Mkgrady8 Neuro 5 Dementia Disorders

Front 1

working memory is were and is what

Back 1

prefrontal association cortex; digit sequence (5-7)

Front 2

recent memory is where and is what

Back 2

medial temporal/diencephalic structures; hippocampus; 5 min recall

Front 3

remote memory is where

Back 3

cortical structures

Front 4

what is dementia, causes if abrupt and causes if insideous and progressive

Back 4

decline in cognitive abilities to impaired functional status; abrupt or step wise (non fluctuating)= trauma/toxic metabolic, vascular, normal pressure hydrocephalus; insideous and progressive= alzheimer's, lewy body/parkinson, alcohol related

Front 5

dementia: the 5 different types

Back 5

alzheimer's; vascular dementia (can be mixed with AD); lewy body/Parkinson's disease, normal pressure hydrocephalus; alcohol induced dementias; frontotemporal dementia

Front 6

early detection of dementia: why is it important, how do you do it

Back 6

essential to proper diagnosis= onset, qualities, progression, overlapping clinical presentation over time; history= pt, family, employer, forgetfulness versus functional decline; screening= asymptomatic not recommended

Front 7

clinical case: 72 yoformer schoolteacher frequently “losing her keys”; Livesalone, pays bills, manages medications; Normalphysical and labs; Mentalstatus exam score= Low normal; what is this?

Back 7

mild cognitive impairment

Front 8

what is normal (typical) memory loss

Back 8

decline in mental processing speed; difficulty learning new material; demential is NOT normal and aging is NOT a disease

Front 9

what is mild cognitive impairment (MCA)

Back 9

NEED TO KNOW THIS ONE; cognitive impairment in aging that does not meet the criteria for dementia= memory impairment w/o functional loss; seen in 15-20% of adults >65 years= 80% diagnosed with dementia in 8 yrs, is this 'pre dementia'? maybe, treatment based on clinical condition AND pt centered discussion (cholinesterase inhibitor)

Front 10

what are the characteristics of dementia

Back 10

memory impairment AND aphasia, apraxia, agnosia, or impaired executive function; significant impairment in social or occupational functioning

Front 11

what is aphasia

Back 11

inability to understand what is being said, naming items, reading and/or writing

Front 12

what is apraxia

Back 12

inability to plan or follow certain movements (motor processing error)

Front 13

what is agnosia

Back 13

inability to recognize familiar objects or people (sensory processing error)

Front 14

what is executive function

Back 14

the ability to plan, initiate, sequence, and monitor complex behaviors; "he can cook an egg, but he can't make breakfast"

Front 15

dementia versusu delerium

Back 15

dementia= insidious onset, not fluctuating, no lack of attention; difficult differential when neuropsychiatric symptoms are present; dementia is a significant risk factor for delirium (including sundowning)

Front 16

screening for dementia

Back 16

sensitive and specific= harm of false positive; reliable= administration and interpretation; validated in pop= race, language, education, etc; efficiency= primary care versus specialty care; screening tests ARE NOT diagnostic

Front 17

what is the mini mental status exam, pros, cons

Back 17

30 items (memory, language, visuospatial); pros= widely used, 5-10 min; cons= normative scoring, sensitivity 18% for MCl and 78% for dementia (cut off is <26 for dementia), requires pt cooperation, copywrite

Front 18

montreal cognitive assessment: what is it, pros and cons

Back 18

MoCHA 30 items; less verbal, higher sensitivity; detects mild cognitive impairment when MMSE > 27; specificity is diminished; more time consuming but better

Front 19

clock drawing/mini cog: what is it

Back 19

rapid clinic tool= low sensitivity, not diagnostic; "draw a clock face showing the time is 10 mins after 11 o'clock"; mini cog additional of 3 item recall= clock score wither 0 or 2, one point for each object recalled, <3/5 points possible impairment

Front 20

what do you do to eval for dementia

Back 20

history and physical; cognitive screening test; reversible causes; neuroimaging; history! include family, others who know over time

Front 21

what do you look at in history

Back 21

time course= initial onset, pattern; function (ADLs, IADLs)= IADLs are medication management, bill paying, shopping, cooking, driving, ADLs are dressing, bathing, toileting, eating, transfers; behavioral/social function; depression; obstructive sleep apnea symptoms

Front 22

history: confounding factors

Back 22

hearing, anxiety, meds, sleep, delirium, family denial/concern; medical conditions (mobility impairment, incontinence, vision, undiagnosed psychiatric conditions)

Front 23

reversible causes of demetia

Back 23

drug toxicity, metabolic, normal pressure hydrocephalus, mass lesion (subdural), infectious, endocrine, collagen vascular

Front 24

reversible causes: labs to get

Back 24

CBC, electrolytes, liver function; thyroid stimulating hormone (TSH); B12, folate; HIV, syphilis

Front 25

reversible causes: neuroimaging

Back 25

CT usually adequate= rule out reversible causes (bleeding), regional/global atrophy late finding; MRI if vascular dementia suspected= will minimize cardiovascular risk anyway, diagnosis of midbrain (lacunar) stroke, may change management (risk/benefit); PET/fMRI= highly sensitive for early dementia, cost inhibiting, area of research

Front 26

reversible causes: lumbar puncture

Back 26

B amyloid, tau protein levels= invasive, inadequate specificity, area of research (minimum invasive LP) blood, saliva B amyloid, tau levels; normal pressure hydrocephalus; neurosyphilis, Creutzfeldt-Jakob rare; EEG may be considered= seizure disorders rare cause

Front 27

neuropsychological testing

Back 27

the gold standard; psychometric specialist consultation= time consuming, expensive (court contested cases, early stage, diagnostic, guides treatment)

Front 28

decision making capacity

Back 28

licensed physician in Texas certifies capacity in deposition to court= probate jude determines competency; evolution of partial competency= how much money can be managed, capable of independent living, ability to consent for med treatment (guardian assigned by court, power of attorney designated by individual)

Front 29

driving: the ultimate ADL

Back 29

laws variable by state (texas)= age 79+, renew in person every 6 yrs may require vision test, med eval, citizen report to DPS requires a panel eval (family responsibility); driving skills largely preserved= multiple fender benders, difficulty navigating new places, limiting one's driving is a major risk factor

Front 30

dementia eval

Back 30

screening; differential diagnosis; treatment= a pt centered decision; management= family centered decision (home safety eval, independent living, driving, capacity); reimbursement? society centered= long term care, memory unit

Front 31

clinical case: 89 year old woman seen with herdaughter visiting from out-of-state, who notes malnourishment and “lots oftrouble with her memory.” Her daughter is concerned because she never wants toleave the house. She notes that “things have been getting worse” lately; She takes no medications and hasn’tseen a doctor in several years.; what is it?

Back 31

NTD

Front 32

Alzheimer's dementia (AD): risk factors

Back 32

most common dementia; age, family history (early onset only), gender (female), vascular risk factors (hyperlipidemia), head trauma, genetic (AD in relative= 4 fold increase), ethnicity or education (no clear evidence)

Front 33

Alzheimer's disease (AD): what is seen in the brain

Back 33

senile plaques (beta amyloid peptide)= most common in neocortex; genetics related to apolipoprotein E4; amyloid precursor protein (APP)=APP -- secretase --> beta amyloid; chromosome 1, 4, 21; neurofibrillary tangles= highly phosphorylated tau proteins; neuronal and synaptic loss= direct cause of dementia

Front 34

Alzheimer's disease: course

Back 34

predictable loss of function over time; early stages= progressive memory loss, impairment in language in 40-50%, impaired executive dysfunction; moderate= decline in function, personality changes, increasing passivity, apathy, restlessness/hyperactivity; severe or late stage= loss of language function, increased behavioral symptoms, poor gait (falls); diagnosis is often late= difficult to differentiate type of dementia

Front 35

neuropsychiatric symptoms that occur late in Alzheimer's

Back 35

agitation, aggression, sleep disturbance, apathy, anxiety, disinhibition, hallucinations, delusions

Front 36

environmental causes of dementia

Back 36

poor sensory function; unfamiliar environment; high noise and activity; comorbid illness; meds; so behavioral management, environmental changes are always first line in treatment

Front 37

pseudodementia: what is it

Back 37

depression is common (10-15%) in the elderly; symptoms of apathy, memory impairment, disrupted sleep may mimic dementia; rule out depression before diagnosing dementia but keep in mind that people with dementia can also have depression

Front 38

vascular dementia

Back 38

KNOW THIS ONE; step wise progression; risk factors= sub cortical changes; motor/constructive and attention/concentration deficits; verbal skills are relatively preserved; minimize cardiovascular risk factors= hypertension, diabetes, smoking, hyperlipidemia; evaluate for atrial fibrillation and carotid stenosis (anticoagulation to reduce risk of thromboembolic disease)

Front 39

clinical case: 74 year old man with difficultyconcentrating for 3 months, now requiring assistance with dressing. Wife alsoreports 3 falls in the past month and increasing urinary incontinence. what is it?

Back 39

normal pressure hydrocephalus

Front 40

normal pressure hydrocephalus

Back 40

abnormality of production, absorption, or flow of cerebrospinal fluid resulting in ventricular dilitation; classic triad of gait or balance disturbance, urinary incontinence, and cognitive deficits; potentially reversible with intraventricular shunt

Front 41

parkinsons's disease dementia

Back 41

cognitive decline one decade after motor symptoms; occurs in 33% of Parkinson's pts predictors= older onset, non tremor or bilateral prominent; diagnostic challenge= parkinson's meds affect cognition, substantial coexisting Alzheimer's disease

Front 42

dementia with Lewy bodies

Back 42

M>F; onset 50-80 yrs; early visual hallucinations (delusions); fluctuating cognitive impairment; early visuospatial and attention deficits; REM sleep behavior disorder; Parkinsonian symptoms (70%)= bilateral often no tremor, falls, depression, autonomic dysfunction; neuronal spherical intracytoplasmic inclusions of alpha synyclein; apolipoprotein E4 at autopsy= 50% show Lewy bodies, widely underdiagnosed; often misdiagnosed as psychiatric illness= hypersensitivity to antipsychotic meds

Front 43

motor impairment in Alzeimers dementia (AD)

Back 43

motor symptoms= gait, motor speed, balance, activity level, occurs even in mild stages; supports over lap between AD and Lewy body dementia

Front 44

head trauma

Back 44

head trauma is a risk factor for both Alzheimers dementia and parkinsons disease; damage to substantia nigra; accelerated neurodegeneration= upregulation of amyloid genes, increased tau phosphorylation

Front 45

frontotemporal dementia

Back 45

NEED TO KNOW THIS ONE; mean onset mid 50s; insidious change in personality or inappropriate behavior; sparing of visuospatial skills and verbal memory; profound, bilateral frontal lobe atrophy and hypometabolism on PET scan= tau and non tau pathology progressive to temporal cortices and basal ganglia

Front 46

meds for dementia

Back 46

haldol if necessary; maybe an atypical= risperidone, olanzapine, quetiapine; insomnia then trazadone, melatonin, DO NOT USE benzodiazepines or antihistamines; mood stabilizer for agitation= valproic acid; for depression and behavioral symptoms use an SSRI