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55 Cards in this Set
- Front
- Back
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The transitional state between normal aging and dementia is called _________________.
What are the 2 types? |
Mild cognitive impairment (MCI)
2 types: 1. Amenestic : Associated with deficits in memory 2. Nonamenstic : Associated with impairments i other cognitive functions |
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T/F: MCI is considered a risk factor for dementia.
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True: MCI is considered a risk factor for dementia, and these patients need close monitoring & follow-up
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In the diagnostic criteria for ALZ:
Dementia is the development of mult. cognitive deficits manifested by ______ _______ (which is defined as?) AND (must have both) _#_or more of: ______ _______ _________ _______ |
A. The development of mult. cognitive deficits manifested by BOTH
1. Memory Impairment (impaired new learning OR impaired recall of previously learned) and 2. One (or more) of: a)aphasia, b) apraxia, c)agnosia d)exec. function |
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Additional diagnostic criteria for ALZ Dementia:
B. deficits cause impairment in: C. Onset is ____ D. Deficits NOT due to: E: Deficits do not only occur with: F: Deficits not better accounted for by: |
B. The cog deficits in A1 and A2 cause impairment in social or occupational fxn & represent a sig decline from previous
C. Gradual onset and continuing cog decline D. Deficits in A1 and A2 are NOT due to -CNS disorders (e.g.: CVA, parkinsons, huntingtons, hematoma, NPH, or tumor) -substance induced (medication, drugs) -systemic conditions (e.g.: hypthyroid, HIV, vit. B def etc.) E. Deficits do not occur only with delirium F. The disturbance is not better accounted for by another Axis 1 disorder (e.g.: Major depression, schizophrenia etc) |
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In addition to the basic criteria of ALZ dementia; vascular dementia differs by having:
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C. Focal neurologic S/S
(e.g.: exaggeration of DTRs, extenor plantor response, peusudobulbar palsy, gait abnormalities, weakness of extremities) OR Lab evidence of CVD (e.g.: mult infarctions) that are etiologically related to the disturbance |
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Pseudobulbar palsy
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Pseudobulbar palsy is a medical condition characterized by the inability to control facial movements (such as chewing and speaking) and caused by a variety of neurological disorders. Patients experience difficulty chewing and swallowing, have increased reflexes and spasticity in tongue and the bulbar region, and demonstrate slurred speech (which is often the initial presentation of the disorder), sometimes also demonstrating uncontrolled emotional outbursts.
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Dementia of multiple etiologies
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Dementia of multiple etiologies: all the same criteria, except: evidence from H&P or labs show there is more than one etiology (e.g.: head trauma + ETOH, ALZ + Vascular)
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Most common type of dementia
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ALZ
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T/F: The degree of atrophy is a good indicator of the degree of cognitive impairment.
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False: degree of atrophy may not correlate with degree of cognitive impairment
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Stages of ALZ: characteristics and complications
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-Early: memory loss, time and spatial disorientation, poor judgment, personality changes, withdrawal or depression, perceptual changes.
complications: getting lost, MVA -Midstage: recent and remote memory worsens, increased aphasia, apraxia, hyperorality, disorientations, restlessness, perseveration, irritability, loss of impulse control complications: incontinence, sleep disturbances -Late: total incontinence, loss of motor skills, rigid, decreased appetite and dysphasia, amnesia, apraxia, severely impaired communication, possible inability to recognize self or family, loss of self-care, severely impaired cognition, depressed immune system complications: contractures, pressure ulcers, UTI, PNA, apraxia w/ eating and swallowing. Weight loss. Death. |
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Vascular Dementia: Characteristics and risks
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Vascular Dementia
-characterized by focal ischemic changes -defining lesion: lacunar infarct -risks: HTN, DM, hyperlipidemia, peripheral vascular occlusion |
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Lewy body Dementia: Characteristics and risks
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Lewy body
-Protein in the brain enter neurons and cause cell degeneration and death -Loss of dopamine and acetylcholine -visual hallucinations, postural instability, and sleep disturbances -increased sensitivity to neuroleptics i.e. Haldol GNRS: At least of the following: visual hallucinations, parkinsonian signs, changes in alertness of attention |
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average duration from diagnosis to death
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9 years
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Screening tools
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-Katz Index of Independence in ADLS
-Get Up and GO -MMSE -Mini-cog -Geriatric Depression Scale |
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Why use tools?
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Why use tools: Gives a year-to-year progression for families; and assess for changes in behavior, specifically anxiety, restlessness, aggression, visual or auditory hallucination and wandering
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Standardized tests of decisional capacity (4)
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a. MMSE
b. Executive Interview 25 item examination of executive functioning c. Clock drawing d. MacArthur Competency Assessment Tool for Treatment |
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MMSE level of not having decisional capacity
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a. MMSE </10: diminished cognitive ability that unlikely person retains decisional capacity
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T/F: The executive Interview 25 item examination of executive functioning correlates well subjective measures of decisional capacity.
-What does it reveal? |
TRUE: . Correlates well with subjective measures of decisional capacity
ii.Can reveal insight, impulsivity, poor self-monitoring, and impaired ability to form and follow through with a plan |
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Clock test can reveal:
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Clock drawing
i. Can reveal insight, impulsivity, poor self-monitoring, and impaired ability to form and follow through with a plan (similar to executive interview) |
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Exam for vascular dementia would include:
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Exam: carotid bruits, BP, cognition, function and mood
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T/F: Most geriatric specialists recommend baseline image studies?
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True: Most geriatric specialists recommend baseline image studies: CT non contrast. However, Imaging studies ID mass lesions, vascular, lesions, and infections but do not confirm DX
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No specific test for dementia, so evaluate possibility of underlying causes with these labs:
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No specific test so evaluate possibility of underlying causes: Labs, CBC, TSH, Vit B12, folate, BMP
Geriatric review syllabus: CBC, UA, serum chem, LFTs, rapid plasma reagent test, thyrotropin, vitamin B12, folate acid level or homocysteine, and methylmalonic acid |
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Differentials for Dementia
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*Delirium, *depression, medical illnesses (liver, kidney disease, infections), overdose, psychiatric illness, nutritional deficits, sensory impairments
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People with dementia have (altered/normal) level of consciousness (with/without) inattention
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People with dementia have normal level of consciousness without inattention
ex: ex: depression will answer: "i dont know", dementia: will confabulate an answer |
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Donepezil (aricept, rivastigmine (Exelon and Galantaminr (Razadyne) are examples of _____________________________s. And they are used to treat:
MOA SE |
Cholinsterase inhibitors
Mild to moderate Dementia -Do not alter course, but delay -No use for vascular or frontotemporal dementia Follow up 6 months of therapy MOA: slow the breakdown of Ach, which facilitates memory function Se: GI, nausea and diarrhea |
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Memantine (Namenda) is an example of an _____________. And it is used for:
MOA Side effects |
NMDA
-used in combo with cholinesterase inhib for mod to severe -Does not alter course, but delay progress MOA: reduces glutamate mediated excitoxicity SE: constipation, dizziness, and headache |
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Specifically, treatment of vascular dementia includes:
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continuing optimal tx of risk factors (HTN, ^lipids etc.)
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Depression tx in dementia
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Often treated with antidepressants, but studies show no more effective than placebo. Treatment: exercise, and participation in pleasurable activities
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What types of meds have a blackbox warning for use in dementia? why?
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antipsychotics: Black box warning for increased risk of cerebrovascular events
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Education with dementia pts/families
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- Resources: day cares etc
- Understand that patients with dementia are at an increased risk for delirium -also my not present with typical S/S of disease (ex MI w/o chestpain, UTI w/o urinary symptoms) |
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Conservatorship
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i. In absence of POA or next of kin, court appoints conservator (guardian)
ii.2 types: conservator of finance, conservator of person |
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Living will
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i. Advanced directives that attempt to demonstrate what decisions a person would make under certain circumstances
ii.Address vegetative state and terminal illness iii. Address CPR, ventilator, artificial food and hydration, and dialysis iv. Are often vague but can be used to evidence preferences |
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T/F: b. A patient can reverse his/her DNR status undergoing anesthesia with understanding it can be reinstated after procedure
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True
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Research Subjects and dementia
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Research protocols that involve more than minimal risk or that do not have a likelihood of direct benefit for the subjects should be offered only to individual who are able to consent or who have an advance directive consenting to participate in research. Exceptions might be made for exceptionally promising treatments but this should be reviewed at a national level.
*surrogates can sign consent, and they can withdrawal pt from study at any time if they don believe that the study is beneficial to the patient |
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Elements of decision making in dementia (4)
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Medical decision
Finances Decision of self-care Last Will and testament |
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Ethical Issues in Dementia: Truth telling
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-Let them know the process and what will happen, give them an opportunity to prepare will, make plans,
also options of research*Get consent from the pt |
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T/F Dementia is progressive and disabling and is not an inherent aspect of aging
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T
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Risk factors of dementia
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AD: age & family hx
Rare forms: mutantions in genes including: 1. amyloid precursor protein (APP), 2. Presenilin 1, Presenilin 2 Late onset: APOE genotyping for asymptomatic adults (not currently recommended) Other risk factors: trauma, CVD, Depression, low education level |
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What may have a protective affect against dementia?
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Physical and intellectual activity
Management of HTN |
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Characteristics of frontal temporal dementia
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i. Younger age
ii.Executive and language dysfunction and significant behavioral changes iii. Social disinhibition before memory decline |
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Treatment with cognitive rehab and dementia:
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Cognitive rehabilitation
1. No evidence of positive effects of those with dementia |
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T/F: High dose vitamin E is highly recommended
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FALSE: High dose vitamin E NOT recommended
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Psychoactive drug and dementia
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1. Carbamazepine and valproid acid: used to manage irritability, hallucinations, and delusions
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T/F: Avoid benzos
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true
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In which form of dementia would it be okay to use levdopa/carbidopa?
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Lewy body
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Assessment and differential diagnosis
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a. Assessment
i. Description of behavior ii. Onset iii. Course iv. Associated circumstances v. Relationship to caregiver and environmental stressors b. Is the behavior a symptom of a new condition, preexisting medical condition, or an adverse drug event? i. An isolated behavioral disturbance can be the sole presenting symptom for many acute conditions such as PNA, UTI, angina, acute pain, constipation, DM ii. Basic needs-can precipitate disturbance c. Is the behavior related to an environmental stimulus? i. Change in routine, time zones, new roommate d. Does the behavioral disturbance result from stress in the patient caregiver relationship? e. If not related to identifiable cause or environmental precipitant i. Brain deterioration f. Lewy body dementia (Extremely sensitive to extrapyramidal adverse events of antipsychotic medications) |
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Treatment approach (3)
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a. Environmental and caregiver interventions
b. Non pharm is first line treatment c. Daily routine and introducing meaningful activities is vital |
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Treatment of Mood disturbances in dementia:
When should you start med? First line? |
a. Patients with depression that lasts >/ 2 weeks and that results in significant distress should strongly be considered for a trial of antidepressant
b. If s/s last > 2 months after initiation of behavioral interventions, antidepressant is warranted c. First line: SSRIs d. Second line: venlafaxine, bupropion, mirtazapine, and TCAs |
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Tx of manic like symptoms
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6. Manic like Behavioral symptoms
a. Divalproex sodium i. Monitor for sedation, ataxia, falls ii. Check LFTS, CBC with platelets prior to therapy, at each dose increase, and 6 months after b. Alternatives: carbamazepine, lamotrigine, lithium |
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Tx of Disturbances in sleep
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a. Begin with sleep hygiene
b. Trazadone or mirtazapine at bedtime can be used c. Avoid benzos and antihistamines d. Zolpidem has effect on improving sleep onset |
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Tx of Hypersexuality
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a. Men-antiandrogen to suppress sexual drive
b. Oral progesterone or leuprolide acetate |
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When is a trial of a low dose antipsychotic warrented?
SE? |
If patient is physically aggressive or severely distressed, then a trial with a low dose antipsychotic medication is warranted
• Second generation antipsychotics o Risk of hyperglycemia and developing DM o Weight gain |
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T/F: Melatonin is safe and effective in sleep disturbance for patients with AD
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Melatonin was not effective in sleep disturbance for patients with AD
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Cholinesterase inhibitors can exacerbate ___________. Doing this may help:
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Cholinesterase inhibitors can exacerbate insomnia
o Change dose to morning hours |
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Some AD biomarkers
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Low CSF beta amyloid, + PET increase of FDG, High CSF tau, disproportionate atrophy on structural MRI.
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