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N22 Neurology
Behavioural Neurology Toronto Notes 2019
Sensitivity and Specificity
Etiology
• seeTable13
• reversiblecauses:alcohol(intoxicationorwithdrawal,Wernicke’sencephalopathy),medication
(benzodiazepines, anticholinergics), heavy metal toxicity, hepatic or renal failure, B12 deficiency, glucose, cortisol, thyroid dysfunction, normal pressure hydrocephalus (NPH), depression (pseudodementia), intracranial tumour, SDH, hypercalcemia (secondary to elevated PTH)
• mustruleoutdelirium
History
• “geriatricgiants”
■ confusion/incontinence/falls
■ memory and safety (wandering, leaving doors unlocked, leaving stove on, losing objects, driving) ■ behavioural (mood, anxiety, psychosis, suicidal ideation, personality changes, aggression)
■ polypharmacy and compliance (sedative hypnotics, antipsychotics, antidepressants,
anticholinergics) • ADLsandIADLs
• cardiovascular,endocrine,neoplastic,renalROS,headtraumahistory • alcohol, smoking
• collateralhistory
Physical Exam
• bloodpressure
• hearingandvision
• neurologicalexamwithattentiontosignsofparkinsonism,UMNfindings
• generalphysicalexamwithfocusonCVD,patient-specificriskfactorsandhistory
• MMSEorMoCA,clockdrawing,frontallobetesting(go/no-go,wordlists,similarities,proverb)
Investigations
• rule out reversible causes
■ CBC (note MCV for evidence of alcohol use and B12 deficiency), glucose, TSH, B12, RBC folate ■ electrolytes, LFTs, renal function, lipids, serum calcium
■ CT head, MRI as indicated, SPECT (optional)
■ as clinically indicated: VDRL, HIV, ANA, anti-dsDNA, ANCA, ceruloplasmin, copper, cortisol,
toxicology, heavy metals • issuestoconsider
■ failure to cope, fitness to drive, caregiver capacity and wellbeing, power of attorney, legal will, advanced medical directives, patient and caregiver safety
Tool
MMSE
Clinical Judgment
DSM IV
Sensitivity Specificity
87% 82% 85% 82%
76% 80%
Vitamin B12 Deficiency Symptoms
• Macrocytic anemia, pallor, SOB, fatigue, chest pain, palpitations
• Confusion or change in mental status (if advanced)
• Decreased vibration sense
• Distal numbness and paresthesia
• Weakness with UMN findings
• Diarrhea, anorexia
Major NCD Considerations for Management
ABCDs
Affective disorders, ADLs
Behavioural problems
Caretaker, Cognitive medications and stimulation
Directives, Driving
Sensory enhancement (glasses/hearing aids)
Most common causes of rapidly progressive neurodegenerative dementia (less than 4
yr survival): CJD, frontal temporal lobar dementia, tauopathies, diffuse Lewy body disease, and AD
Table 13. Selected Causes of Major NCD (Dementia)
Arch Neurol 2009;66:201-207
Head turning sign: when patient looking at his/ her caregiver for answers after being asked a question in clinical interviews
60% sensitivity, 98% specificity for diagnosis of cognitive Impairment
Etiology
PRIMARY DEGENERATIVE
Alzheimer’s disease Dementia with Lewy bodies
Frontotemporal dementia (e.g. Pick’s disease)
Huntington’s disease
VASCULAR
Vascular cognitive impairment (previously Multi-infarct dementia)
CNS vasculitis
Key Clinical Features
Memory impairment Aphasia, apraxia, agnosia
Visual hallucinations Parkinsonism Fluctuating cognition
Behavioural presentation: disinhibition, perseveration, decreased social awareness, mental rigidity, memory relatively spared
Language presentation: progressive non-fluent aphasia, semantic dementia
Chorea
Bradyphrenia without features of parkinsonism (slow thinking, slow rate of learning, slow gait) Dysexecutive syndrome
May be abrupt onset
Stepwise deterioration is classic but progressive deterioration is most common
Systemic signs and symptoms of vasculitis
Investigations
CT or MRI, SPECT CT or MRI, SPECT
CT or MRI, SPECT
Genetic testing
CT or MRI, SPECT
ANA; ANCA; RF CT or MRI Angiography
Early Signs of Major NCD
Forgetting the names of close relations
Increasedfrequency of forgetting
Repeating phrases/ stories in the same conversation
Unpredictablemood changes
Decreased interest in activities and difficulty making choices
Normal Aging
Forgetting the names of acquaintances
Brieflyforgettingpart of an experience
Not putting away things properly
Moodchanges
in response to appropriate causes
Changes in usual interests