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Diagnosis of Alzheimers requires:Development of multiple cognitive deficits manifested by both:
- memory impairment
- one of the following cognitive disturbances: aphasia, apraxia, agnosia, disturbance in executive functio
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Neurotransmitter changes in alzheimers:
- decreased level of acetylcholine (Ach)-disruption of cholinergic mechanisms damages memory
- norepinephrine decreased in the cortex by 50%
- loss of serotonin -- alteration in sleep patterns
- glutamate - too much causes neuronal degeneration
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Stage 1 Alzheimers:
Mild cognitive decline
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Stage 2 Alzheimers:
Moderate cognitive decline with obvious memory impairment
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Stage 3 Alzheimers:
Motor and gait disturbance leading to immobility, loss of verbal abilities, does not recognize familiar people/events
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Pharmacological interventions for alzheimers:
- Cholinesterase inhibitors
- NMDA antagonist
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Examples of NMDA antagonists:
Memantine (namenda)
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Examples of cholinesterase inhibitors:
- Donepezil (Aricept)
- Galantamine (razadyne)
- Rivastigmine (Exelon)
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What medication must be used carefully with cholinesterase inhibitors?
NSAIDS – increase risk of ulcers
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Rapid onset of variable and fluctuating changes in mental status caused by physiologic consequences of a medical disturbance.
Delirium
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Consciousness that is accompanied by a change in cognition that cannot be better accounted for by a preexisting or evolving dementia.
Delirium
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Two forms of delirium.
- Hyperactive (restless, agitated, violent)
- Hypoactive (lethargic, obtunded)
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Delirium vs. Dementia : ONSET
- Delirium = acute
- Dementia = insidious
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Delirium vs. Dementia : COURSE
- Delirium = fluctuating
- Dementia = progressive
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Delirium vs. Dementia : DURATION
- Delirium = days to weeks
- Dementia = months to years
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Delirium vs. Dementia : CONSCIOUSNESS
- Delirium = altered
- Dementia = clear
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Delirium vs. Dementia : ATTENTION
- Delirium = impaired
- Dementia = normal, except for severe dementia
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Delirium vs. Dementia : PSYCHOMOTOR CHANGES
- Delirium = increase/decreased
- Dementia = Often normal
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Delirium vs. Dementia : REVERSIBILITY
- Delirium = usually
- Dementia = rarely
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I in I WATCH DEATH:
Infection
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W in I WATCH DEATH:
Withdrawal
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A in I WATCH DEATH:
Acute metabolic change
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T in I WATCH DEATH:
Trauma
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C in I WATCH DEATH:
CNS pathology (seizure, stroke, tumor…)
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H in I WATCH DEATH:
Hypoxia
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D in I WATCH DEATH:
Deficiencies (B12, folate, niacin, thiamine)
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E in I WATCH DEATH:
Endocrinopathies (hyperglycemia, hyperparathyroid)
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A in I WATCH DEATH:
Acute vascular
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T in I WATCH DEATH:
Toxins (narcotics, etc…)
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H in I WATCH DEATH:
Heavy metals (lead, mercury…)
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Four major risk factors for delirium:
- Elderly
- Pre-existing dementia
- Polypharmacy
- Poor hearing/low vision
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Gold standard for pharmacological treatment of delirium:
Haldol
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Adverse effect of haldol:
Extrapyramidal (parkinsonian)
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Atypical antipsychotics for delirium:
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Rarely used as monotherapy for delirium, except when delirium is caused by withdrawal:
Benzos
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Benzos used for delirium:
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