most families and clinicians are unable to detect these differences |
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How many patients would a physician need to treat with cholinesterase inhibitors (donepezil, rivastigmine, tacrine, galantamine) to achieve minimal improvement or better? |
12 patients with mild to moderate Alzheimer's dementia |
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How many patients would a physician need to treat with cholinesterase inhibitors (donepezil, rivastigmine, tacrine, galantamine) for one to have a treatment-related side effect? |
12 patients with mild to moderate Alzheimer's dementia |
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What is the benefit of vitamin E for patients with Alzheimer's disease? |
- 2000IU daily demonstrated a delay in the onset of death, institutionalization, or progression to severe dementia of 670 days compared to placebo in patients with moderate to severe dementia - Some concern regarding safety due to a meta-analysis that showed a rise in all-cause mortality - A 2012 Cochrane review found on convincing evidence that Vitamin E has any benefit |
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What is the mechanism of memantine? |
NMDA receptor antagonist (approved for moderate to severe dementia; no evidence for its benefit in mild dementia) |
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What are the benefits of NMDA receptor antagonists (memantine)? |
Small, but statistically significant improvements in cognition |
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Which medications for dementia have a black box warning for increased risk of death among elderly patients with dementia? |
Atypical antipsychotics |
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What are home and long-term care services for patients with dementia? |
- Skilled home services - nurses, PTs, speech therapists, CNAs - Nursing home - Adult day program |
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How much of nursing home care will Medicare cover? |
100% of the cost for the first 20 days after a hospitalization |
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What are some signs of advanced dementia on physical exam? |
Primitive reflexes - Patients with advanced dementia or other neurodegenerative diseases may develop primitive reflexes with loss of frontal lobe control - Primitive reflexes are those that may be seen in infants, including grasp, suck, and the "globular tap" (patient continues to blink each time he or she is tapped on the forehead; healthy patients stop blinking after the second or third tap) |
