16 Flashcards
Perspectives
Two classes of cognitive disorders:
1. delirium, an often temporary condition displayed as confusion and disorientation, and
2. mild or major neurocognitive disorder, a progressive condition marked by gradual deterioration of a broad range of cognitive abilities.
DSM-5: neurocognitive disorders—category of various forms of dementia and amnestic disorders
- Major and mild
Rates of cognitive disability increase after age 65
3.8% Canadians 15 years and older had memory-related disability (2017); 5.4% 65 years+ in 2018
Consequences for behaviour and personality
Symptoms include paranoia, agitation, aggression
In the DSM-5, neurocognitive disorders is the category name for the various forms of dementia and amnestic disorders, with “major” or “minor” subtypes; the DSM-5 retains the “delirium” label (American Psychiatric Association, 2013).
When the brain is damaged, the effects are irreversible, accumulating until learning, memory, or consciousness are obviously impaired.
Figure 16.1, Page 490: Rates for disability among Canadians ages 15 years and over, specific for age and source of disability.
Delirium
Clinical Description and Statistics
Impaired consciousness and cognition
- Confusion, disorientation, inability to focus
10%–30% of those who come to acute care facilities
Older adults, people with AIDS, and patients on medication
Usually subsides quickly
Also triggered by age, sleep deprivation, immobility, excessive stress
Environmental factors for hospitalized seniors: number of room changes, absence of a clock, watch, reading glasses
fMRI shows disruption of connectivity between dorsolateral prefrontal cortex with posterior cingulate cortex
Treatment
1. Pharmacological
Antipsychotics
2. Psychosocial
Reassurance
Presence of personal objects
Inclusion of a family member for support
Prevention
Proper medical care
Therapeutic drug monitoring
Interventions, though costly:
- Education, support, reorientation, anxiety reduction, preoperative medical assessment
The disorder known as delirium is characterized by impaired consciousness and cognition during the course of several hours or days.
People with delirium appear confused, disoriented, and out of touch with their surroundings. They cannot focus and sustain their attention on even the simplest tasks.
Treatment for delirium usually involves attention to precipitating medical problems. For example, delirium brought on by withdrawal from alcohol or other drugs is usually treated with benzodiazepines.
Prevention is most successful in persons who are susceptible to delirium, and may include efforts geared toward proper medical care for illnesses and therapeutic drug monitoring.
Major and MildNeurocognitive Disorders
Major neurocognitive disorder
Gradual deterioration of brain functioning
Mild neurocognitive disorder
Early stages of cognitive decline
Clinical Description and Statistics
Initial stages: memory and visuospatial skills impaired
Agnosia, facial agnosia
Can develop at any age, usually over 45 years
7.1% Canadians over 65 are affected; may be more
Survival rates alter the outcomes
See Figure 16.2
DSM-5 identifies neurocognitive disorder on etiology:
Alzheimer’s disease
Vascular injury
Frontotemporal degeneration
Traumatic brain injury
Lewy disease
Parkinson’s disease
HIV infection
Substance use
Huntington’s disease
Prion disease
Another medical condition
Major neurocognitive disorder (dementia) is a cognitive disorder that includes a gradual deterioration of brain functioning that affects judgment, memory, language, and other advanced cognitive processes.
Mild neurocognitive disorder is a condition in which there are early signs of cognitive decline such that it begins to interfere with activities of daily living.
Agnosia, an inability to recognize and name objects, is the most common symptom. Facial agnosia, an inability to recognize familiar faces, may also occur and is extremely distressing to family members.
Dementia can occur at any age but is more common among the elderly.
Figure 16.2, Page 494: Prevalence of dementia increases steadily with age.
Neurocognitive Disorder of the Alzheimer’s Type
Description and Statistics
Includes multiple cognitive deficits that develop gradually and steadily
Impaired memory, orientation, judgment, reasoning
Cognitive impairments
- Aphasia, apraxia, agnosia, anomia
Mini Mental State Examination assesses language and memory problems
Clock Test identifies which elderly will develop disorder
See Figure 16.3
Early detection leads to early intervention
Cognitive deterioration slow in early and later stages
Survival rate 4–8 years, may be more
Appears during 60s or 70s, sometimes earlier
Poor education, intellectual dysfunction, cerebral “reserve” hypothesis
More prevalent in women
- May be result of diminishing estrogen, which may play a protective role
Early research showed lower incidence in low- and middle-income countries
More recent research shows roughly same numbers in all ethnic groups
Rates seem to be increasing more rapidly for Indigenous peoples; age of onset might be earlier
Cognitive disturbances can include aphasia (i.e., difficulty with language); apraxia (i.e., impaired motor functioning); agnosia (i.e., failure to recognize objects); difficulties with planning, organizing, sequencing, or abstracting information; and anomia (i.e., problems with naming objects)
Cognitive disturbances can include aphasia (i.e., difficulty with language), apraxia (i.e., impaired motor functioning), agnosia (i.e., failure to recognize objects), or difficulties with planning, organizing, sequencing, or abstracting information.
Figure 16.3, Page 497: Samples of the clock drawing subtest of the Clock Test developed by Holly Tuokko, as drawn by three patients with neurocognitive disorder due to Alzheimer’s disease.
Cognitive disturbances can include aphasia (i.e., difficulty with language), apraxia (i.e., impaired motor functioning), agnosia (i.e., failure to recognize objects), or difficulties with planning, organizing, sequencing, or abstracting information.
Page 498: The PET scan of a brain with neurocognitive disorder due to Alzheimer’s disease (left) shows significant tissue deterioration in comparison with a normal brain (right).
Vascular Neurocognitive Disorder
Vascular: blood vessels; blockage disrupts oxygen to brain causing damage
Cognitive disturbances: declines in speed of information processing and executive functioning
Lifetime risk: 4.7% among men, 3.8% among women
Sudden onset
Vascular neurocognitive disorder is a progressive brain disorder that is second only to Alzheimer’s disease as a cause of neurocognitive deficits (Stuss & Cummings, 1990). Vascular dementia is caused by blockage or damage to the blood vessels that provide the brain with oxygen and other nutrients.
In Canada, the incidence of strokes is higher in men (329 per 100 000 in 2015) than in women (271 per 100 000 in 2015; CCDSS, 2018).
Other Medical Conditions That Cause Neurocognitive Disorder
DSM-5 specifies eight more specific causes:
1. Frontotemporal degeneration
2. Traumatic brain injury
3. Lewy body disease
4. Substance use
5. Parkinson’s disease
6. HIV infection
7. Huntington’s disease
8. Prion disease
- Creutzfeldt-Jakob disease
- Frontotemporal degeneration: Frontotemporal neurocognitive disorder is an overarching term used to categorize a variety of brain disorders that damage the frontal or temporal regions of the brain—areas that affect personality, language, and behaviour (Gustafson & Brun, 2012). One of the disorders in this category of neurocognitive disorders is Pick’s disease.
- Traumatic brain injury (TBI): includes symptoms that persist for at least a week following the trauma, including executive dysfunction (e.g., difficulty planning complex activities) and problems with learning and memory.
- Lewy body disease: Lewy bodies are microscopic deposits of a protein that damage brain cells over time.
- Substance use
- Parkinson’s disease: Motor problems are characteristic among people with Parkinson’s disease, who tend to have stooped posture, slow body movements (called bradykinesia), tremors, and jerkiness in walking.
- HIV infection: The early symptoms of neurocognitive disorder resulting from HIV are cognitive slowness, impaired attention, and forgetfulness.
- Huntington’s disease is a genetic disorder that initially affects motor movements, typically in the form of chorea, involuntary limb movements (Pringsheim et al., 2012).
- Prion disease: prions—proteins that can reproduce themselves and cause damage to brain cells leading to neurocognitive decline
Substance/Medication-Induced Neurocognitive Disorder
- Major and MildNeurocognitive Disorders
Prolonged drug use, poor diet
- e.g., alcohol dependence (50%–70% have cognitive impairment)
- Brain damage
Memory impairment
Cognitive disturbances
Substance/medication-induced neurocognitive disorder results from drug use in combination with poor diet and results in dementia in some cases. About 7% of alcohol-dependent individuals meet criteria for dementia.
Diagnostic criteria for this form of dementia are essentially the same as for the other forms of dementia and include memory impairment and cognitive disturbances.
Causes - Major and MildNeurocognitive Disorders
Biological Influences
Alzheimer’s: autopsies show brain contains
- Neurofibrillary tangles, amyloid plaques
Multiple genes implicated in development of Alzheimer’s disease
Psychological and Social Influences
Lifestyle factors: drug abuse, poor diet, lack of exercise, stress
Cultural factors: strokes more prevalent in non-Hispanic cultures
Psychosocial factors: low education, expectations
Neurocognitive disorders can be caused by a number of processes: Alzheimer’s disease, Huntington’s disease, Parkinson’s disease, head trauma, substance abuse, and others.
Psychological and social influences do not cause dementia, but may influence its onset and course.
Lifestyle factors such as continued drug use, for example, may produce dementia. Poor diet, lack of exercise, and stress level can also influence cardiovascular disease and risk for vascular dementia.
Treatment and prevention - Major and MildNeurocognitive Disorders
Goals of treatment:
Prevent certain conditions: substance abuse or strokes
Delay onset of symptoms of these disorders
Attempt to help these individuals and their caregivers to cope with advancing deterioration
Biological Treatments
No effective treatments exist
Depression, nutritional deficiencies can be treated if detected early
Stem cell research looks promising
Medications to develop cognitive abilities being developed; negative side effects
Vitamin E, exercise, healthy lifestyle
Psychosocial Treatments
Delay (not stop) the onset of cognitive decline
Coping skills effective in earlier stages of disorder
Teaching caregivers
Cognitive stimulation
Prevention
Controlling risk factors
- Blood pressure control
- Smoking cessation
Protective factors
- Physical and social activity
Treatment of dementia is not as promising when compared to other cognitive disorders.
Treatment of dementia is not as promising when compared to other cognitive disorders.
Drugs can help prevent strokes and are increasingly developed and tested for individuals with dementia of the Alzheimer’s type, and there is some early research on vaccines.
Psychosocial treatments focus on enhancing the lives of people with dementia and their families and include teaching skills to compensate for lost abilities.
Proper treatment of systolic hypertension, stroke, and cardiovascular disease may also cut the risk of dementia, including the use of anti-inflammatory medications.
Increased safety behaviours to reduce head trauma and exposure to neurotoxins are also part of prevention efforts.
