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46 Cards in this Set
- Front
- Back
working memory is were and is what |
prefrontal association cortex; digit sequence (5-7) |
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recent memory is where and is what |
medial temporal/diencephalic structures; hippocampus; 5 min recall |
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remote memory is where |
cortical structures |
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what is dementia, causes if abrupt and causes if insideous and progressive |
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 |
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dementia: the 5 different types |
alzheimer's; vascular dementia (can be mixed with AD); lewy body/Parkinson's disease, normal pressure hydrocephalus; alcohol induced dementias; frontotemporal dementia |
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early detection of dementia: why is it important, how do you do it |
essential to proper diagnosis= onset, qualities, progression, overlapping clinical presentation over time; history= pt, family, employer, forgetfulness versus functional decline; screening= asymptomatic not recommended |
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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? |
mild cognitive impairment |
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what is normal (typical) memory loss |
decline in mental processing speed; difficulty learning new material; demential is NOT normal and aging is NOT a disease |
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what is mild cognitive impairment (MCA) |
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) |
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what are the characteristics of dementia |
memory impairment AND aphasia, apraxia, agnosia, or impaired executive function; significant impairment in social or occupational functioning |
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what is aphasia |
inability to understand what is being said, naming items, reading and/or writing |
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what is apraxia |
inability to plan or follow certain movements (motor processing error) |
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what is agnosia |
inability to recognize familiar objects or people (sensory processing error) |
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what is executive function |
the ability to plan, initiate, sequence, and monitor complex behaviors; "he can cook an egg, but he can't make breakfast" |
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dementia versusu delerium |
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) |
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screening for dementia |
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 |
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what is the mini mental status exam, pros, cons |
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 |
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montreal cognitive assessment: what is it, pros and cons |
MoCHA 30 items; less verbal, higher sensitivity; detects mild cognitive impairment when MMSE > 27; specificity is diminished; more time consuming but better |
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clock drawing/mini cog: what is it |
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 |
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what do you do to eval for dementia |
history and physical; cognitive screening test; reversible causes; neuroimaging; history! include family, others who know over time |
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what do you look at in history |
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 |
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history: confounding factors |
hearing, anxiety, meds, sleep, delirium, family denial/concern; medical conditions (mobility impairment, incontinence, vision, undiagnosed psychiatric conditions) |
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reversible causes of demetia |
drug toxicity, metabolic, normal pressure hydrocephalus, mass lesion (subdural), infectious, endocrine, collagen vascular |
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reversible causes: labs to get |
CBC, electrolytes, liver function; thyroid stimulating hormone (TSH); B12, folate; HIV, syphilis |
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reversible causes: neuroimaging |
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 |
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reversible causes: lumbar puncture |
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 |
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neuropsychological testing |
the gold standard; psychometric specialist consultation= time consuming, expensive (court contested cases, early stage, diagnostic, guides treatment) |
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decision making capacity |
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) |
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driving: the ultimate ADL |
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 |
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dementia eval |
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 |
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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? |
NTD |
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Alzheimer's dementia (AD): risk factors |
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) |
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Alzheimer's disease (AD): what is seen in the brain |
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 |
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Alzheimer's disease: course |
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 |
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neuropsychiatric symptoms that occur late in Alzheimer's |
agitation, aggression, sleep disturbance, apathy, anxiety, disinhibition, hallucinations, delusions |
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environmental causes of dementia |
poor sensory function; unfamiliar environment; high noise and activity; comorbid illness; meds; so behavioral management, environmental changes are always first line in treatment |
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pseudodementia: what is it |
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 |
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vascular dementia |
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) |
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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? |
normal pressure hydrocephalus |
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normal pressure hydrocephalus |
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 |
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parkinsons's disease dementia |
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 |
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dementia with Lewy bodies |
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 |
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motor impairment in Alzeimers dementia (AD) |
motor symptoms= gait, motor speed, balance, activity level, occurs even in mild stages; supports over lap between AD and Lewy body dementia |
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head trauma |
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 |
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frontotemporal dementia |
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 |
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meds for dementia |
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 |