AMS 2

Question 1

Sxs of what?

• Autonomic hyperactivity (diaphoresis, tachycardia, systolic HTN)
• Tremors
• Insomnia
• Transient hallucinations
• Nausea or vomiting
• Psychomotor agitation, restlessness
• Anxiety
• Seizures
• Loss of appetite / rejection of all food
• Confusion

Answer 1

Acute Alcohol Withdrawal

Question 2

Tx what w/ Benzos??

AMS is never tx w/ Benzos, but this is the 1 exception.

Answer 2

Acute Alcohol Withdrawal

Question 3

Result of what?

• Medical emergency manifest by extreme autonomic hyperactivity w/ delirium
• Can have psychosis, agitation, withdrawal seizures
• Hyperadrenergic activity –> cause of mortality (if not tx appropriately)

Answer 3

Delirium Tremens (DTs)

(Severe Alcohol Withdrawal)

Question 4

W/ Delirium Tremens from Severe Alcohol Withdrawal, what is the usual cause of mortality if pt is not treated appropriately?

Answer 4

Hyperadrenergic activity

Question 5

Wernicke’s Encephalopathy

• Medical emergency caused by ____.
• Characterized by what 3 things?
• Most cases associated w/ which 2 things?

Answer 5

• Thiamine deficiency
• Ophthalmoplegia / Ataxia / Confusion
• Alcoholism / Malnutrition (or both)

Question 6

Failure to tx/recognize Wernicke’s Encephalopathy may result in which 2 things?

Answer 6

• Death
• Permanent neurologic impairment

Question 7

Wernicke’s Encephalopathy

• What are the 2 main treatments?
• Tx if associated w/ ETOH?

Answer 7

• Thiamine & Multivitamin
• Benzos if ETOH

Question 8

A toxin of AMS called Anti-Freeze

Answer 8

Ethylene glycol

Question 9

2 types of tests for AMS to test for Toxins

Answer 9

• Urine Drug Screen
• Serum Screening

Question 10

Which test?

• Opioids
• Benzos
• Cocaine
• THC
• Barbiturates
• Amphetamines/Methamphetamines
• TCAs
• Buprenorphine

Answer 10

Urine drug screen

Question 11

Which test?

• Acetaminophen
• Salicylate
• Carboxyhemoglobin
• Digoxin
• Lithium
• Valproic acid
• Iron
• Ethylene glycol
• Lead / mercury

Answer 11

Serum screening

Question 12

Management of AMS

Address the ABCs:

Answer 12

• Airway
• Breathing
• Circulation

Question 13

What 7 things need to be addressed before initiating interventions for AMS?

Answer 13

• VS
• mental status
• Pupil size
• skin temp
• pulse ox
• cardiac monitoring

Question 14

Why do you give Thiamine in the SNOT cocktail before giving glucose?

Answer 14

To avoid inducing Wernicke-Korsakoff Syndrome

Question 15

Tx of AMS is: Identify underlying cause and tx this underlying cause

• what is the “SNOT” cocktain for pts w/ AMS?

Answer 15

• Sugar (glucose)
• Naloxone (Narcan)
• Oxygen
• Thiamine

Question 16

Which condition?

• A progressive intellectual decline
• NOT due to delirium or psychiatric disease
• 4 types

Answer 16

Dementia

Question 17

• 5 risk factors of Dementia
• What are the 4 types?

Answer 17

• Age >65
• Family hx
• Vascular Disease
• DM
• Hx of significant head injury

Four Types:

• Alzheimers (MC)
• Vascular dementia
• Dementia w/ Lewy Bodies
• Frontotemporal dementia (Luis)

Question 18

Dementia

• Typically begins after age ___.
• Prevalence doubles every __ yrs after age ___.
• By ___ y/o approximately 50% have some form of dementia
• Cause is mostly acquired or genetic?
• More prevalent among men or women?

Answer 18

• 65
• 5 years after age 65
• 85 y/o
• Acquired, (some genetic for early onset)
• Women

Question 19

_____ is the most common form of dementia.

• Major public health issue
• How is definitive dx made?
• What is the only therapy available?

Answer 19

Alzheimer Disease

• Autopsy or brain biopsy
• Symptomatic therapies

Question 20

Which condition?

• Type of progressive dementia caused by microscopic deposits that damage brain cells over time

Answer 20

Dementia w/ Lewy Bodies

Question 21

Lewy Bodies are found in Dementia w/ Lewy Bodies and what other 2??

Answer 21

• Alzheimer Disease
• Parkinson Disease (more common in this one)

Question 22

Dementia w/ Lewy Bodies

• Deposits of beta-amyloid?
• Twisted fiber of tau protein?

Answer 22

• Plaques
• Tangles

Question 23

Which condition?

• Caused by impaired blood flow to the brain
• Often occurs after stroke
• Multifocal ischemic change
• “dramatic onset” - Impairment is often more sudden than Alzheimer Dz

Answer 23

Vascular Dementia

Question 24

3 risk factors of Vascular Dementia

Answer 24

• HTN
• HLD
• Smoking

Question 25

Dementia have short or long term memory loss?

Answer 25

Short

Question 26

* Pts w/ ____ are susceptible to episodes delirium. * Recognition of ____ is not possible until \_\_\_\_\_. * ___ is typically dx in what setting? * Pt should be stable when diagnosed, not acutely ill.

Answer 26

* Dementia * Dementia / the delirium lifts * Dementia / Outpatient setting

Question 27

* ____ can lead to impaired cognition in patients w/ depression or anxiety * (--\> poor ___ and \_\_\_\_) * ___ sxs should improve w/ tx * Can be early symptom of \_\_\_\_\_\_. * If untreated, _what disorder_ may predispose an individual to age related dementia?

Answer 27

* **Psychiatric disease** * poor focus & concentration * psychiatric sxs * dementia * Persistent modd disorder

Question 28

Although ____ and/or ___ are signs of both Delirium and Dementia, these are different conditions.

Answer 28

* Confusion &/or Disorientation

Question 29

* Acute confusional state * Is potentially reversible * Usually occurs over a period of days to months

Answer 29

Delirium

Question 30

* Slow & insidious * Progresses slowly over months to years * NOT reversible * (can slow sxs w/ meds, but cannot be cured)

Answer 30

Dementia

Question 31

* What needs to be established when pt presents w/ Dementia? * Document pt's current ability to complete \_\_\_\_.

Answer 31

* Time of symptom onset * Activities of daily life (ADL)

Question 32

**Dementia psych workup:** * \_\_\_\_ * Periodic screening for pts ___ y/o or over * Evaluation by \_\_\_\_\_\_.

Answer 32

* MMSE 70 * trained neuropsychologist

Question 33

**What test for Dementia is indicated if:** * Pts w/ new / progressive complaint * ___ is preferred test * ____ is used to r/o amyloid pathology

Answer 33

**Brain imaging** * MRI preferred * Positive-emission tomography (PET)

Question 34

7 labs to obtain for Dementia workup

Answer 34

* Serum B12 * TSH * RPR * CBC * CMP Lipids * ApoE gene testing

Question 35

What lab should you order if Alzheimer disease is in differential? Why?

Answer 35

ApoE gene testing (esp young patients bc/ good to catch early to tx)

Question 36

2 treatments for Dementia

Answer 36

* Aerobic exercise (45 mins) * Frequent mental stimulation

Question 37

Tx for Dementia w/ Lewy Bodies (Small effect on cognition, mood, behavior)

Answer 37

Memantine

Question 38

3 treatments for Alzheimer Disease and what type of drug they are.

Answer 38

**Cholinesterase Inhibitors** * Donepezil (mild to moderate dz) * Rivastigmine * Memantine (moderate to severe dz)

Question 39

**Mood/Behavioral tx for Dementia** * _____ are generally safe * Avoid ____ due to anticholinergic effect * _____ for insomnia

Answer 39

* SSRI * Paroxetine * Trazadone

Question 40

What is the name of a Psychostimulant used for apathy for select patients w/ Dementia?

Answer 40

Methylphenidate

Question 41

* ____ is the most common cause of rapidly progressive dementia * ___ gene can test for familial susceptibility for ____ disease

Answer 41

* Creutzfeldt-Jakob disease * PRNP / Prion Disease

Question 42

Driving and Dementia

Answer 42

* Recommended to stop driving * Most states have laws concerning dementia/driving

Question 43

**Dementia** * Admit all pts w/ ____ to tx underlying cause * Refer all pts w/ new cognitive decline to \_\_\_\_.

Answer 43

* delirium * Neurology