Neurocognitive Disorders 1

Question 1

What are neurocognitive disorders?

Answer 1

Disorders in which the core feature is acquired dysfunction in a cognitive domain occurring after “early life”

➢ Domains of Cognition
• Memory, language, executive functions, visuospatial
abilities (e.g., capacity to understand and remember the spatial relation among objects), attention, etc

Question 2

What are neurocognitive disorders?

Answer 2

Common NCD Conditions
   – Aphasia 
– Amnesia 
– Delirium 
– Dementia

Question 3

What is delirium?

Answer 3

AKA: Acute confusional state, acute brain syndrome, encephalopathy, ICU syndrome)

➢ A delirium is a disturbance in the level of consciousness (alertness) and is characterized by:

1) Deficits in awareness and attention:
– Awareness is assessed by one’s alertness and
orientation to the environment
– Attention is assessed by one’s ability to direct, focus, sustain, and shift attention

Question 4

What are the symptoms of delirium?

Answer 4

1) Deficits in awareness and attention:
– Awareness is assessed by one’s alertness and
orientation to the environment
– Attention is assessed by one’s ability to direct, focus, sustain, and shift attention

2) An additional cognitive disturbance such as:
– Deficits in memory/language/executive functioning
– Delusions
– Perceptual disturbance
• Hallucinations
• Illusions (sensory misperception)

3) Sudden onset of symptoms
– Usually over hours to a few days
– Typically fluctuate throughout the day

4) Evidence for a direct physiological cause
– Medical condition
– Drug intoxication/withdrawal
– Toxin exposure
➢Typical Clinical Presentation
– Hyperactive presentation
• Increased psychomotor activity
• Mood lability, agitation, uncooperative
– Hypoactive presentation
• Reduced psychomotor activity
• Sluggishness, lethargy approaching stupor
– *Sleep-wake cycle disturbances (e.g., sleep-wake reversals)
– *Diffuse slowing on EEG (theta/delta waves)

*May be seen in both presentation types

Question 5

What is the pathology of delirium?

Answer 5

Pathology
• Multiple etiologies (e.g., fever, dehydration, UTI)
• Widespread brain regions affected

• Deficits in:
– Central cholinergic functioning
– Reticular Activating System and its ascending connections (important for attention and arousal)

Question 6

What are the risk factors of delirium?

Answer 6

Risk Factors
– Non-modifiable (e.g., poor health, older age)
– Modifiable (e.g., immobilization, poor sleep, and
use of benzodiazepines in an ICU)

Question 7

What is the course of delirium?

Answer 7

Course
– Symptoms persist until cause is reversed
– Resolution typically occurs within 3-7 days
– Amnesia for events during delirium is common
– Increased risk of mortality and morbidity

Question 8

How is delirium treated?

Answer 8

Treatment

• Treat underlying medical condition
• Manage associated symptoms (e.g., agitation, psychosis)
  – Use antipsychotics (e.g., risperidone) to treat associated symptoms (e.g., agitation, psychosis) of most deliriums
  – Use benzodiazepines (e.g., diazepam) to treat delirium caused by alcohol withdrawal

Treatment (cont.)

Utilize environmental supportive measures
– Regulate amount of environmental stimulation
– Provide orienting stimuli (e.g., lighting, personal effects, sensory aids)
– Provide for safety needs (e.g., attendant, bedrails)

Question 9

What is dementia?

Answer 9

A dementia:
– Refers to multiple and severe cognitive
impairment without impaired consciousness
– Is usually progressive and irreversible
– Most commonly occurs in the elderly

Question 10

What is Ahlzeimer’s Dementia?

Answer 10

AD involves:
– Significant memory impairment plus impairment in at least 1 other cognitive domain
– A gradual onset with steadily progressive decline
– Exclusion of other causes of the symptoms (e.g., stroke)

Question 11

Describe the early stages of Ahlzeimer’s dementia

Answer 11

Early Stages
• Memory deficits (encoding deficits & rapid forgetting)
• Anomia (word-finding difficulties)

Question 12

What is the general onset of Ahlzeimer’s dementia?

Answer 12

Onset typically in late 70’s with 10+ yr progression

Question 13

Describe the middle stages of Ahlzeimer’s Dementia

Answer 13

Middle Stages
• Further memory and language decline
• Visuospatial deficits (e.g., getting lost)
• Agnosias (loss of knowledge of a perception)
– Visual agnosias (visual stimuli are perceived but
not identified)
• Prosopagnosia: Specific inability to identify
familiar faces by sight
– Auditory agnosias (sounds perceived but not identified)
– Anosognosia: Lack of awareness of one’s disability

Mood changes
• Personality changes (e.g., formerly gregarious, now
reclusive)
• Psychosis (e.g., hallucinations, paranoid delusions)

Question 14

Describe late stage Ahlzeimer’s dementia

Answer 14

Severe deficits in all cognitive domains
• Global aphasia
• Motor dysfunction
• Death from opportunistic infections (e.g., pneumonia)

Question 15

Explain neuropathology of Ahlzeimer’s dementia

Answer 15

Neuropathology of AD
➢ Neuroanatomical
– Cortical atrophy
– Hippocampal atrophy
– Enlarged ventricles

➢ Neurochemical
– Multiple neurotransmitter
deficiencies
– Focus has been on loss of
(ACH) neurons in the
nucleus basalis of Meynert due to its role in memory formation

Question 16

What are the functional and histopathological Ahlzeimer’s disease?

Answer 16

➢ Neurofunctional: Posterior hypometabolism (parietal/temporal)

 ➢ Histopathological
– ß-amyloid plaques and neurofibrillary tangles
– In vivo Biomarkers of AD:
     • CSF amyloid & tau levels
     • PET imaging of amyloid plaques

– Definitive AD diagnosis still depends on post-mortem histopathological confirmation

Question 17

Describe Ahlzeimer’s Dementia treatment

Answer 17

Question 18

What are the risky drugs used to treat Ahlzeimer’s disease?

Answer 18

Established AD drugs
– Considered “ineffective”
– Side effects of hypotension and GI distress
have notable consequences (e.g.,  fragility and risk of falls)

• Newly-approved antibody drug
‒ Lacking data supporting efficacy
‒ Side effects include brain bleeding and
edema

Question 19

What are the interventions of Ahlzeimer’s dementia that treatneuropsychiatric symptom?

Answer 19

Treatment of neuropsychiatric symptoms (aggression, agitation)
– Non-pharm methods (e.g., multi-sensory rooms?)
– Antipsychotics
• Used off-label for demented patients
• FDA-black box warning of increased mortality risk if
used with patients with dementia
– Anticonvulsants & antidepressants
– Rule out non-dementia causes of behavioral problems (e.g., pain) in AD patients

Question 20

What are the psychosocial considerations for Ahlzeimer’s dementia?

Answer 20

Psychosocial Considerations
– Use of external mnemonics in early AD stages
– Assessment and restriction of driving
– Medic Alert-Safe Return Program for wanderers

Question 21

Support for caregivers should be considered for patients with AD?

Answer 21

Support for Caregivers

• Risk of Care Giver Syndrome from psychological, social, and financial sequelae of caregiving
– Palliative care plays an important role in management
– Need for respite care (short-term caregiver relief)

• Resources through AD Assoc/AD Foundation such as:
‒ Support groups
– Caregiver tips (e.g., how to respond to psychosis)
– Long-term care options
– Legal and financial planning