History
Physical Exam
Tests
Management
Diagnosis
100
Which individuals should you interview?
Patient + Collateral (family members, support, GPs, etc.)
100
Why is physical exam important?
Helps us with DDX: delirium, depression, dementia
100
Neurocognitive tests
MOCA and MMSE
100
Primary management goal in treating delirium
Treat the cause
100
Differentiate mild from major neurocognitive disorder
Mild NCD: Cognitive deficits DO NOT interfere with independence in everyday activities
200
Important components of a good history
HPI, PMHx, Meds, Allergies, Hospitalizations, Past psych history, FHx, Shx
200
Physical exam for depression - describe
Mental Status Exam (ASEPTIC)
200
When to use MMSE/MOCA first?
MMSE - more specific, use when you suspect severe cognitive decline; MOCA - more sensitive, use when you suspect mild cognitive decline
200
3 important aspects of management
Medical, Safety, Support
200
A 48 year old male presents to your office with complaints of three months of “poor memory”, word finding problems, tearfulness, insomnia and feelings of panic. His mother has Alzheimer’s disease diagnosed when she was 76 years of age. He is employed as a stock-broker and feels he is not performing at his best but there have been no complaints from him superiors. He is making “lists because he is afraid to forget things.”
Depression
300
Social history
Housing, fall risk, medication administration, ADLs, iADLs, POAs
300
Physical exam for delirium
Vitals, CNS, HEENT, CVS, RESP, ABDO, SKIN, MSK
300
A patient with vascular dementia/LBD/FTD will more likely perform poorly on which sections of MMSE/MOCA?
Visuospatial/executive function
300
Common medications to treat depression
SSRIs, SNRIs, NDRIs, NASSA, TCA, MAOIs
300
An 83 year old female arrives by ambulance from a nursing home with minimal information. She is a known type 2 diabetic who also suffers from Alzheimer’s disease, hypertension and insomnia. In the last 72 hours, the nurses have found her to be markedly more agitated than usual. Her symptoms of confusion, forgetfulness and word finding problems are usually worse at night. Tonight, she has been picking at things in the air, has not recognized her immediate family members and has had urinary retention. She has a low grade fever when the nurses assess her vitals.
Delirium due to urinary retention/UTI against background of Alzheimer's disease
400
Differentiate delirium/depression/dementia on history
Delirium - acute, fluctuating course of poor attention/disorg thoughts/poor LOC, reversible, etiologies of delirium; Depression - mood symptoms preceding memory symptoms, pmhx/fhx of mood disorders, patient has insight of cognitive decline; Dementia - progressive onset, steady course, deficits in various neurocog domains, fhx, patient unaware of cognitive decline
400
Physical exam for Parkinsonian traits
TRAP, Gait (shuffling, small steps, en bloc turning, freezing), Micrographia, Traped facies, Glabellar tap
400
Investigations for depression
CBC, iron studies, B12, TSH
400
How do you "medically" manage dementia?
1) Treatment with CIs or memantine; 2) Stop/limit unnecessary meds; 3) Optimize vascular health
400
Cognitive Assessment Method (CAM) - delirium diagnosis criteria
1 + 2 + one of 3 or 4: 1) Acute onset and fluctuating course, 2) Inattention, 3) Disorganized thinking, 4) Altered level of consciousness
500
4/7 neurocognitive domains
Amnesia, aphasia, apraxia, agnosia, executive function, attention, social cognition
500
Do a full neurological exam
CNs, Cerebellum, Inspection, Tone, Power, Reflexes, Sensation (gross, temperature/pain, proprioception/vibration), Gait, Pronator drift, babinski
500
Name basic investigations for cognitive decline
Blood work, urine, ECG, AXR/CXR, CT head
500
How would you counsel a patient and their caregivers on relevant support systems available?
Support groups and crisis intervention; Educational groups; Adult day program and respite care at home; Linking with Alzheimer’s society, CCAC, Champlain LHIN or other community resources
500
How do you differentiate: AD, Vascular Dementia, LBD, FTD?
AD: short term memory loss, FHx, early amnesia and aphasia, cues don't help, limited insight; Vascular dementia: evidence (RFs/pmhx/imaging), neuro deficits, early agnosia/apraxia, cues help, step-wise decline; LBD: like delirium, hallucinations, early visuospatial deficits and executive dysfunction, parkinsonism features; FTD: younger patients (45-65), behavioural vs language
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