Give me a sign
Patients with Alzheimer's are usually at least this many years old
65
in the early stages of AD, this part of the brain shows rapid loss of its tissue which is associated with the functional disconnection with other parts of the brain.
a. basal ganglia
b. cerebral cortex
c. medulla
d. hippocampus
d. Hippocampus
Aggregation of which protein causes neurofibrillary tangles?
Tau
These drugs are considered first line Tx for patients with Alzheimer's disease.
Acetylcholinesterase inhibitors (Rivastigmine, Galantamine, Donepezil)
An 83-year-old man is brought to his primary care physician by his daughter, who is concerned that he has become increasingly forgetful over the past year. He regularly forgets whether he has taken his medication for the day and has gotten lost twice while driving home from the grocery store. On the Mini-Mental State Examination, he scores 22/30, missing four for time orientation, three for recall, and one for intersecting pentagons. His neurologic examination is otherwise normal, and MRI of the brain only demonstrates mild cortical atrophy.
A. Alzheimer disease
b. creutzfeldt-jakob disease
c. frontotemporal dementia
d. lewy body dementia
e. normal aging
f. pseudodementia
g vascular dementia
A. Alzheimer disease
This patient has slowly progressive memory problems and difficulty performing instrumental activities of daily living. He has preserved sensory and motor functioning, as well as having an unremarkable MRI.
The other choices are incorrect:
Which of these is NOT a reversible cause of dementia?
A. Hypoglycemia
B. Vitamin B2 deficiency
C. Hypothyroidism
D. Vitamin B9 deficiency
B. It's vitamin B12 deficiency
A 48-year-old man with a history of trisomy 21 comes to the physician for evaluation of worsening cognition. The patient is moderately intellectually disabled, but he has been able to work as a store clerk for several years. However, he was recently released from work due to declining performance and inability to remember tasks. The patient recalls having gotten lost in the store while restocking shelves. He drinks 1-2 beers each evening, and he does not consume tobacco or illicit substance. The patient also participates in a local rugby league, but he has found it increasingly difficult to remember practice times. His grandfather died from frontotemporal dementia at the age of 78. The patient's vitals are within normal limits. Physical examination is notable for upward slanting eyelids and bilateral transverse palmar creases. No gait or motor abnormalities are noted. Which of the following risk factors is the most likely cause of this patient’s cognitive decline?
a. substance abuse
b. age
c. family hx
d. aneuploidy
e. physical contact sports
d. aneuploidy
Early-onset Alzheimer disease is associated with several gene mutations, including the PSEN-1, PSEN-2, and APP (located on c21) Patients with trisomy 21 have three copies of the APP gene and are at increased risk of developing Alzheimer disease.
What does the RPR stand for?
Rapid plasma reagin
Which of the following are Adverse effects seen in NMDA receptor antagonists
a. Headaches
b. dizziness
c. nausea, vomiting
d. hallucinations
e. insomnia
A,B,D
Which test is the most accurate in determining Alzheimer's dementia from non dementia? (Assuming there is no sign of a reversible cause of altered mental status)
Neuropsychiatric evaluation
What is the difference between mood and affect?
Affect is the immediate expression of emotion in an individual. Mood describes someone's personality over a longer period of time.
A 73-year-old woman is brought to the clinic by her sister due to worsening
memory loss. The patient has had difficulty balancing her checkbook and has forgotten the names of her grandchildren on several occasions. According to the sister, the patient recently got lost while walking her dog in a park that she has been visiting daily for the past 10 years. She also requires assistance with daily activities, such as housekeeping and purchasing groceries. However, the patient brushes off these concerns, stating “it is merely part of normal aging.” Family history is notable for declining cognitive function in the patient's father and grandfather when they were in their 70s. Laboratory testing is ordered as part of the work-up. Which of the following will most likely be elevated in this patient?
a. free serum copper
b. Apolipoprotein E epsilon 4
c. Apolipoprotein E epsilon 2
d. Amyloid A protein
e. CAG trinucleotide repeats
b. Apolipoprotein E epsilon 4
Late-onset Alzheimer disease is associated with the apolipoprotein E ε4 allele. Apolipoprotein E helps break down beta-amyloid; however, the ε4 allele is less effective than the other alleles, and thus it predisposes patients to developing amyloid-beta plaques.
This elderly patient is presenting with significant cognitive impairment and has a family history notable for dementia. She likely has late-onset Alzheimer disease (AD), which can arise due to an increased number of epsilon 4 (ε4) alleles of the apolipoprotein E gene.
If a patient with suspected dementia has a neuropsych exam how long should they wait before repeating the NPE to check for cognitive decline?
12 months
Which of the following is the most appropriate pharmacotherapy for a patient with moderate to advanced Alzheimer disease who has poor response to cholinesterase inhibitor therapy?
a. Atropine
b. Donepezil
c. Memantine
d. Rivastigmine
e. Scopolamine
C. Memantine
the correct answer is memantine (C). Memantine is an NMDA modulator that can be used adjunctively with cholinesterase inhibitors or as monotherapy when cholinesterase inhibitor therapy has failed. Donepezil (B) and rivastigmine (D) are both cholinesterase inhibitors. Atropine (A) and scopolamine (E) are muscarinic antagonists and are not used to treat AD; muscarinic antagonists may be used to reverse the adverse effects of cholinesterase inhibitors.
During the Mini-Mental State Exam, patients are asked the relationship between different objects. What is this type of question testing?
Visuospatial skills
Describe one of the theories as to why patients with depression are more likely to develop dementia later in life.
Due to the chronic inflammatory processes associated with depression and stress.
Production of certain cytokines that increase brain permeability.
Social component from loneliness.
A 77-year-old man is brought to the clinic by his son due to an “inability to take care of himself.” The patient is unable to prepare food, bathe himself, or take daily medications. According to the son, his father has had difficulty remembering recent events, such as his grandson's birthday party last month, but he is able to recall events that occurred many years ago, such as his own wedding. Eight months ago, the patient was forced to give up driving after he got lost in his own neighborhood on numerous occasions. Which of the following pathologic findings is most likely to be present within the neurons of this patient’s brain?
a. Hyperphosphorylated microtubule-associated proteins
b. alpha-synuclein-positive cytoplasmic inclusions
c. brownish-yellow granular material composed of lipid and protein
d. intracellular aggregates of improperly cleaved precursor protein
e. round eosinophilic cytoplasmic inclusions due to viral infection
a. Hyperphosphorylated microtubule-associated proteins
Tau= microtubule assoc protein in neuronal axons.
In patients with AD, these proteins become hyperphosphorylated and give rise to intracellular neurofibrillary tangles (indicated by the black arrow). The hyperphosphorylated tau is no longer able to stabilize microtubules, leading to cytoskeleton damage and neuronal injury.
Describe the scoring for the Mini-Mental State Exam.
24 or higher = no dementia
19-23 = Mild dementia
10-18 = moderate dementia
9 or less = severe dementia
What are 3 adverse effects of donepezil?
Dizziness, nausea, insomnia, vomiting, cholinergic crisis, bradycardia, conduction abnormalities
This bacteria invades the CNS to cause altered mental status in syphilis.
Treponema pallidum
Describe the difference between a blunted and flat affect.
Blunted means a dull response or inability of the patient to fully express their emotions. Flat affect indicates complete lack of emotional stimuli.
A 77-year-old woman is brought to the physician by her daughter due to worsening irritability and aggression. Over the past year, the patient has been having trouble recalling the names of her children. She has even gotten lost walking back from the park, which she has done nearly everyday without difficulty for 30 years. According to the daughter, the patient also seems more withdrawn and becomes irritated when asked simple questions. She has not had any hallucinations or changes in urinary frequency or gait. Vitals are within normal limits. Physical examination reveals no abnormalities. She says her mood is “annoyed” and scores 19/30 on the Mini-Mental State Examination (normal: ≥ 24). She is oriented to person and place but not time. Which of the following clinical features in this patient's history is indicative of dementia, as opposed to delirium?
a. agitation and irritability
b. memory deficit
c. progressive course of condition
d. mini-mental state examination score
e. lack of orientation
C. progressive course of condition
Major neurocognitive disorder (dementia) has a gradual onset and symptoms progressively worsen over the course of months to years. In contrast, delirium occurs secondary to various conditions (e.g., urinary tract infection, medications) and has an acute onset over hours to day.
Delirium may present with similar impairments in cognitive functioning, but the symptoms develop acutely and fluctuate throughout the day.
Name two limitations of structural MRIs in patients with Alzheimer's.
Structural MRI lacks molecular specificity. It cannot directly detect the histopathological hallmarks of AD.
Atrophy patterns overlap with other diseases and unusual forms of AD have atypical patterns of atrophy too.
In more severely affected individuals and those with claustrophobia, MRI may not be tolerated whereas a rapid CT scan may be more feasible.
In terms of measuring progression, volume changes on MRI may be produced by factors other than the progression of neuronal loss. As the name implies, structural MRI cannot assess function; this is provided with increasing sophistication by functional MRI and PET.
A 70-year-old woman is brought to her physician by her daughter who reports that the patient has been increasingly confused and forgetful over the past year. The daughter reports that the patient has difficulty finding words, remembering names, and maintaining a conversation. She has gotten lost twice while driving. Her past medical history is known for obesity, diabetes, and atrial fibrillation. She takes metformin, glyburide, and warfarin. She drinks socially and has a 30 pack-year smoking history. Her family history is notable for Parkinson’s disease in her father and stroke in her mother. A head CT demonstrates sulcal widening and narrowing of the gyri. The physician decides to start the patient on a medication known to inhibit a cell surface glutamate receptor. Which of the following is a downstream effect of this medication?
a. Decreased intracellular calcium
b. Increased intracellular calcium
c. increased intracellular sodium
d. increased intracellular acetylcholine
e. decreased intracellular acetylcholine
A. Decreased intracellular Calcium
The patient in this vignette presents with memory loss, loss of recall, and imaging findings consistent with Alzheimer's disease. Memantine is an NMDA receptor antagonist that is used in the treatment of Alzheimer's disease to decrease intracellular calcium accumulation.
The NMDA receptor is a cell surface protein that binds the excitatory neurotransmitter glutamate. Glutamate binding leads to a rapid increase in calcium influx into the cell, increasing the concentration of intracellular calcium. This corresponds to an increase in neural excitation which is excitotoxic in patients with Alzheimer's disease. Memantine is a medication used in Alzheimer's disease that inhibits signaling at the NMDA receptor, thereby decreasing the amount of intracellular calcium and preventing excess excitotoxic nerve damage.
Incorrect Answers:
Answer 2: Memantine leads to a decrease, not an increase, in intracellular calcium.
Answer 3: The NMDA receptor does not directly affect sodium influx or efflux from the cell.
Answer 4: Acetylcholinesterase inhibitors are another common drug type in Alzheimer disease. These medications increase the availability of acetylcholine. Memantine does not directly affect acetylcholine levels.
Answer 5: Memantine does not directly affect acetylcholine levels.
A 34-year-old man comes to his physician after experiencing strange jerky movements in his limbs and face which he cannot control. He also reports having mood swings and memory lapses. He says that his father displayed similar symptoms when he was in his 40s. Irregular, brief, purposeless movement of the hands is noted on examination.
a. copper accumulation in the basal ganglia
b. neuritic plaques in the cerebral cortex
c. pigmentation loss in the substantia nigra
d. scattered periventricular plaques
e. ubiquitinated protein aggregates in the caudate nucleus
e. ubiquitinated protein aggregates in the caudate nucleus
The CAG repeats in Huntington disease code for mHTT, which, along with a deficient ubiquitin-proteasome system, leads to mHTT aggregates that disrupt neuronal function in the caudate nucleus.
a= Wilson disease caused by failure of copper to enter circ bound to ceruloplasmin.
b= alzheimer disease
c= parkinson disease
d= multiple sclerosis