Neurocognitive Disorders

Question 1

MIld Neurocognitive Disorder

Answer 1

DSM 5

provides an opportunity for early detection and treatment of cognitive decline before patients’ deficits become more pronounced and progress to:

major neurocognitive disorder (dementia) or other debilitating conditions.

Disorder Characteristics
Mild neurocognitive disorder goes beyond normal issues of aging. It describes a level of cognitive decline
that requires compensatory strategies and accommodations to help maintain independence and
perform activities of daily living.

To be diagnosed with this disorder, there must be changes that impact cognitive functioning. These symptoms are usually observed by the individual, a close relative, or other knowledgeable informant, such as a friend, colleague, or clinician, or they are detected through objective testing.

Early Detection, Better Care
There is substantial clinical need to recognize individuals who need care for cognitive issues that go
beyond normal aging. The impact of these problems is noticeable, but clinicians have lacked a reliable
diagnosis by which to assess symptoms or understand the most appropriate treatment or services.
Recent studies suggest that identifying mild neurocognitive disorder as early as possible may allow
interventions to be more effective. Early intervention efforts may enable the use of treatments that are
not effective at more severe levels of impairment and may prevent or slow progression. Researchers
will evaluate how well the new diagnostic criteria address the symptoms, as well as potential therapies
like educational or brain stimulation.

Question 2

Major Neurocognitive Disorders

Answer 2

Major neurocognitive disorder was previously known as dementia and the primary feature of all neurocognitive disorders (NCDs) is an acquired cognitive decline in one or more cognitive domains.

The cognitive decline must not just be a sense of a loss of cognitive abilities, but observable by others — as well as tested by a cognitive assessment (such as a neuropsychological test battery).

Neurocognitive disorders can affect memory, attention, learning, language, perception, and social cognition. They interfere significantly with a person’s everyday independence in Major Neurocognitive Disorder, but not so in Minor Neurocognitive Disorder.

Specific Symptoms of Major Neurocognitive Disorder

1. Evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains — such as complex attention, executive function, learning, memory, language, perceptual-motor or social cognition.

This evidence should consist of:

Concern of the individual, a knowledgeable informant (such as a friend or family member), or the clinician that there’s been a significant decline in cognitive function; and A substantial impairment in cognitive performance, preferably documented by standardized neuropsychological testing. Of if neuropsychological testing isn’t available, another type of qualified assessment.

2. The cognitive deficits interfere with independence in everyday activities (e.g., at a minimum, requiring assistance with complex instrumental activities of daily living, such as paying bills or managing medications).
3. The cognitive deficits don’t occur exclusively in context of a delirium, and are not better explained by another mental disorder.

Specify whether due to:

Alzheimer’s disease (294.1x/331.9)

Frontotemporal lobar degeneration (294.1x/331.9)
Lewy body disease (294.1x/331.9)
Vascular disease (290.40/331.9)
Traumatic brain injury (294.1x)
Substance/medication use
HIV infection (294.1x)
Prion disease (294.1x)
Parkinson’s disease (294.1x/331.9)
Huntington’s disease (294.1x)
Another medical condition (294.1x)
Multiple etiologies (294.1x)
Unspecified (799.59)

Question 3

NCD neurocognitive disorders

DSM 5

Answer 3

1. Minor (delirium) and Major (dementia) NCD created
2. major or mild vasulcar NCD and major or minor NCD due to Alzheimer’s disease is retained.
3. new separate criteria are now presented for major/mild NCD due to
   
   1. frontotemporal NCD
   2. Lewy Bodies
   3. TBI
   4. Parkinson’s
   5. HIV
   6. Huntington’s
   7. prion disease
   8. another medical condition
   9. multiple etiologies.
   10. substance/medication-induced NCD and unspecfied NCD also included.

Question 4

Delirium

Answer 4

Delirium:

1. disturbance in consciousness: reduced awareness of the environment, shifts in attention, and distractibility
2. change in cognition and/or development of perceptual abnormalities. : loss of memory, disorientation to time/place, impaired language, illusions, hallucinations and other misperceptions.
3. symptoms typically develop rapidly and fluctuate in severity during the course of the day

Etiology:

• older adults (highest risk), followed by younger children.
  
  • older people also more at risk of delirium post operative or due to medical condition.
• people with decreased cerebral reserve due to dementia, stroke or HIV disease
• postcardiotomy patients
• burn patients
• people with drug dependence
• General medical conditions include systemic infections, metabolic dx, fluid and electrolyte imbalances, postoperative states, head trauma.
• older people are at the highest

**Treatment: **

1. treatment of the underlying cause of the disorder and reduction of agitated behaviors
2. combination of environmental manipulation and psychosocial interventions (having access to calm friendly friends/family).
3. haloperidol or other antipsychotic drugs may help reduce agitation, delusions and hallucinations.

Question 5

DEMENTIA

Answer 5

Dementia

• may be caused by a number of substances and medical conditions (alcohol, head trauma or vascular disease) and is characterized by multiple cognitive deficits that include;
  
  • degree of memory impairment
  • aphasia, apraxia, agnosia, impaired executive functioning
  • deficits associated with dementia are progressive and irreversible
  • prognosis: dependent on the disorder’s etiology and availability of effective treatment.
• Anterograde amnesia: difficulty acquiring new information, usually more evident in the beginning of the disorder
• Retrograde amnesia: inability to recall previously learned material
• deterioration in language functioning (APHASIA), difficulty namning people and objects and understanding written and spoken language.
• APRAXIA: trouble executing motor actions, inability to dress, eat, cook or other familiar activities
• AGNOSIA: inability to recognize and identify familiar objects and people.
• Executive Functioning: impairments in abstract thinking, planning, initiating, and stopping complex bx.

Etiology

1. Cortical Dementias: Alzheimer’s type: early appearance of aphasia and impaired calculation ability and deficits in both recall and recognition memory.
2. Subcortical Dementias: Huntington’s/Parkinson’s: early appearance of deficits in executimve functioning, greater impairment of recall memory (vs. recognition), dysarthria (poor articulation), slowed motor speed and control, personality change.

Question 6

Major Depressive Disorder (Pseudodementia)

** vs **

Dementia

Answer 6

Major Depressive Dx :

may resemble dementia in terms of cognitive symptoms, but this form of depression is called pseudodementia.

• onset of cognitive symptoms is likely to be abrupt
• person is concerned about impairments
• uncooperative during testing
• impaired recall but intact recognition memory and their procedural memories are most affected.

Dementia:

• cognitive deficits usually gradual at onset, and progressive course
• person denies or is unaware of impairments
• cooperative (but inaccurate) during cognitive testing
• deficits in both recall and recognition memory and their deficits most apparent for declarative memories.

Mild Cognitive Impairment (MCI):

ongoing memory problems but do not have languaghe, executive functioning and other impairements associated with dementia.

Question 7

Alzheimer’s Type Dementia

Answer 7

single most common cause of Dementia, 65% of all cases

gradual onset and a slow, progressive decline in cognitive functioning

1. Stage 1 (1-3 years): anterograde amnesia (declarative memories) deficits in visuospatial skills (wandering), indifference, irritability, sadness and anomia
2. Stage 2 (2-10 years): increasing retrograde amnesia, flat or labile mood, restlessness/agitation, delusions, fluent aphasia, acalculia, ideomotor apraxia (inability to translate an idea to movement).
3. Stage 3 (8-12 years): severely deteriorated intellectual functioning; apathy; limb rigidity; and urinary/fecal incontinence

• diagnosed only when all other causes of Dementia have been ruled out.
• Autopsy/brain biopsy needed: extensive neuron loss and presence of amyloid (neuritic) plaques and neurofibrillary tangles, especially in the medial temporal structures (antorhinal cortex, hippocampus and amygdala).
• ave. duration from symptom onset to death is 8-10 years.
• Late onset (post 65) is more common and more common for females.
• linked to lower levels of formal education, adult onset diabetis (type 2) and depression.

Etiology:

1. genetic component: chromo 21, 19
2. abnormal levels of neurotransmitters including ACh.
   
   1. recognition of risks of low levels of ACh let to use of cholinesterase inhibitors, which reduce the breakdown of ACh in the brain and include: tacrine (Gognex), donepezil (Aricept), galantamine (Reminyl) and rivastigmine (Exelon).
   2. Such drugs are useful for reversing cognitive impairments and improving some bx symptoms, but only temporarily.

Treatment:

• combination of group therapy (reality orientation and reminiscence); antidepressant druges; behavioral techniques and antipsychotic drugs; environmental manipulation and drugs to enhance meory and cognitive functioning
• interventions for Dementia best when include family members: patients that live with family and family is less likely to institutionalize a family member with dementia when provided adequate individual and family therapy and support.

Question 8

Vascular Dementia

Answer 8

Vascular Dementia (like stroke)

1. cognitive impairment and focal neurological signs (exaggerated reflexes, weakness in an extremity, gait abnormalities) or laborative evidence of cerebrovascular disease.
2. stepwise, fluctuating course with patchy pattern of symptoms that is determined by the location of the brain damage.
3. Recovery depends on the cause.
4. Cerebrovascular accident (stroke): most improvement occures in the first 6 months, with phsycial disabilities resolving more quickly than cognitive deficits.
5. Risk Factors: hypertension, diabetes, smoking, and artial fibrillation.

Question 9

HIV Dementia

Answer 9

HIV dementia;

forgetfulness, impaired attention, psychomotor slowing.

followed by difficulties in problem-solving, concentration, apathy/social withdrawal, loss of initiative, tremor/clumsiness, saccadic eye movement.

**AIDS Dementia Complex (ADC): **

1. Stage 0 (normal): mental/motor functions normal
2. Stage .5 (Equivocal/Subclinical): minimal symptoms with no impairment in performance of work or ADL, mild signs may be present (slowed ocular/extremity movements).
3. Stage 1 (mild): unequivocal evidence of functional, intellectual or motor impairment, but can do most demanding aspects of work or ADL and can walk w/o assistance.
4. Stage 2 (moderate): cannot work but can perform basic activities of self-care and is ambulatory with assistance.
5. Stage 3 (severe): signs of major intellectual incapacity or motor diability
6. Stage 4 (end stage): nearly vegetative, mute, paraparesis/paraplegia, incontinence.

Question 10

Head Trauma Dementia

Answer 10

1. Depends on the location and extent of the brain injury.
2. subcortical type and is likely to involve changes in personality, deficits in executive cognitive functions, altered experience and expression of emotions.
3. Single brain injury: usually nonprogressive
4. Repeated injury (boxing/football): progressive form of dementia (dementia pugilistica)

Question 11

General Medical Condition Dementia

Answer 11

• memory impairment is known to be a direct physiological consequence of a general medical condition and does NOT occur only during the course of delirium or dementia
• Amnestic Disorder Due to a General Medical Condition always involves Antrograde amnesia and may also include some degree of Retrograde amnesia.
• Dissociative Amnesia is characterized by an inability to recall personal information that is often related to a traumatic or very stressful event and involves a circumscribed period of time.