Neurocognitive Disorders

Cognitive impairment

A decline in cognitive function including memory loss, decreased attention span, difficulty problem-solving, visuospatial difficulties, behavioral changes, learning/retention, judgement, reasoning

Delirium

What is characterized by an alteration in attention, consciousness, and cognition with a reduced ability to focus, sustain or shift attention - RAPID

cortical vs. subcortical mechanisms, ACh Drugs (reverse with pyridostigmine)

Pathogenesis for Delirium

elderly, inpatient (1/3), sick

What patient population is delirium common in?

fast and usually fluctuates, includes perceptual disturbances and a reduced ability to focus/maintain attention

How does delirium develop?

Drugs/alcohol (including withdrawals), infection (UTI), neurological disease (stroke, seizures), metabolic disturbances (hypoglycemic, hyperglycemic, electrolyte imbalance), medications

What are some causes of delirium?

Underlying neurological disorders (superimposed dementia (20-90%), stroke, parkinson), older age, sensory impairment

Risk factors for delirium

Short-term memory loss, anxiety, irritability, perceptual disturbances (hallucinations), psychomotor restlessness, sun-downing, Isn’t acting right

What are the symptoms of delirium?

Full head to toe - vitals, head, lung, chest, abdomen, GU, extremities, neuro, skin

Describe the physical exam for delirium

Sun downing

A phenomenon when patients have mild/moderate delirium at night that is more common in patients with dementia and characterized by increase confusion, disorientation, agitation, mood swings, hallucinations, paranoia, and difficulty sleeping

Distractibility

What is the HALLMARK of delirium

Distractibility, disorganized/tangential speech, drowsiness, lethargy, semi-comatose, Hypervigilance (EtOH or sedatives)

Clinical presentation of delirium includes disturbance of consciousness - what does that look like?

Decrease in level of functioning (unable to do tasks - need a baseline), dementia, perceptual disturbances, language difficulties

Clinical presentation of delirium includes change in cognition - what does that look like?

pacing, anxiety, rapid mood swings, hallucinations

The hyperactive symptoms of delirium are easiest to recognize but patients often refuse care → what does this look like?

inactivity, sluggish, drowsiness, dazed

The hypoactive symptoms of delirium are harder to recognize since patients often do not interact→ what does this look like?

CAM (confusion assessment method)

What assessment tool can you use for the diagnosis of delirium?

Acute onset + fluctuating course, Inattention, Disorganized thinking, Altered level of consciousness

What are the components of the CAM (must have the bold)?

Benzos, antihistamines, TCAs (amitriptyline), neuroleptics (clozapine), Parkinsons drugs (levodopa, amantadine), Anticholinergics, opioids (tramodol), sleeping aids, H2 blockers, steroids

What medications can cause delirium - STAR

CBC, CMP (calcium, glucose), UA with culture (Old lady UTIs ARE WACK), tox screen, B12, TSH/T4, ABG

84 y/o patient presents to the ER for AMS. Daughter reports that the patient has a PMHx of dementia, cirrhosis, and is currently on “So many medications I can’t keep up, you should have all of it.” Physical exam reveals inattention, disorganized thinking, and altered level of consciousness. What labs you want?

treatable medical illness/problem, no hx of trauma, no new focal neuro signs, patient is arousable and can follow simple commands

When should can you skip imaging in a delirious patient?

unknown cause, patient not improving with treatment of known

When is a head CT required for delirium (consider MRI if neg)?

Unknown cause with fever

When is a lumbar puncture required for delirium?

Excludes seizures, confirm metabolic/infectious encephalopathies

When is an EEG required for delirium?

Delirium tremens (alcohol withdrawal delirium)

A dangerous symptom of alcohol withdrawals that requires an ER trip characterized by tremors in the hands

ICU admit, Benzos (control agitation, prevents seizures), IV fluids, B1 (prevent werknicke’s encephalopathy)

Delirium tremens Treatment plan

Wernicke’s Encephalopathy

What type of delirium is characterized by a thiamine deficiency caused by EtOH usage (most common), malabsorption, dialysis, bariatric surgery, anorexia, AIDS, hyperemesis of pregnancy

Confusion, ataxia, horizontal nystagmus (Ophthalmoplegia)

Wernicke’s triad

Korsakoff syndrome

Wernicke’s encephalopathy + amnesia + grandiose story telling (confabulation)

BLAST the thiamine IV

Treatment plan for Wernicke’s

Dementia

A progressive decline in intellectual function WITHOUT disturbance in consciousness usually insidious and gradual in nature (usually no precipitating event)

3-15 years from onset to death

How does dementia affect life expectancy

Alzheimer’s Disease (AD - most common), Vascular dementia, frontotemporal dementia, Dementia with Lewy Bodies

Common causes of dementia

Alzheimer’s Disease (AD)

A progressive dementia with insidious onset characterized by atrophy of the cerebral cortex, beta amyloid plaques and Tau tangles

Loss of neurons and synapses and creation of neuritic plaques in the cerebral cortex and subcortical regions that leads to degeneration in the temporal, parietal, frontal cortex, and cingulate gyrus

Pathogenesis of Alzheimer’s Disease (AD)

Short term memory loss

What is the 1st and most prominent symptom of Alzheimer’s Disease (AD)

executive function, visuospatial function, language

Alzheimer’s Disease (AD) presentation includes variable deficits in

Vascular Dementia

What type of dementia results from damaged blood vessels leading to a reduce in circulation (stroke, hemorrhage, stenosis, etc)

PMHx of CVAs, abrupt onset, step-wise/progressive accumulation of deficits (depends on location), focal neuro deficits, depression

Signs of Vascular Dementia

White matter hypersensitivities (MRI), White matter hypo-densities (CT)

What imaging changes will you see on MRI and CT for vascular dementia?

Decreased concentration, forgetfulness, slowed thinking

Subcortical symptoms of Vascular Dementia

abnormal gait, focal weakness, dyscoordination

Motor symptoms of Vascular Dementia

Hx of psychiatric illness (40%), autosomal dominant pattern (10-25%)

Quirks of Frontotemporal dementia

Abnormal protein inclusions in the cytoplasm/nuclei of neuronal/glial cells, Loss of neurons, myelin and astrocystic gliosis in the frontal and temporal lobes

Pathogenesis of FTD

Tau, TAR-DNA binding protein 43

Which proteins aggregate in Frontotemporal dementia

Behavioral (50/50 protein, psychosis), Non-fluent aphasia (70% tau, language), Semantic dementia (100% TDP-43, language)

What are the variations of Frontotemporal dementia

Disinhibition - Kissing, touching, socially inappropriate, Hyperorality (snacking), compulsive behaviors (hoarding)

Hallmark of the Behavioral variant of FTD (most common type)

difficulty producing the sound (articulatory difficulty)

Hallmark of Progressive Non-Fluent Aphasia variant of FTD

impaired single-word comprehension and object naming in the setting of preserved fluency, repetition, and grammar (trouble matching words with what they mean)

Hallmark of Semantic variant of FTD

Dementia with Lewy Bodies

An abnormal collection of alpha-synuclein protein in the neurons in the brain cortex (anterior frontal lobe, temporal lobes, cingulate gyrus, insula)

Motor deficits similar to parkinson’s, AD symptoms, visual hallucinations, fluctuating delirium, visuospatial/executive cognitive disfunction, psychiatric disturbances

Symptoms of Dementia with Lewy Bodies

Short-term memory loss, Word finding difficulty, Visuospatial dysfunction, Executive dysfunction, apathy

General presentation of Dementia

Frontal, subcortical

Executive dysfunction and apathy are associated with damage in what area

Right parietal lobe

Visuospatial dysfunction is associated with damage in what area

Temporal parietal junction of the left hemisphere

Word finding difficulty is associated with damage in what area

Hippocampus

Short term memory loss is associated with damage in what area

Fam hx, chronic illness (especially vascular), head trauma, female

Risk factors for dementia

education, ongoing intellectual stimulations

Protective factors for dementia

ADLs, amount of decline, risk factors, ability to be a reliable historian, speech, depression

What do you need to find out when collecting a hx on a patient with dementia?

occult medical illness, underlying neurological condition (do a neuro exam), exclude treatable conditions, evaluate self care

What do you need to find out when collecting a physical exam on a patient with dementia?

Quick screen patients older than 70 (3 simple nouns, clock, 3 simple noun recall), MMSE if there’s any deficit, Full neuropsych

What are some screening tools for dementia?

MRI

Which imaging is preferred for dementia to r/o CVD, tumor, or structural abnormality

PET (radiolabel beta-amyloid)

Which imaging can help differentiate between AD and FTD

B12, FT4/TSH, RPR, CBC, CMP, CSF (beta amyloid decrease, tau increase)

Labs for Dementia

aerobic exercise, mental stimulation, cannot regain lost skills

Gameplan for dementia - non pharm

Cholinesterase inhibitors (donezepil, rivastigmine, galatamine)

Gameplan for dementia - pharm 1st line for AD and DLB (DOES NOT PREVENT PROGRESSION OR TREAT FTD)

Memantine (AD, DLB - no FTD), SSRI (No paroxetine), Trazodone for the insomnia (other meds can cause delirium), Methylphenidate (for apathy - may cause agitation), Delusions (resperidone, olanzapine, quetiapine - may increase fall risk)

Gameplan for dementia - pharm

r/o delirium if patient is agitated/impulsive, behavioral interventions (reorientation, distraction, mental stimulation, exercise, sleep), Benzos may worsen agitation, maximize cognitive and behavioral therapies, Stop driving

Safety concerns for dementia

prions (jakob-creutzfeldt is common), infections, toxins, neoplasms, autoimmune

If the dementia is rapidly progressive like weeks to months → what gets added to the differential

MRI, spinal tap with CSF, basics, thyroid panel, RPR, HIV, lyme, serology, rheumatology labs

Workup for rapidly progressive dementia