Module Five

Question 1

1. What distinguishes Neurocognitive Disorders (NCDs) from other mental disorders in the DSM-5?

Answer 1

NCDs primarily involve a decline in cognitive function (e.g., memory, attention, executive function) that represents a significant change from previous levels of performance, rather than issues like mood or psychosis. The cognitive impairment is the core feature, not secondary.

Question 2

2. How does the DSM-5 categorize Neurocognitive Disorders by severity?

Answer 2

They are categorized as Major Neurocognitive Disorder (significant cognitive decline interfering with independence) or Mild Neurocognitive Disorder (modest cognitive decline that does not fully impair independence).

Question 3

3. What is the primary feature that sets delirium apart from other NCDs?

Answer 3

Delirium involves an acute disturbance in attention and awareness, developing over a short period and often fluctuating in severity throughout the day.

Question 4

4. In the DSM-5, what are the two central criteria for diagnosing delirium (Criterion A and B)?

Answer 4

Criterion A: Disturbance in attention and awareness.\nCriterion B: The disturbance develops over a short period (hours to days) and tends to fluctuate in severity.

Question 5

5. Name a key specifier for delirium related to cause.

Answer 5

Examples include Substance Intoxication Delirium, Substance Withdrawal Delirium, Medication-Induced Delirium, Delirium Due to Another Medical Condition, or Multiple Etiologies.

Question 6

6. What are the three activity level specifiers for delirium in DSM-5?

Answer 6

Hyperactive (agitation, restlessness), Hypoactive (lethargy, sluggishness), and Mixed (fluctuating between hyperactivity and hypoactivity).

Question 7

7. Name two common risk factors for delirium in older adults.

Answer 7

Advanced age, underlying dementia or other neurocognitive disorders, multiple medications, severe illness, and sensory impairment (like poor vision or hearing).

Question 8

8. How is ‘Other Specified Delirium’ different from a full delirium diagnosis?

Answer 8

It applies when symptoms cause clinically significant distress or impairment but do not meet the full criteria for delirium or any specified form (e.g., attenuated or subsyndromal delirium). The clinician specifies the reason why the criteria are not fully met.

Question 9

9. In what context is ‘Unspecified Delirium’ used?

Answer 9

When presentations suggest delirium but there is insufficient information to make a specific diagnosis, or the clinician chooses not to specify the reason criteria are not met (often in emergency or limited-information settings).

Question 10

10. How do Major and Mild Neurocognitive Disorders differ in functional impact?

Answer 10

Major NCD significantly interferes with independence in everyday activities, whereas Mild NCD only requires more effort or compensatory strategies but not full assistance.

Question 11

11. Which six cognitive domains are assessed in DSM-5 for Major or Mild NCD?

Answer 11

Complex attention, executive function, learning and memory, language, perceptual-motor, and social cognition.

Question 12

12. What is the most common cause of Major Neurocognitive Disorder worldwide?

Answer 12

Alzheimer’s disease is the most common cause of dementia (major NCD) worldwide.

Question 13

13. What is ‘Mild Neurocognitive Disorder,’ and why is it clinically important?

Answer 13

It’s a modest cognitive decline that doesn’t fully impair independence. It’s important for early detection and intervention, as it can be a precursor to major NCD.

Question 14

14. How does the DSM-5 approach the term ‘dementia’?

Answer 14

It retains ‘dementia’ for continuity but primarily uses ‘Major Neurocognitive Disorder.’ ‘Dementia’ may still be used clinically, especially for older adults, while ‘NCD’ suits broader etiologies including younger populations.

Question 15

15. Name three potential etiologies for Major NCD (besides Alzheimer’s).

Answer 15

Vascular NCD, Lewy body disease, frontotemporal lobar degeneration, Parkinson’s disease, traumatic brain injury, HIV infection, Prion disease, etc.

Question 16

16. What key feature differentiates Major or Mild NCD due to Alzheimer’s Disease from other causes?

Answer 16

A gradual onset and progressive cognitive decline, often starting with memory impairment and confirmed either by genetic testing/family history or clear evidence of memory decline plus one other domain.

Question 17

17. When is the Alzheimer’s type NCD considered “probable” vs. “possible” in DSM-5?

Answer 17

Probable if there’s evidence of an Alzheimer’s genetic mutation or a clear, typical progression. Possible if such evidence isn’t fully available, but the presentation is consistent with Alzheimer’s.

Question 18

18. List two core features of Major or Mild NCD with Lewy Bodies.

Answer 18

(1) Fluctuating cognition with variations in attention/alertness and (2) recurrent well-formed visual hallucinations. Parkinsonian features often develop after cognitive decline.

Question 19

19. What is a classic clinical presentation of Major or Mild Frontotemporal NCD (behavioral variant)?

Answer 19

Prominent personality and behavior changes like disinhibition, apathy, loss of empathy, and repetitive/compulsive behaviors, with relative sparing of memory in early stages.

Question 20

20. What distinguishes Vascular Neurocognitive Disorder from other neurodegenerative disorders?

Answer 20

Its cognitive decline is linked to cerebrovascular disease or multiple infarcts, often with a stepwise progression related to discrete vascular events.

Question 21

21. How does Major or Mild NCD due to Traumatic Brain Injury present?

Answer 21

Evidence of TBI (loss of consciousness, posttraumatic amnesia, neurological signs) followed by persistent cognitive deficits beyond the acute recovery period.

Question 22

22. What characterizes Major or Mild NCD due to HIV infection?

Answer 22

Cognitive deficits arising from direct HIV effects on the central nervous system, often presenting with a subcortical pattern (psychomotor slowing, executive dysfunction) and linked to immunosuppression severity.

Question 23

23. Which biomarker findings are commonly associated with NCD due to Prion Disease (e.g., Creutzfeldt-Jakob)?

Answer 23

Rapid progression of dementia with typical EEG changes (periodic sharp waves), CSF markers (14-3-3 protein), and MRI findings consistent with prion disease.

Question 24

24. When diagnosing Major or Mild NCD due to Parkinson’s Disease, what is the required temporal relationship of symptoms?

Answer 24

Motor symptoms of Parkinson’s disease must precede the onset of cognitive decline, distinguishing it from Lewy body dementia (where cognitive and motor features emerge concurrently or close in time).

Question 25

25. What is 'Multiple Etiologies' in the context of major or mild NCD?

Answer 25

When more than one disorder is contributing to the cognitive decline (e.g., Alzheimer’s plus cerebrovascular disease), it’s classified as NCD due to multiple etiologies.

Question 26

26. Name two hallmark signs of delirium that help differentiate it from a chronic NCD.

Answer 26

Acute onset and fluctuating course, often with a disturbed sleep-wake cycle and perceptual disturbances such as hallucinations.

Question 27

27. Give an example of an 'Other Specified Neurocognitive Disorder.'

Answer 27

A scenario where an individual meets criteria for a mild NCD but the exact etiology is not fully determined (e.g., 'Mild Neurocognitive Disorder due to probable autoimmune encephalopathy, with incomplete information'). The clinician specifies why it doesn’t meet full criteria for a specific subtype.

Question 28

28. Why might a clinician code 'Unspecified Neurocognitive Disorder'?

Answer 28

When there is inadequate information to diagnose a specific NCD subtype, or the clinician opts not to specify reasons—often used in acute settings or when follow-up is needed for complete evaluation.

Question 29

29. How does 'major vs. mild' classification in NCD influence care planning?

Answer 29

Major typically requires significant support for daily functioning; mild may only need compensatory strategies or reminders. This classification helps tailor interventions and indicates the level of independence or supervision needed.

Question 30

30. Which cognitive domains are most commonly affected in Mild NCD due to HIV?

Answer 30

Executive functions, psychomotor speed, and learning/memory, often presented in a subcortical pattern of deficits.

Question 31

31. Can delirium and dementia co-occur? If so, how is this clinically addressed?

Answer 31

Yes. 'Delirium superimposed on dementia' is recognized clinically. The acute delirium must be treated (e.g., correcting metabolic causes, stopping offending meds), while also managing the chronic dementia care needs.

Question 32

32. Why is early identification of Mild NCD important according to the DSM-5 and McDonald (2017)?

Answer 32

Early identification allows for interventions that may slow progression, manage risk factors, or aid planning for future care, improving long-term outcomes and quality of life.

Question 33

33. Which non-pharmacological interventions are commonly recommended for individuals with NCD?

Answer 33

Cognitive stimulation/rehabilitation, physical exercise programs, social engagement, occupational therapy, and structured routines to maximize remaining cognitive capacities and independence.

Question 34

34. In the context of dementia care, what are some common behavioral and psychological symptoms caregivers must manage?

Answer 34

Agitation, aggression, wandering, depression, anxiety, hallucinations, or delusions, which often require caregiver support and sometimes cautious pharmacological intervention.

Question 35

35. How is a 'probable' vs. 'possible' vascular NCD determined?

Answer 35

Probable requires neuroimaging evidence of significant vascular lesions consistent with cognitive deficits or a clear temporal link to stroke(s). Possible is diagnosed when clinical criteria are met but imaging or historical data are less definitive.

Question 36

36. What are typical presenting symptoms of Major NCD due to Lewy Bodies aside from cognition?

Answer 36

Parkinsonian motor symptoms (rigidity, bradykinesia), recurrent detailed visual hallucinations, REM sleep behavior disorder, and neuroleptic sensitivity.

Question 37

37. Which domain is often first and most prominently affected in Alzheimer’s Disease?

Answer 37

Learning and memory (especially short-term memory). Patients often have trouble recalling recent conversations, events, or names.

Question 38

38. Can normal aging include mild forgetfulness without meeting Mild NCD criteria?

Answer 38

Yes. Normal aging might involve some forgetfulness, but it does not significantly interfere with independence or represent a notable decline from prior functioning.

Question 39

39. Why might a thorough medical workup be essential in diagnosing an NCD?

Answer 39

Because reversible causes (e.g., hypothyroidism, vitamin B12 deficiency, normal pressure hydrocephalus) or comorbidities can mimic or contribute to cognitive decline, and addressing them can improve or stabilize symptoms.

Question 40

40. What role do genetics play in the etiology of certain NCDs?

Answer 40

Certain forms have strong genetic links (e.g., familial Alzheimer’s with PSEN1/PSEN2 mutations, frontotemporal lobar degeneration with MAPT mutations), significantly increasing risk and influencing early onset.

Question 41

41. How do biomarkers aid in diagnosing some NCDs (like Alzheimer’s)?

Answer 41

CSF beta-amyloid and tau levels, and neuroimaging (PET amyloid scans) help detect early pathological changes and strengthen diagnostic certainty, especially in Mild NCD with suspected AD etiology.

Question 42

42. Why is delirium often called an acute confusional state?

Answer 42

Because it develops quickly (hours to days) and presents with confusion, reduced awareness of the environment, and fluctuating cognition throughout the day.

Question 43

43. Which NCD might present with stepwise declines in function?

Answer 43

Vascular NCD often shows a stepwise decline following discrete cerebrovascular events (like infarcts or strokes).

Question 44

44. In Major NCD due to frontotemporal degeneration, which two broad variants are recognized?

Answer 44

Behavioral variant (changes in behavior, personality, social conduct) and language variant (speech production or comprehension impairments).

Question 45

45. Which NCD is often associated with REM sleep behavior disorder and severe neuroleptic sensitivity?

Answer 45

NCD with Lewy Bodies frequently presents with REM sleep behavior disorder and an extreme sensitivity to typical antipsychotics.

Question 46

46. What is the significance of 'probable' vs. 'possible' NCD with Lewy Bodies?

Answer 46

Probable requires at least two core features (e.g., detailed visual hallucinations and parkinsonism) or one core plus one suggestive feature (e.g., REM sleep behavior disorder). Possible typically has fewer combined features present.

Question 47

47. How can TBI lead to a Neurocognitive Disorder?

Answer 47

Physical trauma to the brain can cause posttraumatic amnesia, neurological changes, and enduring cognitive deficits in areas like memory, attention, or executive function, persisting beyond acute recovery.

Question 48

48. What cognitive pattern often appears in HIV-associated NCD?

Answer 48

A subcortical pattern: slowed processing, executive dysfunction, and possible motor slowing, often reflecting direct HIV effects on subcortical brain regions.

Question 49

49. How is Major or Mild NCD due to Prion Disease distinguished from other rapidly progressing dementias?

Answer 49

It shows extremely rapid progression (months), frequently accompanied by myoclonus or other motor abnormalities, and may have characteristic EEG or CSF biomarker findings (14-3-3 protein).

Question 50

50. What is the typical progression time frame for frontotemporal NCD?

Answer 50

It often progresses over 6 to 11 years from symptom onset, but it can vary considerably among individuals.

Question 51

51. Why might a patient be diagnosed with 'Other Specified Neurocognitive Disorder'?

Answer 51

If the patient shows cognitive impairment causing distress or functional deficits but doesn't exactly meet the criteria for any specific NCD etiology; the clinician specifies the atypical or insufficiently clarified presentation.

Question 52

52. Name a preventative approach recommended by McDonald (2017) to reduce future NCD risk.

Answer 52

Regular physical exercise (aerobic), cognitive engagement (puzzles, learning), managing vascular risk factors (hypertension, cholesterol), and social interaction to bolster cognitive reserve.

Question 53

53. How do comorbidities like depression influence clinical management of an NCD?

Answer 53

Depression can worsen cognitive symptoms, complicate diagnostic clarity, and demand integrated treatment (e.g., antidepressants, therapy) alongside direct NCD management.

Question 54

54. According to McDonald, why is public health prioritization needed for NCDs?

Answer 54

Because the global population is aging, the prevalence of dementia is rising sharply, and early detection/intervention can significantly improve outcomes, reduce healthcare costs, and ease caregiving burdens.

Question 55

55. Summarize the difference between delirium, mild NCD, and major NCD in one sentence each.

Answer 55

Delirium: Acute, fluctuating disturbance in attention and awareness. Mild NCD: Modest cognitive decline not fully impairing independence. Major NCD: Significant cognitive decline that substantially compromises daily functioning and independence.