Dementia

Question 1

Delirium

Answer 1

1. A disturbance in attention (i.e., reduced ability to direct, focus, sustain, and shift attention) and awareness (reduced orientation to the environment).
2. The disturbance develops over a short period of time (usually hours to a few days), represents a change from baseline attention and awareness, and tends to fluctuate in severity during the course of a day.
3. Theres a disturbance in cognition (e.g., memory deficit, disorientation, language, visuospatial ability, or perception).

Question 2

Types of dementia

Answer 2

• Alzheimer’s
• Frontotemporal
• Lewy Body
• Parkinson’s Vascular
• Huntington’s
• HIV
• Traumatic Brain Injury
• Prion Disease

Question 3

Dementia causes a progressive decline in intellectual functioning severe enough to _______

Answer 3

interfere with person’s normal daily activities and social relationships

Question 4

Dementia causes progressive declines in

Answer 4

• memory
• visual-spatial relationships
• performance of routine tasks
• language and communication skills
• abstract thinking
• ability to learn and carry out mathematical calculations

Question 5

2 categories of dementia

Answer 5

Reversible and Irreversible

*Individuals must have intensive medical physical to rule out reversible types of dementia

Question 6

Reversible causes of dementia

Answer 6

"DEMENTIA" 
D-drugs, delirium 
E-emotions (depression) & endocrine disorders
M-metabolic problems
E-eye & ear problems
N-nutritional disorders
T-tumors, toxicity, trauma to head
I-infections 
A-alcohol, arteriosclerosis

Question 7

Irreversible causes of dementia

Answer 7

• Alzheimer’s
• Lewy Body Dementia
• Pick’s Disease (Frontotemperal Dementia)
• Parkinson’s
• Heady Injury
• Huntington’s Disease
• Jacob-Cruzefeldt Disease

Question 8

Alzheimer’s Dementia

Answer 8

• Insidious onset/gradual progression
• Memory & learning impairment, sometimes executive impairment
• Then perceptual-motor & language impairment
• Social cognition affected late in disease
• Gait disturbance, dysphagia, incontinence, myoclonus, seizures
• 5% Diagnosed between around age 65, prevalence increases steeply, esp in 80s
• Mean survival 10yrs after diagnosis

Question 9

Alzheimer’s dementia- About 0.1 % autosomal dominant inheritance, which have an onset before age

Answer 9

65

-This form of the disease is known as early onset familial Alzheimer’s disease

Question 10

Alzheimer’s dementia-

Most of autosomal dominant familial AD can be attributed to mutations in one of three genes:

Answer 10

• those encoding amyloid precursor protein (APP)
• those encoding presenilins 1 and 2

*Most mutations in the APP and presenilin genes increase the production of a small protein called Aβ42, which is the main component of senile plaques.

Question 11

Most cases of Alzheimer’s disease do not exhibit

Answer 11

autosomal-dominant inheritance

Question 12

Alzheimer’s dementia- environmental and genetic differences may act as risk factors. The best known genetic risk factor is the

Answer 12

inheritance of the ε4 allele of the apolipoprotein E

Question 13

know mini mental status exam

Answer 13

in other deck too

Question 14

Frontotemporal Dementia

Answer 14

• Encompasses Pick’s disease and several related illnesses.
• Insidious onset/gradual progression
• Reflect loss of frontal and temporal lobe function
• FT dementia accounts for 15% cases of dementia
• Higher proportion in individuals younger than 65
• Tau inclusions, pick bodies

Question 15

Symptoms of Frontotemporal Dementia

Answer 15

-Broad decline in insight
-Social skills, interpersonal conduct
-And executive functioning
-Mental rigidity
-Easily distractibility, labile affect and speech and language impairments
(echolalia and perseveration)
-Disinhibition
-Apathy
-Loss of sympathy/empathy
-Perseverative or compulsive behavior
-Hyperorality and diet changes

Question 16

Frontotemporal Dementia shows a prominent decline in ______, but a relative sparing of _________

Answer 16

• prominent decline in social cognition or executive abilities
• also decline in language ability, object naming, grammar
• Relative sparing of learning, memory, and perceptual-motor function

Question 17

Frontotemporal Dementia average age of onset is

Answer 17

53 years followed by fatal progression lasting less than 4 years

Question 18

Compared to Alzheimer’s disease, FT Dementia does not have impairments in

Answer 18

visual-spatial abilities – a function governed largely by the parietal lobes

• maintain their ability to copy a picture but not to draw one from their memory.
• do not lose their sense of direction, even in new surrounding
• do not manifest constructional apraxia

Question 19

FT shows prominent personality and behavioral disturbances accompanied by only relatively mild ________

Answer 19

memory impairment

Question 20

On CT/MRI, FT shows

Answer 20

• Frontal and anterior temporal lobes are atrophic. -Plaques and tangles are uncommon or absent
• Pick’s disease – neurons containing argentophilic (silver staining) inclusions (Pick bodies)

Question 21

FT has some gene mutations, 10% linked to mutant gene on _______

Answer 21

chromosome 17, which codes for tau (MAPT)

Question 22

Dementia with Lewy Bodies

Answer 22

• Cognitive decline, ≥1 yr prior to onset of parkinsonism features
• Fluctuating cognition w/ variations in attention/alertness (looks like delirium)
• Recurrent VH
• REM sleep behavior disorder
• Severe neuroleptic sensitivity (50%)
• Lewy bodies have greater distribution than in Parkinson’s

Question 23

Dementia with Lewy Bodies age

Answer 23

Older than 65

-sometimes initially diagnosed as alzheimer’s

Question 24

Pathology of Dementia with Lewy Bodies age

Answer 24

• abundance of intracytoplasmic inclusions (lewy bodies) in cerebral cortex neurons that stain with alpha- synuclein antibodies
• Concentration of lewy bodies correlates with dementia
• Similar to Alzheimer’s disease, but older individuals with nonspecific cognitive deficits.

Question 25

Non-cognitive features of Dementia with Lewy Bodies (aka-S/S)

Answer 25

- characterized by mild extrapyramidal features, masked face, bradykinesia, and gait impairment. - sudden unexpected changes in cognition, attentiveness and alertness; mimics episodes of delirium or toxic-metabolic encephalopathy - Visual Hallucinations: detailed visions of people and animals, associated with lewy bodies in the temporal lobes - Visual hallucinations also frequently develop in pts with advanced Alzheimer’s and Parkinson’s disease – but not at the onset of these illnesses

Question 26

About 50% of patients with Dementia with Lewy Bodies have REM sleep behavior disorder, which consists of

Answer 26

running, punching, and similar motions while asleep

Question 27

DLB is similar to extrapyramidal symptoms you see in Parkinson’s however DLB does not __________

Answer 27

repond to Parkinson’s treatment with L-dopa -also pt will have visual hallucinations

Question 28

DLB pt with visual hallucination can be treated with

Answer 28

- antipsychotic agents - dopamine blockers, readily produce pronounced extrapyramidal signs - small amounts of antipsychotic agents can cause EPS (extrapyramidal symptoms)

Question 29

DLB treatment- what to give for cognitive function and visual hallucinations

Answer 29

Cholinesterase inhibitors stabilize or improve cognitive function and reduce visual hallucinations for several months

Question 30

DLB treatment- what will help REM sleep behavior disturbance

Answer 30

Long acting benzodiazepines, such as clonazepam, suppresses the REM sleep behavior disturbance

Question 31

Neurocognitive disorder due to Parkinson’s

Answer 31

- Established Parkinson’s Disease prior to cognitive decline - Many diagnosed in their 60s, mild neurocognitive disorder occurs early but does not progress to major neurocognitive d/o until late * Apathy, depressed/anxious mood, hallucinations/delusions, change of personality * Lewy bodies present

Question 32

Vascular Dementia

Answer 32

- Clinically consistent with vascular etiology: 1. Onset of cognitive deficits is temporally related to cerebrovascular event 2. Evidence for decline is prominent in complex attention and frontal-executive tasks 3. Evidence of the presence of cerebrovascular disease 4. History, physical exam, and/or neuroimaging 5. Classically is acute stepwise decline in cognition

Question 33

Vascular Dementia risk factors

Answer 33

- HTN, DM, obesity, smoking, high cholesterol, high homocysteine levels - Diagnosis: MRI/CT

Question 34

Med to give for Vascular Dementia

Answer 34

Because of frequent comorbidity of Alzheimer’s Disease, cholinesterase inhibitors provide symptomatic benefit in vascular dementia

Question 35

see comparative chart

Answer 35

slide 30, screen shot in folder

Question 36

Traumatic Brain Injury

Answer 36

- LOC, post-traumatic amnesia, disorientation, neurological signs - Emotional and personality changes, physical sx (tinnitus, dizziness, fatigue) - CT/MRI– not always, but may reveal petechial hemorrhages or evidence of contusion

Question 37

HIV

Answer 37

- Need documented infection with HIV - 25% of pts with HIV have mild neurocognitive D/O - Risk: poor control of HIV - CSF – high viral load; MRI- cortical thinning, ↓ brain volume, ↓ white matter

Question 38

Prion Disease

Answer 38

- Rapid progression; most common is Creutzfeldt-Jakob - triad of dementia, myoclonus, and distinctive EEG patterns - CSF: 14-3-3 protein and tau protein - MRI: multifocal gray matter hyperintensities

Question 39

Huntington's

Answer 39

- CAG repeats on chromosome 4 - 50% will develop dementia - MRI- volume loss in basal ganglia

Question 40

Treatment for vascular dementia KNOW!

Answer 40

- preventative measures: diet and exercise, control of HTN/DM, statins may slow progression * Cholinesterase inhibitors (donepezil, rivastigmine, galantamine, tacrine); Increase Ach, modest improvement in memory and goal-directed thought * NMDA antagonist - (Memantine); Protects neurons from excessive glutamate activity, which may be neurotoxic

Question 41

Psychosocial intervention:

Answer 41

Reduce stressors, education of caregivers, safety (assess driving, prevent wandering, reduce risk of falls)

Question 42

How to manage agitation

Answer 42

* All antipsychotics have a black box warning: Risk of increased mortality when used for dementia- related psychosis – deaths due to cardiac or infectious events* - Antidepressants, cholinesterase inhibitors, non-pharmacologic (redirection, recreational therapy) antipsychotics, mood stabilizers, benzodiazepines

Question 43

Treatment for Lewy body dementia

Answer 43

use quetiapine or clozaril if need to use an antipsychotic

Question 44

Pseudodementia

Answer 44

-"Depression in old age” -Depression occurs first, then neurocognitive deficits Relatively abrupt onset -Evaluation : MSE, neuropsychological testing - Lack of effort on part of the patient – “I don’t know”

Question 45

Treatment for psuedodementia

Answer 45

Improvement with antidepressant treatment