History
Physical Exam
Tests
Management
Diagnosis
100
In assessing cognitive decline, which individuals should you interview to get a good history of the patient?
Patient Collateral (family members, support, GPs, etc.)
100
Why is physical exam important?
Helps us with DDX: delirium, depression, dementia
100
What are some neurocognitive tests you can use to assess cognitive decline?
MOCA and MMSE
100
What's your primary management goal in treating delirium?
Treat the cause
100
How do you differentiate mild from major neurocognitive disorder?
Mild NCD: Cognitive deficits DO NOT interfere with independence in everyday activities
200
What are important components of a good history that you should cover in assessing cognitive decline?
HPI PMHx, Meds, Allergies, Hospitalizations, Past psych history FHx Shx
200
Physical exam for depression is known as? Descri
Mental Status Exam Appearance Speech Emotion: Mood/affect Perception: Hallucinations/illusions Thought content/organization Insight/judgement Cognition
200
How do you decide 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
What are 3 important aspects of management you should cover in someone who has cognitive decline?
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
What information is important when you're assessing social history?
Housing Fall risk Medication administration ADLs (DEATH: dressing, eating, ambulating, toileting, hygiene) iADLs (SHAFT: shopping, housekeeping, accounting, food preparation, transport) POAs
300
If you suspect someone has delirium, give examples for you would examine for?
Vitals CNS: neurological deficits, signs of meningitis HEENT: ears, oropharynx, lymphadenopathy CVS: S3/S4/murmurs, carotid bruits RESP: decreased AE, crackles/wheezing ABDO: pain, masses, poor bowel sounds SKIN: abscess, rashes, lacerations MSK: joint infections
300
When someone performs more poorly on visuospatial/executive function on MMSE/MOCA, which dementia are they more likely to have?
Vascular, LBD, FTD
300
What are some common medications you can use 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 Background of Alzheimer's disease
400
In assessing cognitive decline, what are some important questions to ask to differentiate delirium/depression/dementia?
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
How do you assess for Parkinsonian traits on exam?
Resting tremor (pill rolling) Cog-wheel rigidity Akinesia/bradykinesia Posture Gait (shuffling, small steps, en bloc turning, freezing) Micrographia Traped facies Glabellar tap
400
In someone who has symptoms of depression, which investigations would you pay particular attention to?
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
List 4 neurocognitive domains and how you would elicit them on history
Amnesia: Repeats self in conversation, reminders Aphasia: Difficulty with language (“you know”) Apraxia: Difficulty with familiar activities (tools, driving) Agnosia: Difficulty recognizing familiar people/objects Executive function: iADLs (SHAFT) Attention: Difficulty in multiple stimuli Social cognition: Changes in behaviour (insensitivity to social standards)
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: CBC, lytes, Ca/Mg/PO4, glucose, BUN, Cr, LFTs, alb, bili, INR, TSH, B12, folate Urine: Urinalysis, R&M, C&S Misc: ECG, AXR/CXR, CT head Other investigations: Toxicology, heavy metal screen, VDRL, HIV, lumbar puncture
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, 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
M
e
n
u