2. Case 1
• A 79-year-old man is admitted to the hospital
for an elective total knee replacement. He
lives by himself and performs all of his
activities of daily living. His medical history
includes degenerative joint disease, coronary
heart disease, and hypertension. He has no
history of psychiatric problems or alcohol and
drug history.
3. • In the evening, several hours after an
uneventful surgical procedure, the patient
becomes diaphoretic and tachypnic. He is
alert, but also agitated and confused, and
cannot give full attention to the hospital staff
and their questions. He does remember his
name, but does not believe that he is in a
hospital.
4. Choose the most likely diagnosis
1. Amnesic Disorder
2. Delirium
3. Dementia
4. Multi-infarct dementia
5. • For the past 10 years the memory of a 74-year-
old woman has progressively declined. Lately,
she has caused several small kitchen fires by
forgetting to turn off the stove, she cannot
remember how to cook her favorite recipes,
and she becomes disoriented and confused at
night. She identifies an increasing number of
objects as “that thing” because she cannot
recall the correct name. Her muscle strength
and balance are intact
Case 2
6. Choose the most likely diagnosis.
a.Huntington’s disease
b. Multi-infarct dementia
c. Creutzfeldt-Jakob disease
d. Alzheimer’s disease
e. Wilson’s disease
7. case 3
• A 70-year-old male with a dementing disorder
dies in a car accident. During the previous five
years, his personality had dramatically changed
and he caused much embarrassment to his family
due to his intrusive and inappropriate behavior.
Pathological examination of his brain shows
fronto-temporal atrophy, gliosis of the frontal
lobes’ white matter, characteristic intracellular
inclusions, and swollen neurons. Amyloid plaques
and neurofibrillary tangles are absent
8. Choose the correct diagnosis:
a. Alzheimer’s disease
b. Pick’s disease
c. Creutzfeldt-Jakob disease
d. B12 deficiency dementia
e. HIV dementia
9. Case 4
• 65-year-old woman with a history of MI, hypertension,
and asthma presents with new onset of hallucinations.
She can no longer sleep at night because she sees small
children and cats in her apartment. She thinks she
must be going crazy and is too frightened to explain the
symptoms to her husband. She has no prior psychiatric
history. Her vital signs are blood pressure supine
115/80 mm Hg and standing 90/60 mm Hg. Physical
examination reveals an alert, oriented elderly woman
with a slight resting tremor and mild rigidity in her
upper and lower extremities, but no cog wheeling.
Mini-mental status examination reveals deficits in long-
term recall.
10. Choose the most likely diagnosis.
a.Huntington’s disease
b. Parkinson disease
c. Creutzfeldt-Jakob disease
d. Alzheimer’s disease
e. Lewy body dementia
11. Case 5
• A 78-year-old man comes to the physician for
evaluation after falling five times in 2 months.
An x-ray skeletal survey reveals no fractures,
but the patient admits to worsening urinary
incontinence over the previous 4 months. His
wife states that his memory and concentration
have deteriorated recently.
12. Choose the most likely diagnosis.
a.Huntington’s disease
b. Multi-infarct dementia
c. Normal pressure hydrocephalus
d. Alzheimer’s disease
e. Lewy body dementia
13. A 72-year-old married man is brought for evaluation to a
primary care physician by his wife. His wife is very
concerned about her husband’s decline in memory, as
well as his development of stuttering speech and a slow
gait over the past two to three years.
She reports that he now requires assistance with bathing
and grooming, and that he has been reporting seeing
children hiding in their bedroom closet. He often
refuses to go to bed at night until he removes all of the
clothing from the closet in order to “find the children.”
He has no prior history of any medical problems and
takes no medications .
Case 6
14. On physical examination : muscle rigidity, with a
slow, shuffling gait but no tremor. The patient
appears very confused, and his score on a
Mini-Mental State Exam is 15/30
Investigations:
a complete blood count, chemistry panel, thyroid
profile, syphilis serology, and vitamin B12 and
folate levels are all within normal limits.
MRI was ordered (reveals generalized atrophy
with no sign of acute infarction) .
15. The patient’s wife calls on the day of the
scheduled MRI, stating that her husband had
become aggressive while she was trying to
dress him..
The physician prescribes risperidone 1 mg twice
per day to control his aggression. The patient
then develops profound rigidity, with difficulty
swallowing and drooling.
16. What is the most likely diagnosis?
a.Huntington’s disease
b. Multi-infarct dementia
c. Parkinson disease
d. Alzheimer’s disease
e. Lewy body dementia
17. A 78 years old female is brought to the clinic by her
daughter . The daughter tells you that her mother
is having difficulty with her memory .
2 years ago & since that time she has deteriorated in
a slow steady manner . However she is not totally
incapacitated.
She is able to perform some of the activities of daily
living : dressing & bathing .When she cooks ,she
often leaves burners on & when she drives the car
she often gets lost.
18. What are the points that make the diagnosis of
dementia most likely in this case???
The daughter states that her mother’s memory and
confusion have been getting worse
Her personality has changed ,her kind &caring mother
now displays periods of both agitation and aggression
No history of trauma
not alcoholic
PMH : unremarkable FH: unremarkable
Examinations : unremarkable
19. -Progressive deterioration of intellectual
function with preservation of consciousness .
-Most important risk factor is increasing age
5% of population over the age 65 years
20% of population over the age 80 years
20.
21. vs.
Variable Delirium Dementia
Level of attention Impaired (fluctuated) Usually, alert
Onset acute Gradual
Course Fluctuating from hour to
hour ( sun downing)
Progressive deterioration
consciousness Clouded Intact
Hallucinations Present In advanced case
Prognosis Reversible Largely irreversible , but up
to15% due to treatable
causes and are reversible
26. Alzheimer s disease 50-60%
Vascular disease 15-20%
Mixed dementia 10-20%
Other <10%
like lewy-body dementia, pick s disease,
alcohol related,vitm B12...
aafp.org
27. Aims:
*identify rare treatable conditions that may present as dementia
*diagnose any condition that may exacerbate dementia (..eg.. Delirium, infection)
* Obtain the information needed to plan continuing care.
Assessment of functional capacity in dementia pt:
*Continence
*Dressing
*Self-care
*Cooking ability and nutrition
*Shopping/ housework
*Degree of orientation at home
*Social contact
*Safety in the home
28. • Patient history:
Interview the patient and their family members
about nature of onset, specific deficits, physical
symptoms, and comorbid conditions
Review medications, as well as family and social
history
30. Mini Mental State
Examination
Maximum score Score
5 ___
5 ___
3
___
5 ____
3
____
Orientation
1. What is the (year) (season) (date) (day) (month)?
2. Where are we: (state) (county) (town or city) (hospital) (floor)?
Registration
3. Name three common objects (e.g., "apple," "table," "penny"):
Take one second to say each. Then ask the patientto repeat all three after
you have said them. Give one point for each correct answer. Then repeat
them untilhe or she learns all three. Count trialsand record.
Trials: ___
Attention and calculation
4. Spell "world" backwards. The score is the number of lettersin correct order.
(D___L___R___O___W___)
Recall
5. Ask for the three objects repeated above. Give one point for each correct
answer.
(Note: recall cannot be testedif all three objectswere not remembered
during
registration.)
31. Mini Mental State
Examination- cont
Maximum score Score
2 ___
1 ___
3
___
1 ___
1 ___
1 ___
Total score:
30 ___
Language
6. Name a "pencil" and "watch."
7. Repeat the following: "No ifs, ands or buts."
8. Follow a three-stage command:
"Take a paper in your right hand, fold it in half and put it
on the floor.“
9. “CLOSE YOUR EYES”.
10. Write a sentence.
11. Copy the following design:
Scores of 24 or higher are generally
considerednormal.
32. Blood test
• FBC, ESR, CRP
• T4 and TSH
• urea and
creatinine
• glucose
• B12 and folate
• syphilis serology
• HIV
• caeruloplasmin
other
• cerebrospinal
fluid
examination
• electroencephal
ography (EEG)
Imaging
• MRI
• CT
• SPECT
33. :
Treat any treatable physical disorders
Treat the cause of superimposed delirium
Treat even minor medical problems
Involve and support relatives
Arrange help for carers
Medications for night and daytime restlessness
If home care fails, arrange hospital care
36. • most common type of dementia.
• The prevalence increase with age .Alzheimer’s
disease
• FH
• down syndrome
• Head injury
RF
• Accumulation B amyloidal peptide cause
progressive neural damage increase
number of senile plaques reduced
cerebral production of acetylcholine
synthesis
Cause
37. Pathophysiology
• Genetic factors
• Pathogenesis:
Gross pathology :
o diffuse atrophy especially frontal and
temporal and parietal lobes Dilation of
ventricles
40. • slowly progressive memory loss of
insidious onset in a fully conscious
patient
• slowly progressive behavioral changes
CF
• Aphasia
• Apraxia
• Agnosia
• Disturbance of executive functions
CF
• cholinesterase inhibitors,(donepezil,
rivastigmine, and galantamine are
currently approved
• Antiglutamatergic (memantine)
Treatment
41. • 2nd most common cause of
dementia.
VD
• Multiple infarcts of varying size
• The brain is atrophic , ventricular
dilatationPathology
• Stepwise progression
• Episodes of confusion
• Seizure
• Neurological signs
Clinical
features
42. • Vascular risk factors such as
hypertension, coronary
disease, and diabetes
mellitus
• Specific evidence of :
• strokes and transient -
ischemic attacks
• Neuroimaging evidence of
strokes
• Psychiatric disturbances (eg,
emotional lability,
depression, apathy)
Diagnostic
criteria for
Vascular
dementia:
43. • characterized by dementia and
Parkinson’s disease .
• More rapid than in Alzheimer's disease
LBD
• Lewy bodies (pale halo-like intracellular,
eosinophilic inclusions. )
Pathology
• Initially ,visual hallucination predominant .
• Fluctuating cognitive loss
• sings of parkinsonism
• Sensitive to side effects of neuroleptic
drugs
CF
44. • hydrocephalus that occurs in
adults, usually older adults.
• It is tried of: dementia, ataxia,
incontinence
Normal pressure
hydrocephalus
• The drainage of CSF is blocked
gradually, and the excess fluid
builds up slowly.cause
• Shunt surgery is the most common
treatment for the symptoms of normal
pressure hydrocephalus.
treatment
45. • A rare, progressive form of dementia
characterized by core symptoms of:
• disinhibtion, emotional lability,
apathy and or detachment
• (PICK’S DISEASE)
FTD
• front temporal atrophy in MRI or
CT.
• Cytoplasmic inclusion bodies (Picks
bodies)Diagnosis
46.
47. • Dementia is common and its different from cognitive
decline due to normal aging process
• The most common type of dementia is AD followed by VD
• Early detection of AD plays a significant role in better
prognosis
• VD can be prevented by controlling the risk factors
• There are several treatable forms of dementia like in:
hypothyroidism, nutritional deficiencies, NPH
48.
49. MCQ1
• One of the most common features of
neurological disorders are Language deficits
and are collectively known as
• a) Dysphasias
• b) Alogias
• c) Anomias
• d) Aphasias
50. MCQ2
• When an individual displays a deficit in the
comprehension of speech involving difficulties
in recognising spoken words and converting
thoughts into words is known as
• a) Wernicke's aphasia
• b) Broca's aphasia
• c) Beidecker's aphasia
• d) Warnick's aphasia
51. MCQ3
• If an individual has an inability to initiate
speech or respond to speech with anything
other than simple words is known as
• a) Nonfluent aphasia
• b) Fluent aphasia
• c) Disruptive aphasia
• d) Anomic aphasia
52. • Aphasia is an impairment of language.
(speak , understand ,fluency ,reading and writing)
• Most of the lesion that cause aphasia involve
dominant hemisphere. (95% of R handed people,
the L cerebral hemisphere is dominant.
53.
54. PROCESS OF
SPEECH
TYPES OF SPEECH
DISORDERS
HEARING
UNDERSTANDING
THOUGHT &
WORD PROCESSING
VOICE PRODUCTION
ARTICULATION
DEAFNESS
APHASIA
APHASIA
DYSPHONIA
DYSARTHRIA
55. • stroke (most common cause )
• injury to the brain
• tumors in the brain
• Alzheimer's disease
57. Boca's Area or Brodmann areas 44 & 45
• Its The motor speech area
• posterior inferior frontal gyrus
• formation of words
• connections with the adjacent primary motor
areas
- the muscles of the larynx, mouth, tongue,
soft palate, and the respiratory muscles
• controls the output of spoken language.
58. Broca’s aphasia
• Expressive, no fluent aphasia
• comprehension is intact .
• Effortful speech and slow .
• Often associated with a right side
hemiparesis.
59. Wernicke's area or Brodmann's area 22
• sensory speech area
• superior temporal gyrus
with extensions around
the posterior end of the
lateral sulcus into the parietal region.
• It receives fibers (visual cortex and auditory
cortex in the superior temporal gyrus).
• It permits understanding written and spoken
language
60. Wernicke’s Dysphasia
• Receptive ,fluent aphasia .
• Impaired comprehension of writing or
spoken language.
• intact speech ,but not make much sense .
-Phonemic problem e.g. flush for brush
61. Conduction Aphasia
• Communication between Broca’s and
Wernicke’s area is impaired
• Repetition is impaired
• Comprehension and fluency are less affected
62. Nominal aphasia
• Naming of objects is impaired, but other
aspects of speech are intact
• Lesion is usually in the posterior dominant
temporoparietal area
63.
64. DYSARTHRIA
• Acquired speech disorder caused by impaired
control of muscle responsible for speech
• Caused by weakness, paralysis, or
incoordnation of the speech muscle.
• The language content is normal .
67. Spastic dysarthria
• Common type of dysarthria
• Caused by bilateral damage to UMN
• Causes
- stroke
- ALS ( amyotrophic lateral sclerosis)
- MS
• Neurological symptoms
- weakness, reduced ROM, decrease fine motor
control
68. Flaccid dysarthria
• Caused by impairment of LMNs in cranial nerve
and spinal nerve
• Weakness in speech or respiratory musculature
• Vital CNs to speech production
- trigeminal , facial , glossopharyngeal, vagus ,
accessory and hypoglossal
• Relevant SNs
- cervical and thoracic
70. Hypokinetic dysarthria
• Associated with basal ganglion pathology
• The only dysarthria that may have increased speech
rate
• Causes
- Parkinson's disease
- traumatic head injury
* punch drunk encephalopathy
- toxic metal poisoning
-stroke
• Neurological symptoms
- increased muscle tone , decreased range and frequency of
movement
71. Hyperkinetic dysarthria
• Dysfunction to basal ganglia
• Produce involuntary movements that interfere
with normal speech production
• Causes
- chorea
- tardive dyskinesia
- dystonia
72. DYSPHONIA
• Is due to defect in the production of sound
CAUSES
1) Laryngeal diseases-eg;laryngitis
2) Vocal cord lesions
3) Xth cranial nerve palsy
4) psychogenic
73. Evaluation
• Assess comprehension:
– Ask the patient to carry out one, two or several steps
of command
– E.g. Stand up, jump and close the door
• Assess repetition:
– Ask the patient to repeat a sentence
• Assess naming:
– Ask the patient to name common and uncommon
things
• Assess reading and writing:
– Usually affected in dysphasia
74. Evaluation
• Dysarthria and dysphonia
– Listen to spontaneous speech, note VOLUME,
RHYTHM and CLARITY
– Ask the patient to repeat phrases like ‘yellow
lorry’ to test lingual sounds and ‘baby
hippopotamus’ to test labial sounds and some
tongue twisters
– Ask the patient to count till 30 to assess muscle
fatigue
– Ask the patient to cough and say ‘Aaah’
75. Evaluation
• Dysphasias
– During spontaneous speech, listen to FLUENCY
and APPROPRIEATNESS of content, particularly for
par aphasias and neologisms
– Ask the patient to name common objects
– Give the patient a 3-stage command
– Ask the patient to repeat simple sentences
– Ask the patient to read a paragraph
– Ask the patient to write a sentence and examine
the handwriting
76. Management
• Most patients recover spontaneously or
improve within the first month
• Speech therapy can be helpful, but unlikely to
be of benefit after the first few months
77. • Pharmacological treatment for aphasia
following stroke (Review)
• Speech and language therapy for aphasia
following stroke (Review)
78. Resources
• Macleod’s clinical examination
• Davidson’s principles and practice of medicine
• Oxford handbook of clinical medicine
• Step up to medicine
Editor's Notes
The classical clinical findings of normal pressure hydrocephalus are 1-3:
urinary incontinence
intellectual deterioration
gait disturbances
These can be remembered with the unkind mnemonic Wet, Wacky and Wobbly.
As the name suggests mean CSF opening pressure in patients with NPH is within the normal range (<18 cm H2O or 13 mm Hg) 3.
The cerebrum has 2 parts: the right cerebral hemisphere and the left cerebral hemisphere. They are connected at the bottom and have a deep groove running between them. In general, the right cerebral hemisphere controls the left side of the body, and the left cerebral hemisphere controls the right. The right side is involved with creativity and artistic abilities. The left side is important for logic and rational thinking.
The hemispheres of the cerebrum are divided into lobes, or broad regions of the brain. Each lobe is responsible for a variety of bodily functions:
Frontal lobes are involved with personality, speech, and motor development
Temporal lobes are responsible for memory, language and speech functions
Parietal lobes are involved with sensation
Occipital lobes are the primary vision centers
Frontal lobe:
Function[edit]
The executive functions of the frontal lobes involve the ability to recognize future consequences resulting from current actions, to choose between good and bad actions (or better and best), override and suppress socially unacceptable responses, and determine similarities and differences between things or events.
The frontal lobes also play an important part in retaining longer term memories which are not task-based. These are often memories associated with emotions derived from input from the brain's limbic system. The frontal lobe modifies those emotions to generally fit socially acceptable norms.
Stuss, et al. discuss in a review of many studies how damage to the frontal lobe can occur in an assortment of ways and result in many different consequences.Transient ischemic attacks (TIAs) and/or strokes are common causes of frontal lobe damage in older adults (ages 65 and older). These strokes and TIAs (or mini-strokes) can occur due to blockage of blood flow to the brain or because of the rupturing of a blood vessel/aneurysm inside of the brain. Other ways in which injury can occur include head injuries such as concussions incurred during accidents, diagnoses such as Alzheimer’s Disease or Parkinson’s Disease (which cause dementia symptoms), and frontal lobe epilepsy (which can occur at any age)
Temporal lobe:
Less than 7% of AD is familial
Autosomal dominant mainly
Senile plaques: central core of amyloid beta (Aß) surrounded by distorted, swollen neurites
Amyloid angiopathy - Aß deposition in blood vessels of leptomeninges and brain
Neurofibrillary tangles – hyperphosphorylation of tau protein
A region at the posterior end of the superior temporal gyrus
called Wernicke's area is concerned with comprehension of
auditory and visual information. It projects via the arcuate
fasciculus to Broca's area (area 44) in the frontal lobe
immediately in front of the inferior end of the motor cortex.
Broca's area processes the information received from
Wernicke's area into a detailed and coordinated pattern for
vocalization and then projects the pattern via a speech
articulation area in the insula to the motor cortex, which
initiates the appropriate movements of the lips, tongue, and
larynx to produce speech.
The probable sequence of events that occurs when a subject
names a visual object is shown in Figure 19-8. The angular
gyrus behind Wernicke's area appears to process information
from words that are read in such a way that they can be
converted into the auditory forms of the words in Wernicke's
area.