NR547 Final Exam complete review. Final exam questions and detailed correct and verified answers.

NR547 Final Exam complete review. Final exam questions and detailed correct and verified answers. Ameeta, a 42-year-old female, presents to the primary care clinic with a three-month history of "feeling low and sad" with poor energy, inability to concentrate, and irritability. She indicates that the symptoms were initially present once per week but have increased to 4-5 times per week. She reports making an error last week at the grocery store where she works as a cashier and snapping at the customer when the error was brought to her attention. She is concerned about her loss of interest in her usual social activities and a 20-pound weight gain. She also reports frequent headaches, difficulty getting out of bed in the morning, feeling worthless, and low libido. She acknowledges that she feels guilty daily as she has not visited her son in 6 months and believes that she has "let him down". Thinking about it keeps her "up at night". She has difficulty falling and staying asleep every night. She denies suicidal idea - Correct Answer citalopram 20 mg po daily Rationale: Although all three drugs are appropriate to use when treating unipolar depression, Citalopram is an SSRI and is considered a first-line choice. Medications for depression - Correct Answer SSRIs SNRIs SDRIs TCAs MAOIs SSRIs - Correct Answer -Action: inhibit 5-HT reuptake -Examples: citalopram, escitalopram, fluoxetine, paroxetine, sertraline -Adverse effects: • nausea • agitation • diarrhea • headache • weight gain • sexual side effects SNRIs - Correct Answer -inhibit 5-HT reuptake -inhibit NE reuptake (↑ energy, focus) -increase DA in prefrontal cortex (↑ cognition) -Examples: desvenlafaxine, duloxetine, levomilnacipran, venlafaxine -Adverse effects: • elevated blood pressure • nausea • sweating • tremors • anxiety • insomnia • constipation • anorexia • sexual dysfunction SDRIs - Correct Answer -inhibit DA reuptake (↑alertness, motivation) -inhibit NE reuptake (↑energy) -Adverse effects: • agitation • headache • dry mouth • constipation • weight loss TCAs - Correct Answer -Action: inhibits the reuptake of serotonin and norepinephrine; blocks norepinephrine, histamine, and acetylcholine receptors -Examples: amitriptyline, clomipramine, desipramine, doxepin -Common Side Effects: • dry mouth • constipation • blurred vision • urinary retention • sedation • weight gain • hypotension • tachycardia • sexual dysfunction MAOIs - Correct Answer -Action: increases norepinephrine and serotonin by inhibiting the enzyme that inactivates it -Examples: isocarboxazid, phenelzine, tranylcypromine -Common Side Effects: • sedation • dizziness • sexual dysfunction • hypertensive crisis Prescribing pearls: citalopram (Celexa) - Correct Answer mild antihistamine effects Prescribing pearls: escitalopram (Lexapro) - Correct Answer no known drug interactions Prescribing pearls: fluoxetine (Prozac) - Correct Answer longest half-life Prescribing pearls: paroxetine (Paxil) - Correct Answer also treats social anxiety and insomnia Prescribing pearls: fluvoxamine (Luvox) - Correct Answer treats anxious depression smokers require increased dose Prescribing pearls: sertraline (Zoloft) - Correct Answer also treats social anxiety and hypersomnolence Prescribing pearls: bupropion (Wellbutrin) - Correct Answer NDRI may improve energy, alertness, and motivation; not first line treatment for anxiety; contraindicated in clients with a history of seizures Prescribing pearls: duloxetine (Cymbalta) - Correct Answer effective for atypical pain at higher doses; appropriate for clients who present with somatic symptoms of depression; effective for atypical pain, such as fibromyalgia and diabetic neuropathy Prescribing pearls: venlafaxine (Effexor) - Correct Answer treats both depression and anxiety disorders, ensure trial of higher dose before switching to a different medication Prescribing pearls: desvenlafaxine (Pristiq) - Correct Answer effective for perimenopausal vasomotor symptoms considered when selecting a medication: - Correct Answer -Client preference -Prior treatment response -Anticipated adverse effects -Comorbidities -Half-life and interactions -Cost if a medication is not achieving efficacy: - Correct Answer -Increase dose gradually -Switch to a different drug within the same class -Switch to drug in a different class -Add a second medication Use to protect against suicide - Correct Answer lithium MDD and BPD genetics - Correct Answer genetic factors contribute 31-42% of the disease risk in MDD and 59-85% in BPD monoamine hypothesis of depression - Correct Answer -posits that depression occurs as a result of a deficiency of one or all three monoamine transmitters • serotonin, norepinephrine, and dopamine -while mania may result from an excess *Emphasis is now shifted from the monoamines to their receptors and other downstream events such as the regulation of gene expression, growth factors, environmental factors, and epigenetic changes - Correct Answer Three principal neurotransmitters -norepinephrine (NE), dopamine (DA), and serotonin 5HT • comprise the monoamine neurotransmitter system • implications for the pathophysiology and treatment of mood disorders • All known pharmacologic treatments for mood disorders act upon one or more of these three neurotransmitters -Many of the symptoms of mood disorders are hypothesized to involve dysfunction of various combinations of the monoamine neurotransmitters Mood disorders include ____________________ and ___________________ - Correct Answer depressive disorders and bipolar disorders Major depressive disorder (MDD) - Correct Answer one of the most prevalent psychiatric disorders -estimated that more than 300 million people suffer from -leading cause of disability worldwide -7.1% of adults and 13.3% of adolescents in the U.S. had at least one major depressive episode -An imbalance of specific neurotransmitters, including dopamine, serotonin, and norepinephrine, can influence brain activity and result in depression -decreased neurotransmitter activity in the prefrontal cortex (PFC) MDD dx - Correct Answer -occurrence of at least one episode of major depression lasting at least two weeks. -must experience 5 or more of the following symptoms in two weeks to be diagnosed with a major depressive episode: • feeling low most of the day for most days • decreased interest in activities • substantial weight loss, significant change in appetite • fidgeting, random movement (i.e. pacing) • decreased energy • sense of guilt or worthlessness • lack of focus or ability to make decisions • repeated thoughts of death and suicide risk factors associated with major depressive disorder (MDD) - Correct Answer female gender older adults with multiple health problems and disabilities non-white populations family history of MDD, suicide attempts and completion, substance abuse history of abuse/neglect financial, job loss, divorce, or other life stressors low socioeconomic status lack of relationships and support systems Certain conditions are associated with depression, including: - Correct Answer epilepsy post-stroke Parkinson's disease multiple sclerosis degenerative brain disease Alzheimer's disease coronary artery disease depression in malignancy hypothyroidism hyperthyroidism hyperparathyroidism Cushing's syndrome Addison's disease diabetes mellitus key symptoms of depression: - Correct Answer depressed mood and a loss of interest or pleasure -may also present with physical symptoms, including fatigue, inattention, poor appetite, decreased libido, psychomotor retardation, or agitation -often report difficulty sleeping, lack of motivation, or trouble completing tasks -severe cases, depressed clients may report delusions or hallucinations -may even present as catatonia MDD by severity: mild, moderate, or severe - Correct Answer Mild: The intensity of symptoms is manageable with minimal impairment in functioning. There are few symptoms beyond those required for diagnosis. Moderate: The number of symptoms, intensity, or impairment in functioning is between mild and severe. Severe: The intensity of symptoms is unmanageable and distressing. Symptoms interfere with functioning. The number of symptoms is beyond what is required for diagnosis. melancholic features - Correct Answer Symptoms worse in the morning, excessive guilt, significant weight loss atypical features - Correct Answer Weight gain, hypersomnia, heavy feeling in arms or legs Screening tools for depression severity - Correct Answer -Patient Health Questionnaire (PHQ) -Beck Depression Inventory-II (BDI-II) -Hamilton Depression Rating Scale (HAM-D) -Edinburgh Postnatal Depression Scale (EPDS) in post-partum and pregnant women -Children's Depression Inventory (CDI) -Children's Depression Rating Scale (CDRS) -Geriatric Depression Scale (GDS) in older adults The United States Preventive Services Task Force (USPSTF) recommends depression screening: - Correct Answer for adults 18 years of age or older and adolescents ages 12-18 years old. The American Academy of Family Physicians recommends screening for depression in: - Correct Answer the general adult population, including pregnant and post-partum women. The American Academy of Pediatrics recommends maternal screening for postpartum depression at: - Correct Answer infants' 1, 2, and 4- month visits. The American Academy of Pediatrics' Bright Futures program recommends: (screenin) - Correct Answer annual screening in adolescent clients for emotional and behavioral problems. Medicaid's child health component, the Early and Periodic Screening, Diagnosis and Treatment program recommends: - Correct Answer screening to detect physical and mental conditions at various age intervals. If a risk is identified, the provider should follow up with diagnosis and treatment. Immuno-Psychiatry (neuroimmunology) - Correct Answer explores how the immune system interacts with the brain and the mind -This interaction can affect both physical and mental health -The immune system protects the body from infection • Macrophages are the centurions of the immune system. Macrophages warn the immune system of a potential threat by secreting cytokines alerting more macrophages to come to the injured site • Cytokines (inflammatory proteins in the blood) can send signals across the blood-brain barrier. • Nerve cells exposed to cytokines are more likely to die than regenerate • In rat studies, rats injected with cytokines exhibited social withdrawal, less movement, and altered sleeping and eating patterns. • Inflamed nerve cells cannot effectively transmit 5-hydroxytryptamine (5HT) or serotonin receptors. • Persons with inflammatory conditions are significantly more depressed than the general population. *People who frequently eat foods known to cause inflammation (carbs) are more likely to exhibit depressive symptoms • People tend to feel better when they eat clean, possibly due to the decreased inflammation Medical Diagnoses that Mimic Depressive Disorders - Correct Answer hypothyroidism vitamin D deficiency anemia chronic fatigue syndrome Medications with side effects mimicking depression include: - Correct Answer cannabis, alcohol, clonidine, antidepressants, anticonvulsants, antimigraine agents, corticosteroids, contraceptives, and varenicline (Chantix) Depression treatment: pharmacological - Correct Answer Selective Serotonin Reuptake Inhibitors (SSRIs) Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) Tricyclic Antidepressants (TCAs) Monoamine Oxidase Inhibitors (MAOIs) Must Not Miss Diagnosis: BD - Correct Answer Clients with bipolar disorder may present during the depressive phase -may not report any symptoms of hypomanic or manic episodes • provider must obtain a careful history from the client and/or family members to differentiate between bipolar disorder and depression -Bipolar disorder should be ruled out as a cause of depression before prescribing medication as certain antidepressant medications can precipitate a manic episode or induce rapid-cycling bipolar depression *may contribute to the increased incidence of death by suicide in children and adults younger than 25 Bipolar disorder - Correct Answer mental illness that causes extreme shifts in emotions, mood, and energy levels -Shifts in mood usually occur over several days to weeks -classified according to the types of mood episodes exhibited -affects approximately 2.6% of the adult population in the U.S. -sixth leading cause of disability in the world -most frequently diagnosed in late adolescence or early 20s -lifelong condition cause of bipolar disorder - Correct Answer unknown -Individuals with family members who have bipolar disorder are more likely to develop it -interaction between genetic factors and the environment may be contributory -Brain imaging reveals white matter hyperintensities, reduction in gray matter volume, increased ventricular size, and decreased frontal cortical area volumes Bipolar disorder symptoms - Correct Answer Depressive Symptoms -similar to MDD Manic Symptoms -elevated, expansive, or irritable mood Hypomanic Symptoms -milder form of mania Mixed Symptoms -presence of symptoms of depression and mania simultaneously dx manic - Correct Answer -elevated, expansive, or irritable mood for at least one week, mood present most of the day and nearly every day -severe enough to cause significant impairment in social or occupational functioning, to req hospitalization to prevent harm to the client or others, or symptoms include psychotic features -three or more of the following symptoms (APA, 2022) must be present and represent a significant change from usual behavior: • inflated self-esteem or grandiosity • decreased need for sleep • increased talkativeness • racing thoughts • distracted easily • increase in goal-directed activity or psychomotor agitation • engaging in activities that hold the potential for painful consequences, e.g., unrestrained buying sprees dx hypomania - Correct Answer must experience symptoms for at least four consecutive days with symptoms present most of the day and nearly every day. -energy level is higher than normal but not as high as with mania -episodes can lead to challenges but do not tend to lead to major issues with daily functioning -episodes do not involve psychotic symptoms and are less likely to lead to hospital visits. Bipolar disorder triggers - Correct Answer Environmental factors can trigger -Selective Serotonin Reuptake Inhibitors (SSRIs) can trigger manic episode -Stimulant drugs can be legal or illegal -Changes in circadian rhythm (could be due to shift work or change in time zones) -Life stressors Clinical presentation: Bipolar Tyle I - Correct Answer at least one episode of mania for at least one week (or any hospitalization) -Hypomanic episodes may also occur -MDD episodes are common in bipolar I (not req for diagnosis) Clinical presentation: Bipolar Tyle II - Correct Answer at least one major depressive episode and at least one current or past hypomanic episode, but no full mixed or manic episode -symptoms last for at least four days, but fewer than seven and include the same symptoms as mania without causing severe impairment or requiring hospitalization -Psychotic features are not present with bipolar II disorder, although irritability and anger are common. Carlo is a 24-year-old married auto mechanic who works full-time. His wife reports that he began several home repair projects about three weeks ago "out of the blue." He is painting the exterior of the home, remodeling a bathroom, and digging a new garden. He used to sleep 6-7 hours per night, but he is now sleeping about 3 ½ hours per night. Although Carlo has no history of bipolar disorder, his wife is concerned that this may be a manic episode. Her father was diagnosed with bipolar I disorder; she worries that Carlo's symptoms are similar. Based on the DSM-5-TR (APA, 2022), does Carlo meet the diagnostic criteria for bipolar I disorder? yes no unable to determine - Correct Answer unable to determine Rationale: Carlo meets category A criteria (abnormal and persistent increased activity lasting at least one week) and two diagnostic criteria in category B for bipolar I disorder (decreased need for sleep and increase in goal-directed activity). However, three symptoms are required for diagnosis; more information is needed to determine if Carlo is experiencing additional symptoms or if his behaviors are significantly impacting his occupational or social interactions. In addition, the PMHNP should inquire about the use of medications and/or legal and illegal stimulants to determine if they may be impacting Carlo's behavior. Rapid cycling - Correct Answer four or more episodes of depression and mania occur within one year Cyclothymia - Correct Answer numerous episodes of hypomanic symptoms that do not meet the criteria for a hypomanic episode and numerous periods of depressive symptoms that do not meet the criteria for a major depressive episode -at least two consecutive years during which clients are symptomatic at least half the time and not symptom-free for more than two consecutive months Tariq is a 22-year-old who presents with symptoms of racing thoughts and an inability to pay attention in his college classes. He is currently failing most of his courses. He feels like he needs to talk constantly. He calls friends at all hours and tries to engage strangers in conversation. He also reports feeling restless and tense. He has experienced these symptoms continuously for the past two weeks. His toxicology screen is negative, and he takes no medications. What is the appropriate ICD-10 code for Tariq? - Correct Answer F31.89 Rationale: The ICD-10 code is F31.89 bipolar 1 disorder with anxious distress. Tariq meets diagnostic criteria for Bipolar I, with symptoms including racing thoughts, difficulty paying attention, and constant talking. He is experiencing consequences from his behavior as he is failing classes. He has experienced the symptoms for two weeks. Because he also has symptoms of restlessness and increased tension, he also meets the qualifying diagnostic criteria for anxious distress. Savannah is a 32-year-old who presents with her husband. Her husband states that Savannah has spent thousands of dollars on new clothing and shoes in the past month. The clothing she has purchased is much more revealing than her typical wardrobe. She is sleeping for just a few hours per night. She is spending hours on Twitter and is constantly boasting about how many retweets she receives and how many followers she has. Two days ago, Savannah reported that the drummer of her favorite band began following her; she is planning to skip work for a week to travel out of state and attend the band's concert. She asserts that the drummer has invited her backstage to have sex following the concert. Savannah has never had behaviors like this in the past. Her toxicology screen is negative. What is the appropriate ICD-10 code for Savannah? - Correct Answer F31.2 Rationale: The ICD-10 code is F31.2 bipolar 1 disorder with mood-congruent psychotic features. Savannah meets diagnostic criteria for bipolar I, with symptoms of grandiosity, decreased sleep, and excessive shopping. She is experiencing impairment in social and occupational functioning. She has experienced these symptoms for a month. Because Savannah is also experiencing delusional thinking consistent with her mood, she also meets the criteria for mood-congruent psychotic features. Vladimir is a 25-year-old who presents with feelings of racing thoughts. His thoughts are centered on feelings of worthlessness. He reports feeling very fatigued and continually paces around the room. He has been irritable and easily distracted for the last two weeks. He endorses an increase in sexual behavior, including several recent episodes of unprotected sex with multiple partners. He admits to having suicidal ideations. What is the appropriate ICD-10 code for Vladimir? - Correct Answer F31.12 Rationale: The ICD-10 code is F31.12 bipolar 1 disorder manic episode with mixed features. Vladimir meets diagnostic criteria for bipolar I disorder, with symptoms including racing thoughts, psychomotor agitation, distraction, risky behaviors, and irritability for the past two weeks. Because he also endorses fatigue, feelings of worthlessness, and suicidal ideation, he meets the criteria for a manic episode with mixed features. Screening tools for bipolar disorders: - Correct Answer Mood disorder questionnaire -a non-diagnostic, self-rated instrument that provides information to clients who may need additional assessment. Bipolar spectrum diagnostic scale -a self-rated instrument presented in story format that is sensitive to subtle symptoms of bipolar disorder Medical Diagnoses that Mimic Bipolar Disorder - Correct Answer -hyperthyroidism -hyperaldosteronism -brain tumor -neurocognitive disorder -delirium Rationale: Medical conditions that commonly present with symptoms that mimic mania include hyperthyroidism, hypercortisolemia, hyperaldosteronism, brain tumor, neurocognitive disorder, acromegaly, delirium, lupus, HIV, or syphilis. medications or substances commonly cause symptoms that mimic mania? - Correct Answer steroid medications hallucinogens methamphetamine marijuana Rationale: Medications and substances with effects that mimic mania include levodopa, hallucinogens, antidepressants, methamphetamine, marijuana, or cocaine. Bipolar disorder tx: pharmacological - Correct Answer Antipsychotics Anticonvulsants Benzodiazepines Lithium salts Antidepressants Bipolar disorder tx: _____________Acts as a mood stabilizer, more effective at treating mania than depressive symptoms. - Correct Answer Lithium salts Bipolar disorder tx: _____________SSRIs may trigger manic episodes in individuals who are predisposed to them. - Correct Answer Antidepressants Bipolar disorder tx: _______________Acts on dopamine receptors to reduce levels of excess dopamine, exhibit high affinity for D2, D3, 5-HT1A, and 5-HT2A receptors. - Correct Answer Antipsychotics Bipolar disorder tx: ______________May be combined with other medications to treat bipolar disorder, may improve both mania and depressive symptoms. - Correct Answer Anticonvulsants Bipolar disorder tx: ______________Slows the activity of the brain resulting in a reduction of mania, anxiety, and panic disorder - Correct Answer Benzodiazepines lab tests required for Lithium: - Correct Answer serum lithium level renal function thyroid function lab tests required for Valproic acid (Depakote): - Correct Answer serum valproate level liver function CBC lab tests required for Carbamazepine: - Correct Answer serum carbamazepine level renal function liver function CBC lab tests required for Atypical antipsychotic medications: - Correct Answer CBC HbA1C Bipolar disorder tx: Nonpharmacological - Correct Answer adjunct nonpharmacological treatment options may help reduce symptom burden -Health Education -Client and family support -Electroconvulsive therapy (ECT) -Psychotherapy Suicide in the U.S. - Correct Answer -Approximately 2/3 of clients with depression contemplate suicide • 10-15% die by suicide -Suicide is the second leading cause of death between the ages of 10-24 years -Almost 2 million adolescents attempt suicide each year -One in four older adults suicide attempts are fatal -One in 200 adolescent suicide attempts are fatal -Conversations about suicidal ideation are critical • Screening tools such as the National Institutes of Health (NIH) Ask Suicide-Screening Questions (ASQ) are helpful resources to support these conversations. Risk factors for suicide: - Correct Answer -family history of suicide -history of depression -drug and alcohol use -history of school difficulties -high achiever -anxiety -having been bullied -access to lethal means -exposure to others with previous thoughts or actions of suicide -incarceration -traumatic life events or relationship issues -identifying as LGBTQ+ -Native American descent Depression Lifespan Considerations: Older Adults - Correct Answer second leading cause of disability after cardiovascular disease -impacts around 7% of the geriatric population -often underreport symptoms of depression -not a normal part of the aging process -Risk factors: • Chronic illness • Disability/ loss of mobility • Change in living situation • Role transitions • Loss of independence • Bereavement • Economic hardships Depression Lifespan Considerations: Older Adults, pertinent information for an interview - Correct Answer -socialization, including recent changes or loss -ability to complete activities of daily living (ADLs) -typical physical activity -appetite changes -weight loss or gain -psychotic symptoms -suicidal thoughts or ideations Bipolar Lifespan considerations: older adults - Correct Answer Approximately 10% of bipolar cases are diagnosed after the age of 50 -mania is more likely to be expressed as agitation or irritability rather than euphoria -more likely to experience mixed episodes -Late-onset bipolar disorder may be difficult to distinguish from dementia Geriatric Depression Scale (GDS) - Correct Answer self-reporting tool that may be used to diagnose and treat depression 0-4: No depression No treatment indicated 5-8: Mild depression Pharmacologic or psychotherapeutic treatment may be indicated Base treatment on duration of symptoms and functional impairment 9-11: Moderate depression Pharmacologic, psychotherapeutic, or combination treatment indicated 12-15: Severe depression Pharmacologic, psychotherapeutic, or combination treatment indicated It is important to evaluate _______________ when depression is suspected - Correct Answer cognitive function -Older clients may have associated memory loss, slowed processing, or impaired executive functioning • Depression is an independent risk factor for dementia • A Mini-Cog or other cognitive screening tool can provide a baseline assessment for clients In clients who have dementia, self-reporting scales, such as the GDS, may be inappropriate. The __________________________________ may be used as an alternative - Correct Answer Cornell Rating Scale for Depression in Dementia goal of treatment for older adults experiencing depression - Correct Answer achieve symptom remission -Options • pharmacotherapy • psychotherapy • psychosocial interventions Depression tx for older adult: Pharmacologic - Correct Answer SSRIs & SNRIs -Escitalopram, citalopram, and sertraline have fewer drug-drug interactions than other medications and are appropriate choices for initial therapy in older adults taking multiple medications Depression tx for older adult: Nonpharmacologic - Correct Answer Engagement Social support Exercise Relaxation DIGFAST - Correct Answer mnemonic that may be helpful to assess for bipolar disorder in the clinical setting: Distractibility Impulsivity Grandiosity Flight of ideas Activity level Sleep Talkativeness Neurocognitive disorders - Correct Answer delirium and dementia Dementia - Correct Answer -a group of symptoms that mainly affects memory, cognition and social interactions, and the ability to do everyday tasks. -Symptoms start gradually often with no clear beginning, and are usually permanent. -Most dementias are caused by neurodegenerative diseases, most commonly Alzheimer's disease, Lewy body dementia and frontotemporal dementia • clumps of abnormal proteins to build up inside neurons, damaging them, and causing them to slowly degenerate and die -vascular dementia is another common cause of progressive dementia • brain damage occurs when the blood supply to the neurons is reduced or blocked, again causing them to malfunction or die -Cognitive Symptoms: Difficulty with complex tasks, Difficulty planning and organizing, Loss of coordination -Psychological symptoms: Personality changes, Inappropriate behaviour, Paranoia, Fear, anxiety, anger or depression. Delirium - Correct Answer ACUTE SUDDEN CHANGE IN MENTAL STATE -typically begins suddenly with a noticeable start point. -mainly affects attention, and often resolves after a few days or weeks, although it can last longer. -acute, transient, and usually reversible brain malfunction -thought to be brought on by multiple neurotransmitter imbalances Delirium symptoms - Correct Answer -Cognitive Symptoms: Rambling or nonsense speech, Difficulty reading and writing, Wandering attention, Becoming easily distracted, Becoming withdrawn, -Psychological symptoms: Inability to focus, Reduced awareness of the environment, Disturbed sleep -May have hallucinations -symptoms can fluctuate throughout the day causes of delirium - Correct Answer -lack of oxygen -drugs • anticholinergics • psychoactives • opioids -withdrawal • delirium tremens -stressful situations -dehydration & electrolyte imbalance infections tell the difference between delirium and dementia - Correct Answer onset attention do symptoms fluctuate? Alzheimer's disease - Correct Answer -type of dementia • 60-80% of dementias -neurodegenerative disease -Hallmarks: • plaques - abnormal protein (beta-amyloid plaques) between neurons • tangles - tau protein inside neurons (neurofibrillary tangles) Alzheimer's disease brain progression - Correct Answer -Plaques & tangles usually start forming and spread from the cortex • earliest areas affected temporal lobe (learning & memory) • as it spreads goes to frontal lobe (thinking & planning) • then more temporal (speaking & communicating) • then parietal lobe (sense of where body is in relation to objects around you) • severe & late Alzheimer's disease, plaques & tangles spread throughout most of cortex, brain shrinks (atrophy) dramatically (atrophy primarily affects hippocampus and cerebral cortex) Vascular dementia - Correct Answer -20-30% of dementia cases -lack in blood supply to the brain -changes • suddenly (stroke) • gradually (small vessels) -risk factors • similar to heart problems • smoking • high BP • no exercise • obesity • poor diet Lewy body dementia - Correct Answer -10-25% of dementia cases -abnormal protein structures forming inside neurons (lewy bodies) • alpha synuclein protein = lewy bodies -lewy bodies can be found it ppl with alzheimers & parkinsons too • ppl with parkinsons can develop parkinsons later on -symptoms • thinking & memory • movements & trembling • hallucinations • physically acting out dreams Parkinsons disease dementia - Correct Answer affects motor control and mental functions -lewy bodies found in ppl with parkinsons disease, leads to dementia Frontotemporal dementia - Correct Answer -Frontal lobe damage • spacial orientation -Temporal lobe damage • speech other causes of dementis - Correct Answer -alcohol misuse -repeated head injuries -can have more than one type of dementia present risk factors for dementia - Correct Answer -Age • more common after 80 -family hx • genetic factors (risk/deterministic genes) • environmental factors -down syndrome -head trauma -heart trauma Risk gene that has strongest association with developing Alzheimer's - Correct Answer apolipoprotein E-E4 • APOE-E4 • factor in 20-25% of alzheimer's cases Deterministic genes for alzheimer's - Correct Answer mutation in any 3 genes can cause early onset alzheimers (before 65) due to a build up of amyloid plaques -Amyloid Precursor Protein (APP) -Presenilin 1 (ps-1) -Presenilin 2 (ps-2) Stages of Alzhimer's disease - Correct Answer 3 stage model Reisberg scale Alzheimer's disease: 3 stage model - Correct Answer Early (1-3 years) -short term memory deficits -disoriented to date -diminished recall of recent events -mild language and decision-making deficits -mild problem copying figures (clock drawing) -social withdrawal -mood change -personality changes -problems with managing finances Middle (2-8 years) -disoriented to date and place -may get lost in familiar places -impaired learning new skills -agitation, aggression, restlessness, or anxiety -difficulty with ADLs such as cooking and grooming Late (6-12 years) -disoriented to person, time, or place -non-verbal -long term memory diminished -unable to groom or dress -progress to need for total care at end stage -incontinent -motor or verbal agitation Alzheimer's disease: Reisberg scale - Correct Answer -stage 1: no impairment -stage 2: mild cognitive decline -stage 3: mild cognitive impairment, signs of early confusion -stage 4: mild alzheimer's disease, lasts about 2 years -stage 5: early dementis to moderate alzheimer's diease, cognitive decline more drastic, lasts 1.5 years -stage 6: moderatly severe alzheimer's disease, help with basic daily tasks, lasts 2.5 years -stage 7: final stage, speech severely limited, decline in basic abilities, movement abilities affected Diagnosis of dementia and Alzheimer's disease - Correct Answer -Patient History -Physical Exam -neurological eval -neuropsychological test • MMSE: scores 20-24 mild dementia, 13-20 moderate, <13 severe dementia • mini-cog test -Psychiatric evaluation -Brain scans • CT scans • MRI • reason for brain scans: ID larger masses, differential diagnosis, monitor disease progression, research purposes Other conditions that can cause dementia like symptoms - Correct Answer anemia depression infection diabetes kidney disease etc. Treatment of dementia and Alzheimer's disease - Correct Answer No Cure -Medications lesson symptoms -meds target neurotransmitters: • acetylcholine • glutamate -Cholinesterase Inhibitors -Memantine Cholinesterase Inhibitors - Correct Answer acetylcholine neurotransmitter -helps neurons communicate Acetylcholinesterase -breaks down acetylcholine CHOLINESTERACE INHIBITORS -stop acetylcholinesterase from breaking down acetylcholine • allowing more acetylcholine to build up, helping neurons communicate -delay worsening dementia symptoms for 6-12 months • for about 1/2 of patients -side effects: N/V, loss of appetite Medication: -Donepezil (Aricept) -Rivastigmine (Exelon) -Galantamine (Razadyne, Razadyne ER) Memantine - Correct Answer Glutamate -excitatory neurotransmitter -normal levels: learning & memory -too high: toxic (excitotoxicity) • cell too stimulated, may die -Memantine blocks NMDA receptor for glutamate, keeping channel closed so too many ions do not get in so cell doesn't get excitotoxicity -used to tx moderate to severe alzheimer's disease -often taken with cholinesterase inhibitors -side effects: headache, confusion, dizziness Medication: -Memantine (Namenda) heritability of AD - Correct Answer late-onset AD showing heritability of 58-79% and early-onset AD showing over 90% Donepezil (Aricept) - Correct Answer -inhibits centrally active acetylcholinesterase -Side effects: • GI symptoms, headache, dizziness, muscle weakness -Precautions: • sick sinus syndrome • seizure disorder -Pearls: • Taper to avoid withdrawal effects • approved to treat moderate to severe AD at 23 mg/day dose, minimal improvement in cognitive functioning when compared to a 10 mg/day dose • added to CYP2D6 or CYP3A4, there is a possibility of peripheral side effects, and inducers of CYP2D6 and CYP3A4 may increase the rate of elimination Rivastigmine (Exelon) - Correct Answer -acts centrally for both acetylcholinesterase and butyrylcholinesterase • potentially increasing its efficacy -side effects: • GI symptoms, weakness, dizziness, tremor -Precautions • asthma or COPD • sick sinus syndrome • GI Bleeding • weight < 50 kg -Pearls: • orally or topically (transdermal patch) • transdermal patch is used for dementia associated with Parkinson's disease Galantamine (Razadyne, Razadyne ER) - Correct Answer -elevating acetylcholine (Ach) in the cerebral cortex, modulating the nicotinic Ach receptors to increase Ach release from existing presynaptic nerve terminals, increases glutamate and serotonin levels -Side effects: GI symptoms, headache, dizziness, fatigue -Precautions: • NSAID use • GI bleed • asthma or COPD • concurrent use with medications that slow or decrease heart rate -Contraindications • severe hepatic impairment • severe renal impairment -Pearls • two major metabolizing enzymes CYP3A4 and CYP2D6 increase galantamine concentrations or reductions in clearance and anticholinergic side effects when given concurrently with inhibitors of these enzymes Memantine (Namenda) - Correct Answer -prevents glutamate, an excitatory neurotransmitter, from binding at the receptor site. • NMDA receptors control activity throughout the brain by regulating how much calcium enters the nerve cell -Side effects: GI symptoms, urinary freq, confusion, dizziness, headache, cough -Precautions: • concurrent use with (amantadine, rimantadine, ketamine, or dextromethorphan) • severe hepatic impairment • severe renal impairment • medications or conditions that increase the pH of the urine -Pearls: • used as monotherapy or in conjunction with ChEIs; when given with ChEIs, fall precautions are required and driving is forbidden due to delayed reactions. • Minimal inhibition of CYP450 enzymes CYP1A2, CYP2A6, CYP2C9, CYP2D6, CYP2E1, and CYP3A4 occurs, which means there are no pharmacokinetic interactions with medications metabolized by these enzymes Cognitive Domains - Correct Answer Complex attention Executive function Learning and memory Language Perceptual motor Social cognition cognitive domain impairment: Complex attention - Correct Answer -easily distracted -difficulty with mental calculations and multitasking cognitive domain impairment: Executive function - Correct Answer -unable to complete complex projects or solve problems -difficulty with instrumental activities of daily living (bills and pills) and making decisions cognitive domain impairment: Learning and memory - Correct Answer frequent reminders needed, recent memory impaired cognitive domain impairment: Language - Correct Answer -difficulties with expressive or receptive language -word-finding difficulty cognitive domain impairment: Perceptual motor - Correct Answer difficulty with navigating familiar environments or using complex tools (carpentry, sewing) cognitive domain impairment: Social cognition - Correct Answer -changes in behavior or attitude -declining ability to read and respond to social cues Cognitive impairment is suspected when: - Correct Answer one or more cognitive domains are impacted Clinical Presentation: Delirium - Correct Answer -more common in hospitalized older adults or residents in long-term care facilities • can be younger clients & primary care settings as well -often worse later in the day • sleep-wake disturbances increase the incidence of symptoms -physiological consequence of a medical condition, or substance or medication use or withdrawal • Determining underlying cause, crucial to a treatment plan DSM-5-TR -Attention Disturbance -Cognitive Changes -Acute Onset -Direct Consequence of Medical Condition Clinical subtypes -hyperactive -hypoactive -mixed Pete is a 69-year-old who has been in an inpatient surgical unit for 9 days after a thoracic aneurysm replacement. His recovery has been complicated by a history of chronic obstructive pulmonary disease (COPD). The family nurse practitioner (FNP) has been consulted due to changes in his behavior over the past two nights. The night shift nurse reported that Pete became disoriented to time and place and stated that the mylar balloons in the corner of his room were people standing over him, watching him breathe. He was unable to be reoriented, became agitated, and required soft wrist restraints for safety. In the morning interview, Pete is alert, oriented, pleasant, and cooperative. He complains that he has not had a good night's sleep since before his surgery, and states that last night he asked for and was given a "sleeping pill." Review of his electronic medical record (EMR) confirms a as needed (PRN) dose of zolpide - Correct Answer F13.221- moderate delirium due to sedative Rationale: Pete meets diagnostic criteria for medication-induced acute hyperactive delirium due to the administration of zolpidem. Clinical Presentation: Mild and Major NCDs - Correct Answer NCD, or dementia, are chronic and progressive processes characterized by cognitive deficits in language, speech, memory, and a decline in motor skills -often accompanied by a decline in emotional control, social behavior, or motivation -Differentiation between mild and major disorders is a continuum • PMHNP must conduct a thorough functional assessment to determine the level of impairment • Both types of NCD may present with or without concurrent behavioral disturbance • Major NCD may be further classified as mild, moderate, or severe, based on the level of impairment. Lisheng is a 77-year-old who lives independently. She presents with her daughter to the clinic. Her daughter has concerns about her mother's memory and functioning. She reports that in the past 12 months, Lisheng has become increasingly forgetful and does not remember what she had for breakfast or what she did the prior day. Lisheng still drives but admits that she has gotten "turned around" a few times when driving to familiar places, especially in the evening. Lisheng's daughter has begun managing the household finances, as Lisheng missed several payments on the mortgage and utilities. Her medical history includes hypertension. She does not have a psychiatric history. Based on the DSM-5-TR (APA, 2022) criteria, which of the following is the most appropriate criteria for Lisheng? major neurocognitive disorder mild neurocognitive disorder - Correct Answer major neurocognitive disorder Rationale: Lisheng meets the criteria for major neurocognitive disorder. Both mild and major neurocognitive disorders involve a significant decline in cognitive function; however, cognitive deficits that interfere with independence, such as difficulty paying bills or managing medications, meet the criteria for major neurocognitive disorder. Based on DSM-5-TR (APA, 2022) criteria and the information provided, which of the following is the most appropriate classification for Lisheng's behavioral symptoms and severity? mild - with behavioral disturbance mild - without behavioral disturbance moderate - with behavioral disturbance moderate - without behavioral disturbance severe - with behavioral disturbance severe - without behavioral disturbance - Correct Answer mild - without behavioral disturbance Rationale: The classification of severity and behavioral symptoms for Lisheng is mild without behavioral disturbance. Lisheng presents with difficulties with instrumental ADLs, such as managing money and driving, consistent with mild severity of NCD. Neither she nor her daughter indicates any behavioral disturbance, such as apathy, depression, or agitation. Clinical Presentation: Mild or Major NCDs due to AD - Correct Answer AD - approximately 60-70% of cases of dementia AD results in substantial cognitive and functional impairment -neurodegenerative complications • loss of function and cell death Stages of AD: - Correct Answer Stage 1 Normal Aging: No difficulty either subjectively or objectively Stage 2 Possible Mild Cognitive Impairment: Complains of forgetting the location of objects, subjective work difficulties Stage 3 Mild Cognitive Impairment: Decreased job functioning evident to co-workers, difficulty in traveling to new locations, decreased organizational capacity (developmental age 12+). Stage 4 Mild Dementia: Decreased ability to perform complex tasks, e.g., planning dinner for guests, handling personal finances (such as forgetting to pay bills), difficulty shopping, etc. (developmental age 8-12) Stage 5 Moderate Dementia: Requires assistance in choosing proper clothing to wear for the day, season, or occasion, e.g., client may wear same clothing repeatedly unless supervised (developmental age 5-8) Stage 6 Moderately Severe Dementia: Needs help putting on clothes (developmental age 5). Needs help bathing (developmental age 4). Need helps using the toilet (developmental age 3-4). Urinary incontinence (developmental age 2-3). Bowel incontinence (developmental age 2-3). Stage 7 Severe Dementia: Speaks 5-6 words in a day (developmental age 15 months). Speaks only one word clearly (developmental age 1). Can no longer walk (developmental age 1). Can no longer sit up without assistance (developmental age 6-10 months). Can no longer smile (developmental age 2-4 months). Can no longer hold head up by self (developmental age 1-3 months) Clinical Presentation: Other Mild and Major NCDs - Correct Answer Additional diagnoses may be considered as differentials for a client with cognitive impairment -delirium -depression -schizophrenia -head trauma • place the client's health and safety in immediate danger and, if unrecognized, may result in poor outcomes. Tonia is a 66-year-old who presents with memory difficulty. She states she can't remember anything for longer than a few minutes. She also states that she is having difficulty making complex decisions. She also "doesn't want to do anything anymore." She has stopped attending her exercise class and lunch bunch social club because she no longer has an interest in these activities. She feels "down" every day. Her symptoms began 6 weeks ago, and she has never experienced anything like this. Which of the following diagnoses is most appropriate for Tonia? Major depressive disorder Vascular neurocognitive disorder NCD with Lewy bodies Frontotemporal neurocognitive disorder Neurocognitive disorder due to Parkinson's disease Mild neurocognitive disorder due to traumatic brain injury - Correct Answer Major depressive disorder Rationale: Tonia is most likely experiencing major depressive disorder (MDD). The hallmark features that indicate MDD are depressed mood or loss of interest in usual activities. Although memory difficulties and loss of concentration are common with MDD, they are not predominant features. Daron is a 72-year-old who presents with complaints of memory changes. He states he often walks into a store and forgets why he is there. He reports that he frequently struggles to find the right word to complete a sentence. He endorses difficulty in organizing his monthly finances, although he has not missed any bill payments. He states that he has also been feeling "down" lately. His past history includes hypertension and carotid endarterectomy. Which of the following diagnoses is most appropriate for Daron? Major depressive disorder Vascular neurocognitive disorder NCD with Lewy bodies Frontotemporal neurocognitive disorder Neurocognitive disorder due to Parkinson's disease Mild neurocognitive disorder due to traumatic brain injury - Correct Answer Vascular neurocognitive disorder Rationale: Daron's symptoms indicate a possible diagnosis of mild vascular neurocognitive disorder. He presents with memory loss, difficulty in executive function, and feelings of depressed mood, which are frequently associated with vascular NCD. He has cardiovascular risk factors, including hypertension and a past vascular intervention. The PMHNP should ask about symptoms of TIA or CVA, and imaging studies should be conducted to confirm the diagnosis. Trent is a 75-year-old who presents with changes in cognition. He states that there are times that he cannot follow a TV show or decide what to have for dinner, and then the next day, his attention and functioning seem intact. This type of fluctuation is common. He states that he has experienced some very vivid visual hallucinations. He has had several falls in the past few months and has started to use a walker due to his instability. Which of the following diagnoses is most appropriate for Trent? Major depressive disorder Vascular neurocognitive disorder NCD with Lewy bodies Frontotemporal neurocognitive disorder Neurocognitive disorder due to Parkinson's disease Mild neurocognitive disorder due to traumatic brain injury - Correct Answer NCD with Lewy bodies Rationale: Trent's symptoms are consistent with NCD with Lewy bodies. Hallmark features include fluctuating cognitive symptoms with deficits often seen in attention and executive function, vivid visual hallucinations, and repeated falls. As the disease develops, clients may develop motor deficits similar to those seen in Parkinson disease. The PMHNP should conduct additional detailed cognitive testing, including assessment scales to measure fluctuation of symptoms and sleep symptoms, and imaging studies should be conducted to rule out other forms of NCD. Cassie is a 56-year-old professor of economics. Her partner endorses recent changes in Cassie's behavior; she refuses to throw anything away and has begun to hoard food items in the home, and has lost interest in socializing with their friends. She also appears to have difficulty finding words during conversations. She does not have complaints of memory loss. Which of the following diagnoses is most appropriate for Cassie? Major depressive disorder Vascular neurocognitive disorder NCD with Lewy bodies Frontotemporal neurocognitive disorder Neurocognitive disorder due to Parkinson's disease Mild neurocognitive disorder due to traumatic brain injury - Correct Answer Frontotemporal neurocognitive disorder Rationale: Cassie's symptoms are consistent with frontotemporal NCD. Hallmark features include behavioral disturbances such as impulsivity, socially inappropriate behavior, hoarding, or apathy; personality changes; and decline in language abilities. Memory is typically intact. Frontotemporal NCD presents at an earlier age than many other forms of NCD. Imaging studies should be conducted to rule out other forms of NCD; frontal lobe atrophy is commonly seen on the CT scan. Dae is a 72-year-old who presents with complaints of increasing memory loss; he is having difficulty remembering things that happened recently. He states that his wife has started preparing his medications after he missed a few doses. He also complains of apathy and daytime sleepiness. Walter was diagnosed with Parkinson's disease three years ago; he has experienced motor symptoms, but the cognitive symptoms are new to him. Which of the following diagnoses is most appropriate for Dae? Major depressive disorder Vascular neurocognitive disorder NCD with Lewy bodies Frontotemporal neurocognitive disorder Neurocognitive disorder due to Parkinson's disease Mild neurocognitive disorder due to traumatic brain injury - Correct Answer Neurocognitive disorder due to Parkinson's disease Rationale: Since Dae has an existing diagnosis of Parkinson's disease, he may meet the criteria for NCD due to Parkinson's disease. In addition to memory loss and decreased executive functioning, symptoms often include apathy, depressed mood, visual hallucinations, and daytime sleepiness. Isaiah is a 28-year-old who presents with difficulty concentrating. He states that he cannot follow conversations when more than one person is talking, and he is having problems at work completing multi-step tasks. He endorses feelings of irritability. He was involved in a motor vehicle crash two days ago; he hit his head on the windshield and briefly lost consciousness. He was treated and released from the emergency department after the crash. Which of the following diagnoses is most appropriate for Isaiah? Major depressive disorder Vascular neurocognitive disorder NCD with Lewy bodies Frontotemporal neurocognitive disorder Neurocognitive disorder due to Parkinson's disease Mild neurocognitive disorder due to traumatic brain injury - Correct Answer Mild neurocognitive disorder due to traumatic brain injury Rationale: Isaiah meets diagnostic criteria for mild NCD due to traumatic brain injury; he sustained a head injury with loss of consciousness and his symptoms of difficulty with complex and sustained attention began shortly after the injury. Emotional disturbances, such as irritability, frustration, or anxiety are common. Mild NCD due to traumatic brain injury typically resolves within a few weeks to months after the injury. causes of neurocognitive disorders include: - Correct Answer Alzheimer's disease frontotemporal lobar degeneration Lewy body disease vascular disease traumatic brain injury substance/medication use HIV infection prion disease Parkinson's disease Huntington's disease Neurocognitive Disorders Screening Tools - Correct Answer Mini-Cog Geriatric Depression Scale Montreal Cognitive Assessment (MoCA) Saint Louis University Mental Status Mini-Cog - Correct Answer three-item recall test and a scored clock-drawing test -can be effectively used with minimal training -Assessment results help determine the need for a full-diagnostic assessment Geriatric Depression Scale - Correct Answer often used to initially assess depression in older adults -brief survey instrument is used in conjunction with other tools for full cognitive assessment Montreal Cognitive Assessment (MoCA) - Correct Answer -evaluates eight cognitive domains -quick and easy to use and score -can be adapted for use in the clinical setting Saint Louis University Mental Status - Correct Answer -widely used resource for cognitive assessment -evaluates patient orientation, executive function, memory, and attention -also a preliminary tool that is used to determine if a full-diagnostic assessment is warranted Bob, an 87-year-old male, presents with his daughter to discuss his living situation. He currently lives alone, unassisted. His daughter expresses concern for his safety and requests support for moving him to an assisted living facility, which he dismisses. A routine medical workup is completed. Which of the following information is most important to consider in determining the safest place for Bob to live? Family Dynamics Cognitive function of the patient Economic status Cultural background - Correct Answer Cognitive function of the patient Rationale: Bob's cognitive function is key in determining his ability to make the decision or if a healthcare proxy should be implemented, which has identified his daughter as his agent. An assessment of Bob's cognitive function will help in determining his ability to make his own decisions and express them. If he is found to be lacking full cognitive capacity, securing a proxy may be necessary. Laws, policies, and standards should always be followed when securing and using a proxy. Consulting with other disciplines such as social work or legal is also beneficial 72-year-old Luciana presents with concerns about her memory. She reports having trouble remembering what day it is and has missed weekly bunco with her friends six times in 2 months. A Mini-Cog™ assessment is performed. Which of the following is the most appropriate supplemental assessment for Luciana? Administer a figure rearranging test. Ask the patient to name as many types of mammals as possible in 1 minute. Ask the patient to explain the meaning of "you can't judge a book by its cover." Show the patient photos of three vegetables, then ask her to name the vegetables later. - Correct Answer Ask the patient to name as many types of mammals as possible in 1 minute. Rationale: The figure rearranging test would be similar to the clock drawing activity in the Mini-Cog™; repeating this activity will not yield meaningful results. Likewise, showing Luciana photos of three vegetables and asking her to recall them is similar to the word recall exercise in the Mini-Cog™. Asking her to explain the meaning of "you can't judge a book by its cover" is a test of abstract thought which is a higher-level domain than is relevant to her concern. Naming items within a particular category is an executive function test in alignment with Luciana's current concerns. Kim, an 82-year-old male, presents with his wife and son with complains of memory loss and poor hygiene. The client and family report no significant past medical history but express a need for assistance in caring for him. Labs and imaging are completed to rule out anemia, hypothyroidism, depression, and stroke. All results are negative. A Montreal cognitive assessment (MoCA) yields inconclusive results. The client becomes frustrated. Which of the following is the most appropriate management strategy for Kim? Start Risperidone Obtain a complete neuropsychology exam Conduct a family history for Alzheimer's Disease Draw a CMP to evaluate for electrolyte imbalances - Correct Answer Obtain a complete neuropsychology exam Rationale: A diagnosis has not yet been determined and a cognitive assessment screening tool is inconclusive; therefore, a full neurocognitive exam is warranted. A neuropsychological exam will help identify areas of cognitive impairment and aid in the creation of a comprehensive management plan. Note, the first course of action was to eliminate any underlying medical issues that could explain the concerning behaviors. Chantoya, a 78-year-old female, is being seen for her annual wellness exam. During the exam, she reports that, over the past year, she has had trouble finding her words and expressing her thoughts and feelings. She worries that this may be indicative of a stroke or Alzheimer's disease. Chantoya has a positive medical history for significant coronary artery disease, hypertension, and dyslipidemia. She denies recent surgeries. Her vital signs and recent lab values are normal. Her physical and neurological exams are unremarkable. A Montreal Cognitive Assessment (MoCA) is completed with a score of 28/30 (>26 is normal). The two points lost were due to delayed recall. Which of the following is the most appropriate management strategy for Chantoya? CT scan of the brain MRI of the brain Complete cognitive evaluation Reassurance - Correct Answer Reassurance Rationale: Chantoya's MoCA assessment was negative and her symptoms align with expressive aphasia which can be attributed to aging. An MRI may be warranted if major cognitive impairment or pathologies were identified in the assessments. If the MoCA assessment indicated impairment in a specific part of the brain, referral to neurology for follow-up interventions would be indicated. Normal aging processes may manifest as mild short-term memory loss, a slight loss in processing speed, and expressive aphasia (the inability to find words); No significant loss of function in the cognitive domains or the activities of daily living are seen. Possible differential diagnoses for delirium include: - Correct Answer dementia pain CVA or TIA myocardial infarction acute systemic infection hypoglycemia hyperglycemia hypoxia hypercapnia acute urinary obstruction alcoholic ketoacidosis haptic encephalopathy renal failure electrolyte imbalance meningitis brain tumor dehydration constipation urinary tract infection Unlikely but possible diagnoses for dementia include: - Correct Answer amnestic syndromes aphasia brain tumors thyroid imbalances Wilson's disease vitamin B12 deficiency Lyme disease tuberculosis late-stage syphilis what Diagnostic testing can be used to narrow the list of possible diagnoses for clients who present with cognitive deficits. - Correct Answer Laboratory -blood chemistry profiles (including glucose, sodium, potassium, chlorine, bicarbonate, bun, and creatinine) -fasting blood glucose -CBC with differential -TSH -cobalamin level -folate level -ESR -CRP -urinalysis with culture -chest x-ray -HIV testing in those considered at risk -syphilis testing -urine toxicology panel (for opiates, benzodiazepines, cannabinoids, and cocaine) -collagen vascular profile (if there is evidence of systemic vascular involvement) -urinalysis for heavy metals Neuroimaging -CT to identify if there are any brain tumors or structural issues -MRI to identify atrophy, vascular lesions -neurofibrillary tangles -amyloid plaques -fluorodeoxyglucose (FDG)-positron emission tomography (PET) can provide better accuracy than MRI -amyloid PET can make an earlier and more accurate diagnosis of Alzheimer dementia Dementia: Pharmacological Interventions - Correct Answer N-methyl-D-aspartate (NMDA) or cholinesterase inhibitors to treat symptoms related to memory and thinking -aducanumab, an intravenous drug that changes the disease progression to reduce cognitive and functional decline Aducanumab - Correct Answer has been used with clients with mild dementia in clinical trials. This drug acts by binding to and reducing amyloid-beta plaque in the brain. A client with Alzheimer's dementia is prescribed donepezil. Which of the following is the most anticipated client outcome? cured Alzheimer's disease complete return of cognitive function prevention of further cognitive and functional decline improved memory and thinking - Correct Answer improved memory and thinking Rationale: The effect of donepezil is to increase the availability of acetylcholine, which results in enhanced transmission and improved cognition. Donepezil does not cure Alzheimer's disease, result in a complete return of cognitive function, or prevent further decline, although it may slow progression. Personality disorders involve: - Correct Answer -"an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture" per the Diagnostic and Statistical Manual on Mental Disorders, Fifth Edition (DSM-5) -pervasive unhealthy patterns of thinking, functioning, and behaving -usually begins by late adolescence or early adulthood and causes distress or problems in functioning -affect at least two of these areas: • Way of thinking about oneself and others • Way of responding emotionally • Way of relating to other people • Way of controlling one's behavior -Diagnosis is only applicable to individuals 18 or older • People under 18, personalities are still developing -3 clusters • A, B, C -occur in 10-20% of the general population and about 50% of psychiatric clients personality disorders should not be diagnosed unless: - Correct Answer the symptoms are long-standing and impact functioning. Cluster A - Correct Answer Cluster A personality disorders are characterized by odd or eccentric thinking or behavior. -PARANOID PERSONALITY DISORDER • long-standing, pervasive mistrust or suspicion of others and their motives • may refuse to take responsibility for their feelings, often assigning responsibility to others • may appear angry, irritable, or hostile, perceiving innocent remarks as personal insults or attacks -SCHIZOID • lifelong pattern of social withdrawal, introversion, and discomfort with social interaction • difficulty reading social cues and may have an inability to find pleasure in most activities • Affect is bland and constricted and others may perceive their behaviors as cold, indifferent, lonely, or isolated -SCHIZOTYPAL • often appear odd to others • may dress peculiarly and exhibit magical thinking, odd notions, illusions, ideas of reference, and derealization • emotional responses may be flat or inappropriate Rico is a 30-year-old who is referred to the clinic by his wife, Tracy. Rico and Tracy have been married for eight years. She states that in the past year, his behaviors have become disquieting. He constantly accuses her of cheating on him. He often takes her phone and scrolls through her calls, texts, and social media accounts. He is suspicious about texts she receives from coworkers and other acquaintances. He starts frequent arguments with her about where she has been and who she was with, and often replies to her responses with sarcastic, "mean" comments. Tracy is concerned about Rico's paranoid behavior. Based on DSM-5-TR (APA, 2022) criteria, does Rico meet diagnostic criteria for paranoid