Dementia 2010

1. Dementia 2010

2. Mild cognitive impairment is defined as impairment of _______ beyond that expected for a person’s age.(A) Information processing speed (B) Memory(C) Executive functioning (D) Attention

3. Answer • (B) Memory

4. Dementia is a syndromal term that refers to which of the following?(A) Loss of cognitive function associated with impaired daily functioning(B) Marked change in emotions and temperament(C) Neurologic dysfunction(D) All the above

5. Answer • (D) All the above

6. An imaging report notes “white matter changes consistent with microvascular disease”; this _______ the diagnosis ofvascular dementia.(A) Establishes (B) Does not establish

7. Answer • (B) Does not establish

8. Lewy body dementia is characterized by:1. Insidious onset and relentless progression of cognitive dysfunction2. History of stroke3. Fluctuating cognitive impairment4. Dysautonomia with unexplained falls5. Formed and/or microhallucinations(A) 1 (B 2,3 (C) 3,4,5 (D) 2,3,4,5

9. Answer • 3. Fluctuating cognitive impairment • 4. Dysautonomia with unexplained falls • 5. Formed and/or microhallucinations • (C) 3,4,5

10. The hallmark of frontotemporal dementia is:(A) Marked change in personality or language(B) Early severe cognitive impairment(C) Loss of executive functioning

11. Answer • (A) Marked change in personality or language

12. The diet believed to be most beneficial for brain health is the equivalent of the _______ diet.(A) South Beach (B) Pritikin (C) Mediterranean (D) Vegan

13. Answer • (C) Mediterranean

14. If cognitive impairment resolves after treatment of depression, there is little risk that the patient will later developdementia.(A) True (B) False

15. Answer • (B) False

16. A longer interval between the diagnosis of depression and that of Alzheimer disease (AD) _______ the risk fordeveloping AD.(A) Increases(B) Decreases(C) Has no association with

17. Answer • (A) Increases

18. In evaluating a patient for dementia, which of the following are significant findings?1. Significant weight loss2. Urinary incontinence3. Unexplained falls4. History of stroke, seizure, or head injury with loss of consciousness(A) 1,3 (B) 1,3,4 (C) 3,4 (D) 1,2,3,4

19. Answer • 1. Significant weight loss • 2. Urinary incontinence • 3. Unexplained falls • 4. History of stroke, seizure, or head injury with loss of consciousness • (D) 1,2,3,4

20. Select the correct statement about obtaining neuroimaging of patients with depression in mid to late life:(A) All require neuroimaging(B) None require neuroimaging(C) No hard and fast rule exists

21. Answer • (C) No hard and fast rule exists

22. Of the following, which is considered the key indicator that a patient is suffering from delirium?(A) Impaired recall (B) Visuospatial impairment (C) Fluctuating attention(D) Visual hallucinations

23. Answer • (C) Fluctuating attention

24. Thiamine deficiency typically presents as enlargement of the _______ on magnetic resonance imaging.(A) Sulci (B) Mammillary bodies (C) Caudate nuclei(D) Subarachnoid space

25. Answer • (B) Mammillary bodies

26. Comatose patients without involvement of the deep gray matter of the thalamus are typically able to:(A) Localize painful stimuli (B) Track faces or fingers (C) Sit or stand (D) All the above

27. Answer • (A) Localize painful stimuli

28. In patients displaying altered mental status, nystagmus across the vertical plane typically indicates:(A) Metabolic disorder (B) Delirium (C) Parasympathetic overactivity (D) Structural pathology

29. Answer • (D) Structural pathology

30. Symptoms of bleeding into the subarachnoid space include:(A) Chemical meningitis and delirium (B) Aphasia and tremor (C) Horizontal nystagmus and myoclonus (D) All the above

31. Answer • (A) Chemical meningitis and delirium

32. Patients with Alzheimer disease typically exhibit loss of recent memory, but unlike with delirium, their_______ is frequently preserved.(A) Attention span (B) Visuospatial cognition (C) Abstract reasoning (D) Motor skills

33. Answer • (A) Attention span

34. Patients who score _______ on a Mini-Mental State Examination (MMSE) are considered to have milddementia.(A) 30 (B) 20 (C) 10 to 20 (D) <10

35. Answer • (B) greater than or equal to 20

36. Studies show that driving abilities significantly deteriorate once a patient with dementia scores _______ onthe MMSE.(A) <25 (B) <20 (C) <15 (D) <10

37. Answer • (B) <20

38. Acting as a caregiver for an individual with dementia is associated with a high likelihood of developing:(A) Post-traumatic stress disorder (B) Acute stress disorder (C) Anxiety and depression (D) Adjustment disorder

39. Answer • (C) Anxiety and depression

40. In patients with advanced dementia, feeding tubes reduce the rates of aspiration pneumonia and are associatedwith measurable increases in survival.(A) True (B) False

41. Answer • (B) False

42. Delerium • the ability to provide lucid history with normal orientation, attention, recent recall, and speech eliminates the possibility of delerium • A history that suggests cognitive problem necessitates methodical mental status examination • In the setting of altered mental status, signs on general examination indicate presence of delirium and differentiate sympathetic nervous system overactivity from underactivity • in delirium, acute cognitive changes occur over hours to days • fluctuating attention key indicator; may affect all aspects of cognition, including memory, language, and visuospatial testing

43. Diagnostic tests • memory tests unreliable after diagnosis of confused state • digit span testing—in young adults, average recall spans 7 forward and 4 backward • forward testing typically sufficient • digit span recall declines slightly with age (80-yr-old should still recall 6 digits forward) • test of recent memory—patients must retain information for short period (eg, recall 3 different objects 5 min later) • sympathetic overactivity states—eg, alcohol withdrawal, hyperthyroidism, drug effect • sympathetic underactivity—caused by eg, sedative hypnotics • history from witnesses frequently presents conflicting information due to fluctuating nature of syndrome

44. Risk factors for delirium • age >65 • baseline cognitive dysfunction (lowers threshold for delirium; prolongs recovery) establish true baseline by contacting caretakers • diminished hearing or vision • poor general health • bladder catheters (associated urinary tract infections) • new medications • Restraints • sleep deprivation; • screen for metabolic causes and sepsis

45. Dementia • poor intellectual or cognitive function with no disturbance of consciousness • older patients at risk for both delirium and dementia • patients with dementia typically • display social behavior and engage in basic conversation • similarities and differences—useful bedside test assesses abstract thinking; eg, ask patient to explain differences and commonalities between apples and oranges • delirium impairs even basic abstract thought • cognitive functioning— established by questioning family and friends after establishing cognitive baseline • ask about functional cognitive activi activities engaged in by patient (eg, finances)

46. Dementia • Visual hallucinations—frequently attributed to metabolic disorders (eg, alcohol withdrawal) • typically related to neurodegeneration in patients with Parkinson’s disease • Lewy body dementia—frequently causes visual hallucinations • may account for 15% to 25% of patients diagnosed with Parkinson’s disease • visual hallucinations increase over time; responds to carbidopa-levodopa (Sinemet), resulting in frequent misdiagnosis of Parkinson’s disease • carbidopa-levodopa causes visual hallucinations in absence of pathology • as neurodegeneration progresses, even low doses may trigger hallucinations • stroke and visual deficit—typically produces inability to see, rather than hallucinations in visual field; neurodegenerative symptoms overlap with symptoms of delirium, but persist significantly longer

47. Thiamine deficiency • presents with enlarged mammillary bodies on MRI • metabolic cause of delirium with highly specific treatment • frequently underrecognized • in autopsy studies, only 10% of patients accurately diagnosed before death expecting presence of all 3 major indicators (confusion, limitation of eye movements, truncal ataxia) frequently leads to missing diagnosis of thiamine deficiency • suspect when confusion of unknown cause present with malnourishment • deficiency typically impairs absorption, necessitating intravenous or intramuscular thiamine

48. Encephalopathy • clonus—typically elicited by rapid movement of joint or hyperreflexia • frequently occurs at ankle, occasionally entire leg • rhythmic and induced by movement • myoclonus—almost uniformly presents with asynchronous features (eg, twitching, but not rhythmic) • ongoing seizure—especially with rhythmic twitching of digit or ocular deviation to one side with nystagmoid movement • dystonia—presents as abnormal, fixed posture (typically of leg or trunk) with no rhythmic movements • postural tremor—fine high-frequency tremor when limb held against gravity; subsides at rest

49. Seizures and delirium • delirium may persist after seizure into postictal state • mimics sedative-hypnotic drug effect, but may indicate sympathetic overactivity • evaluate patient for earlier seizure • frequent subtle seizures (particularly • partial-complex type) may induce prolonged postictal state • actual seizure activity often too short-lived for observation • specific metabolic disorders predispose patients to both seizures and delirium (eg, severe hypoglycemia)

50. Receptive aphasia • patients frequently fabricate words (neologisms) or speak nonsensically • occasionally clinically indistinguishable from delirium (neuroimaging requiered to confirm diagnosis) • majority of patients displaying receptive aphasia present with hemiparesis or visual field cuts • screen for aphasia assesses repetition, naming, and comprehension (varies with severity of delirium) • Meaningful response to any questions establishes comprehension, ruling out receptive aphasia