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33 Cards in this Set

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Transient loss of consciousness and postural tone due to inadequate cerebral blood flow and O2 delivery
Syncope
Syncope is most common in what three types of patient?
More common in pts with heart dz, older men and young women
2/2 excessive vagal tone or impaired reflex control of peripheral circulation
Vasomotor syncope
What are two types of vasomotor syncope?
Enhanced vagal tone secondary to hypotension
-Syncope in carotid sinus hypersensitivity
-Post micturation syncope

Vasodepression
-Often initiated by stressful, painful or claustrophobic experience
-Often in young women
Vasoconstritctive response is impaired
Common in elderly, diabetic, pt w/ hypovolemia
Pt s taking vasodilators, diuretics, beta blockers
Idiopathic orthostatic hypotension (elderly men)
Orthostatic (postural) Syncope
No prodrome leading to injury is common

2/2 mechanical problem
Aortic stenosis, pulm stenosis, hypertrophic obstructive cardiomyopathy, right –to-left shunting, LA myoma obstructing the mitral valve

2/2 automaticity problem
Sick sinus syndrome, AV block, tachyarrhythmia
Cardiogenic syncope
What is used to diagnose syncope, ie. what tests?
EKG, Tilt Table Testing, Electrophysiology studies, exercise testing
Used in pts with recurrent syncopal episodes, nondiagnostic ambulatory EKGs and negative autonomic testing

Check sinus node fct and AV conduction

Try to repeat induction of supraventricular or ventricular tachycardia
Electrophysiology studies
This is used in patients who experience syncope with exertion or stress.
Exercise testing
How do you TX Syncope?
Avoid predisposing situations
Stay hydrated
Stand up slowly
Maybe some serotonin reuptake inhibitors
Acute fluctuating disturbance of consciousness associated w/ change in cognition or the development of perceptual disturbances
2/2 underlying medical condition such as infection, coronary ischemia, hypoxemia or metabolic derangement
Present in 25% of pts
Delirium
This is associated with the following:

↑ in hospital and post d/c mortality
↑ length of stay
↑ probability of NH placement
Delirium
What are the symptoms of delirium?
Acute agitation (‘sun downing’)
Anxiety and irritability
Perceptual disturbance (visual hallucinations)
Psychomotor restlessness w/ insomnia
Marked deficit of short-term memory
Retrograde amnesia (can’t recall past memories) and anterograde (can’t recall events since onset of delirium)
Hypoactivity
Cognitive slowing
Inattention
All of these things are risk factors for what?
Cognitive slowing
Male
Severe illness, infection
Fever
Hip fracture
Hypotension
Respiratory d/o
Malnutrition
Polypharmacy
Use of psychoactive medications
Sensory impairment
Use of restraints
Use of IV lines, urinary catheters
Metabolic d/o
Depression
Intoxication or withdrawal
Delirum
What is extremely important in delirium assessment?
Current meds
Newly added meds
Discontinued meds (withdrawal)
How do you manage delirium?
Correct underlying cause
Eliminate unnecessary meds
Avoid restraints
Haldol 0.5-1 mg qhs or bid or
Quetiapine 25mg qhs or bid
In emergency: Haldol 0.5 mg po or IM q 30 min prn agitation
Side effect: prolonged sedation
If delirium doesn't clear up shortly after treating it, what should you consider?
Dementia
Acquired, persistent, progressive impairment in intellectual fct with compromise of memory and at least one other cognitive domain

Insidious onset over months to years

Dx requires significant decline in fct that is severe enough to interfere with work or social life

Often associated with depression in early dz
Dementia
What are the risk factors of Alzheimer's
Older age
Fam Hx
Lower education level
Female gender
What are the risk factors of vascular dementia?
Older age
HTN
Tobacco
Afib
DM
Hyperlipidemia
What are the less common, potentially reversible causes of dementia?
Drug effect
Depression
Thyroid dz
Vitamin B12 deficiency
Subdural hematoma
HIV infection
Normal-pressure hydrocephalus
Dementia is characterized by Memory impairment + at least one of these
Language impairment (initially word finding difficulty leading to difficulty following conversation leading to mutism)

Apraxia ( inability to perform previously learned task e.g. cutting loaf of bread, in spite of intact motor fct)

Agnosia ( inability to recognize objects)

Impaired executive fct ( poor abstraction, mental flexibility, planning and judgment)
Problems w/ memory & visiospacial abilities (becoming lost in familiar surroundings, inability to copy geometric design on paper)

Social ability intact

Personality changes & behavioral difficulties (wandering, inappropriate sexual behavior, agitation)

Hallucinations (in moderate to sever dz)

End stage: near mutism, inability to sit up, hold up the head, track objects with eyes, difficulty with eating and swallowing, weight loss, bowel and bladder incontinence, recurrent urinary and respiratory infections
Alzheimer's Disease
Fluctuating cognitive impairment (thus can be confused with delirium)
Rigidity
Bradykinesia
Rare tremor
Poor response to dopaminergic agonists
Early Sx: Hallucinations (of people or animals)
Lewy Body Dementia
(group of dzs such as Pick’s dz. and others)
Personality change (euphoria, disinhibition, apathy)
Compulsive behavior (peculiar eating habits or hyperorality)
Fronto-temporal Dementias
This imaging in dementia is for younger pts w/ acute onset of focal neurologic symptoms, sz, gait abnormalities
MRI
This imaging in dementia is for older pts w/ classic presentation of Alzheimer’s
Non-Contrast CT
You use this to distinguish depression from dementia
In pts w/ very poor education or very high premorbid intellect
In pts with very mild impairment
Neuropsych evaluation
Plaques - deposits of the protein beta-amyloid accumulate between neurons

Tangles - deposits of the protein tau that accumulate inside of nerve cells
Alzheimer's
Plaques and tangles
Neuronal loss especially in subtantia nigra
Lewy Body Dementia
How do you TX mild to moderate dementia?
Mild to moderate dz: Acetylcholinesterase inhibitor (donezepil, galantamine, rivastagmine)
Modest improvement in cognitive fct, but no difference in NH placement
Side effects: diarrhea, nausea, anorexia and weight loss
How do you TX severe dementia?
Severe dz: N-methyl-D-aspartate antagonist (memandine) +/- Acetylcholinesterase inhibitor
Unknown long-term benefit
It is important to rule out what with dementia?
R/o delirium 2/2 pain, urinary obstruction or fecal impaction