delirium, dementia, amnesia Flashcards

delirium vs dementia
Terms Definitions
is delirium a predictor of increased mortality?
yes - up to 1 year after hospitalization.
what are the 3 C's of delirium?
consciousness, cognition, and course.
what characterizes consciousness in delirium?
unaware of surroundings and disruption of attention (*separates from dementia*)
what characterizes cognition in delirium?
difficulty w/recent memory, registration, knowing who people are, disorientation, and language difficulties.
what characterizes course in delirium?
abrupt with fluctuations (waxing/waning)
do most physicians know what delirium looks like?
no - delirious pts often get sent to a psych hospital, when they need to be sent to the ER (considered a medical emergency).
what is the #1 tx for delirium?
haldol. also ativan/atypicals.
what is the pathophysiology of delirium?
decreased ACh (usually suppresses DA levels), increased DA (causes the language/memory/orientation/fluctuation of attention problems - target for tx), and disordered melatonin levels (delta sleep is not present - not the same w/dementia).
what are structural etiologies for delirium?
CVA, intracranial lesion, subdural hematoma
what are infectious etiologies for delirium?
urosepsis (common in elderly pts), pneumonia, and CNS infections such as AIDS defining infections
what are metabolic etiologies for delirium?
hyper/hyponatremia, hyper/hypoglycemia, hyper/hypocapnia, hyper/hypocalcemia, hypoxia (esp in COPD/emphysema), and alcohol withdrawal
what are iatrogenic etiologies for delirium?
BZDs (often overused), anticholinergics (often overused), analgesics, H2 blockers, digoxin, antiepileptics, and steroids
how is delirium assessed?
confusion rating scale, clinical assessment of confusion, delirium rating scale etc. CAM-ICU for ventilated pts.
what are risk factors for pts in the ICU?
HTN, smoking hx, bilirubin level, morphine/ativan use, and rooms w/o windows.
what characterizes delirium in ventilated pts?
this carries a 3x risk of death (after controlling for co-morbidities, illness, severity, coma, and medication use).
what are the 4 basic principles in delirium tx?
*tx underlying condition, avoid casual factors, support to prevent further physical/cognitive decline, and control aggressive behaviors.
what characterizes use of haldol in tx of delirium?
this DA2 receptor blocker is primary tx for delirium @ low doses as it corrects the underlying neurochemical issue (increased DA).
can BZDs help w/delirium?
*only if the delirium is due to alcohol withdrawal (used in alcohol withdrawal because it is a GABA-ergic, hyperglutamatergic situation which can be reversed by BZDs). otherwise BZDs have no effect on the neurochemical imbalance, disinhibit the pt and add to memory issues.
what characterizes the atypical antipsychotics in tx of delirium?
zyprexa and risperidol have been shown to be as efficacious as haldol, but haldol is cheaper, safer (less side effects), and can be used in lower doses.
what characterizes consciousness in delirium vs dementia?
delirium: decreased or hyper alertdementia: alert
what characterizes orientation in delirium vs dementia?
delirium: disorganized thoughtdementia: disoriented (but lack disorganized thought)
what characterizes course in delirium vs dementia?
delirium: fluctuating (moments where ok, mistaken for psychosis)dementia: steady slow decline
what characterizes onset in delirium vs dementia?
delirium: acute/ sub-acutedementia: chronic
what characterizes attention in delirium vs dementia?
delirium: impaired, can’t sustain shift or focus attentiondementia: usually normal
what characterizes psychomotor in delirium vs dementia?
delirium: usually agitated, but possibly lethargic as in renal failure (high mortality in lethargic delirious patients because don’t present as a problem or get attention)dementia: usually normal
what characterizes hallucinations in delirium vs dementia?
delirium: perceptual disturbances commondementia: usually not present, exception of the rule when occur
what characterizes sleep-wake-cycle in delirium vs dementia?
delirium: abnormaldementia: normal
what characterizes speech in delirium vs dementia?
delirium: slow, incoherentdementia: aphasic, anomic, difficulty finding words
what are the inherited types of dementia?
wilson disease, adrenoleukodystrophy, and gaucher disease
what characterizes wilson disease?
this is an autosomal recessive disease which leads to *hepato-lenticular degeneration: copper deposits in the liver and lenticular nucleus (globus pallidus and putamen) of the basal ganglia due to a decrease in the enzyme which binds copper to ceruloplasmin. pts will have myoclonic movements, memory deficits, language problems, and dementia over time. often seen in young pts. dx: *kayser-fleischer rings (around iris) and *decrease in serum ceruloplasmin.
what is adrenoleukodystrophy?
in this x-linked disease, fatty acid chains deposit in the CNS, adrenal glands and testes = early onset dementia.
what is gaucher disease?
a deficiency in glucocerebrosidase which results in lysosomal packaging problems = lipid deposits in the spleen, liver, kidney, lung, and CNS = dementia at an early age.
what are the toxic metabolic types of dementia?
wernicke-korsakoff, B12 deficiency, hypothyroidism, and hypercalcemia
what can lead to hypercalcemia and thus dementia?
paraneoplastic syndrome (small cell lung CA). if Ca++ goes above certain levels = dementia, which when the Ca++ imbalance is treated, goes away.
can hypothyroidism present as severe memory problems?
yes, which is usually hashimoto's
how does B12 deficiency lead to dementia?
B12 is necessary for glial cells and nutritional support of neuronal bodies. neurons in the diencephalon and mamillary bodies are particularly vulnerable to B12 deficiency (*memory problems). B12 deficiency also leads to pernicious anemia. gastric bypasses can cause B12 deficiency.
what is wernicke delirium/korsakoff dementia?
wernicke: potentially reversible delirium due to thiamine (B1) deficiency characterized by *ataxia and *disconjugate gaze (affects medial longitudinal fasiculus). may occur if alcoholic gets dextrose before thiamine. korsakoff: potentially reversible dementia due to thiamine deficiency characterized by thiamin deficiency over a long period of time affecting the mammillary bodies and diencephalon = *memory problems which the pt will often confabulate to fill in.
what are the degenerative types of dementia?
alzheimer's (most common overall dementia), vascular, lewy body, parkinson's, frontotemporal (pick disease), and huntington's
what characterizes alzheimer's disease?
this, most common form of dementia is progressive to incapacity and death. initially newly aquired info is lost, then later language, abstraction and executive functioning. 20% have delusions and hallucinations. only a clinical dx, can only be confirmed by autopsy. neuroimaging is nonspecific (dilated lateral ventricles, widening of cortical sulci, mild atrophy - hypometabolism in temporal and parietal lobes). genetics: APP on chr 21, presenilin 1 on chr 14, presenilin 2 on chr 1, and APOE on chr 19 (polygenetic disease). pathology: atrophy of cerebral cortex (frontal/temporal/parietal), earliest cell loss in entorhinal area, basal nucleus of meynert cell loss (ACh center in brain), senile/beta amyloid plaques, and neurofibrillary tangles. tx: acetylcholinesterase inhibitors.
what characterizes dementia due to vascular disorders?
this is the second leading cause of dementia. it is due to a series of ischemic strokes occurring in key areas of the brain (basal ganglia, lenticulate nucleus) affecting memory, executive function, behavior. risk increases 5% per year after ischemic strokes. vascular dementia has the soft symptoms of memory problems (like alzheimers), but also the hard symptoms of focal weakness/aphasia/dysnomia which can be used to localize the stroke.
what characterizes parkinsons/lewy body dementia?
parkinsons: alzhiemer disease changes, lewy bodies (cortical/subcortical intracytoplasmic inclusions esp in basal ganglia), and *primary nigral degeneration. lewy body dementia: *rapid cognitive decline, visual hallucinations, parkinsonism (cogwheel rigidity, resting tremor, postural instability, akinesia/bradykinesia), and sensitivity to neuroleptics (like haldol - b/c already low on DA).
what characterizes frontotemporal dementia?
this is rare. mutations on chr 17 (tau gene). initial presentation (unique to this dementia): personality changes, speech disturbances, inattentiveness, +/- extrapyramidal signs, atrophy of the frontal, then temporal poles, and deterioration of memory/executive function. also pick bodies (intraneuronal) may be present as pick disease is a type of frontotemporal dementia.
what characterizes huntington disease?
trinucleotide/CAG repeats, autosomal dominant, symptoms start at 35-40, choreic movements (proximal/distal/axial - caudate nucleus degeneration), personality changes, and dementia. there is a genetic phenomenon called anticipation w/huntingtons where symptoms come on earlier and become more severe from one generation to the next.
what characterizes creutzfeldt-jakob disease?
this is due to prions (proteinaceous infective agents/no DNA/RNA) which cause *myoclonus, *periodic EEG complexes (sharp waves), and *dementia. often seen in elderly pts.
what are the infectious types of dementia?
HIV dementia complex and prion related disease (CJD, gerstmann-straussler-scheinker, fatal familial insomnia)
what characterizes HIV dementia complex?
apathy, memory loss, *cognitive slowing before other neurologic changes (but is also subcortical), neurological abnormalities, frontotemporal atrophy, *multinucleated giant cells, *microglial nodules, and *perivascular infiltrates. on imaging: cortical atrophy (often seen in young pts). tx: supportive.
what are the reversible dementias?
B12/folate deficiency (increased incidence w/gastric bypasses), neuroborreliosis (cognitive deficits, memory problems, behavioral issues, depression), neurosyphillis (latent infection, tx:PCN), normal pressure hydrocephalus (magnetic gait, due to clogged arachnoid vestibules), hypothyroidism, and major depression (pseudodementia)
what generally characterizes the amnestic disorders?
memory loss w/preserved intellect due to injury or dysfunction of the hippocampus/other parts of limbic system. may be transient or permanent.
what characterizes the transient amnestic disorders?
wernicke-korsakoff/blackouts, head trauma (concussions), medications (any GABA-ergic: BZDs, barbiturates, anticonvulsants), partial complex seizures (post-ictal phase), transient global ischemia (vascular insufficiency of the temporal lobes = limbic ischemia), and ECT
what characterizes the permanent amnestic disorders?
wernicke/korsakoff, HSV encephalitis, severe head trauma (contusions) , kluver-bucy (congenital absence of temporal lobe), and paraneoplastic limbic encephalitis (usually small cell lung CA).
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