Chapter 11 - Changes in Behavior

Section 3

I. Dementia

Common Brain-related Syndromes
Dementia of the Alzheimer's Type (DAT)

Dementia with Lewy Bodies (DLB)

Frontotemporal lobar dementia (FTLD)

Vascular Dementia (VaD)

Mixed dementias

Parkinson's disease

Traumatic brain injury

Common General Medical Causes

Hypothyroidism

B12 deficiency

Thiamine deficiency (Korsakoff's syndrome)

Sleep apnea

Less Common Brain-related Syndromes

Huntington's disease

AIDs-dementia complex

Neurosyphilis

Chronic meningitis

Creutzfeldt-Jakob disease

Normal pressure hydrocephalus

Other hydrocephalus

Space-occupying lesion

Less Common General Medical Causes

Hyperthyroidism

Addison's disease

Cushing's disease

Panhypopituitatarism

Hyperparathyroidism

Folate deficiency

Vitamin A, D toxicity

II. Confusion/Delirium

More Common Brain-related Causes

Sleep deprivation

Exacerbation of dementia by intercurrent illness ("Beclouded" dementia)

Migraine

Stroke, especially brainstem, thalamic, right parietal, or bi-occipital

Traumatic brain injury with or without loss of consciousness

Subdural hematoma

Increased intracranial pressure (IICP, e.g. tumor, hydrocephalus)

Herpetic encephalitis

Cysticercosis

Thiamine deficiency causing Wernicke's encephalopathy, Korsakoff's syndrome

Syndrome of inappropriate ADH excretion (SIADH)

Postictal state

Depression with psychomotor retardation

Schizophrenia

More Common General Medical Causes

Drug toxicity or withdrawal (seeTable 4)

Fever

Low output cardiac failure

Pulmonary hypertension

Hypertensive encephalopathy

Hypo- or hyperglycemia

Hyponatremia

Hypothyroidism

Anemia (hematocrit <24)

Hepatic encephalopathy

Uremic encephalopathy

Anoxia/hypoxia/pulmonary disease

Serotonin syndrome

Post-operative confusion

Less Common Brain-related Causes
Epidural hematoma

Nonherpetic viral encephalitis

Bacterial or fungal meningitis

Carcinomatous meningitis

Limbic encephalitis

Carotid or vertebrobasilar insufficiency without stroke

Creutzfeldt-Jakob disease

Neurosyphilis

Complex partial or petit-mal status epilepticus

Multiple sclerosis

Neuroleptic malignant syndrome

Mania

Less Common General Medical Causes
Porphyria

Addison's disease

Cushing's disease

Systemic lupus erythematosus

Temporal arteritis

Hyperthyoidism

Hyperparathyroidism

Hypercalcemia

Panhypopituitarism

Carcinoid syndrome

Post-CABG delirium

Carbon monoxide poisoning

Heavy metal toxicity

Acetylcholinestase inhibitor toxicity (e.g., insecticide)

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SELF-ASSESSMENT QUESTIONS

  1. Which of the following items in the past medical history is of special concern when assessing a recent change in behavior in an older adult?
    1. Adolescent mental health interventions
    2. Recent ETOH dependence
    3. Current lung tumor
    4. A and B only
    5. A, B, and C
  2. Which of the following is true in regard to changes in mental status?
    1. Dementia requires altered level of attention and arousal
    2. A history of rapid decline helps to rule out a chronic process
    3. Delirium has a mortality rate of 15 to 65 percent
    4. The rate of change often guides the urgency of assessment
    5. C and D only
    6. All of the above
  3. Poor sleep or insomnia is common in:
    1. Sleep apnea
    2. Mood disorders
    3. Hydrocephalus
    4. Hypoglycemia
    5. A and B only
    6. A, B, and D
  4. Unilateral weakness can occur in:
    1. Stroke
    2. CNS tumor
    3. Hypoglycemia
    4. A and B only
    5. A, B, and C
  5. New onset confusional syndromes can be attributed to drugs in approximately:
    1. 10 to 15 percent of cases
    2. 15 to 30 percent of cases
    3. 35 to 60 percent of cases
    4. 60 to 75 percent of cases
    5. 75 to 90 percent of cases
  6. Drugs commonly reported to cause altered mental status include:
    1. acetaminophen (Tylenol®)
    2. dysopyramide phosphate (Norpace®)
    3. baclofen (Lioresal®)
    4. sulfamethoxazole
    5. C and D only
    6. B, C, and D
  7. Which of the following is true about the mental status exam?
    1. The Folstein MMSE score in Alzheimer's disease falls between 0 and 21.
    2. Asking the patient to name the stem of a watch or the lapel of a jacket is usually a good test of dominant hemisphere function.
    3. An acute confusional state is often very similar to a Broca's aphasia
    4. Repeating three words is a test of working memory
    5. D only
    6. A, C and D only
  8. The following statements about neurodegenerative conditions are true:
    1. Stepwise progression is expected in vascular dementia.
    2. Definitive biological markers have been identified which distinguish Alzheimer's disease from normal aging.
    3. The Hachinski Ischemia Scale can be used to diagnose vascular dementia.
    4. A and C only
    5. none of the above
  9. The diagnostic workup for dementia must include:
    1. Neuropsychological testing
    2. Neurological examination
    3. MRI scan
    4. Thyroid function tests
    5. B and D only
    6. B, C, and D only
  10. If you introduce yourself to the patient in a loud voice and see no response, this could be explained by:
    1. Deafness
    2. Language barrier
    3. Paralysis
    4. Encephalopathy
    5. A, C, and D only
    6. All of the above
  11. Abnormal gait can help to diagnose a change in mental status, since it is common in:
    1. Dementia with Lewy Bodies
    2. Increased intracranial pressure
    3. Parkinson's disease
    4. Alzheimer's disease
    5. B and C only
    6. A, B, and C only
  12. In regard to Alzheimer's disease:
    1. About 15 percent of adults are affected by age 70
    2. Onset is often rapid
    3. About 35 percent of adults are affected by age 85
    4. Time from diagnosis to death averages four years
    5. A and C only
    6. A, C, and D

ANSWERS

  1. E
  2. E
  3. E
  4. E
  5. C
  6. F
  7. E
  8. E
  9. E
  10. E
  11. F
  12. C