Neurocognitive Disorders

Question 1

DSM-5 Change & Definition

Answer 1

1. Previously called cognitive disorders
2. Changed to better reflect the fact that cognitive functions such as thinking, memory, and attention are closely linked to particular brain regions and neural pathways or networks in the brain.
3. Not psychologically based; caused by physical or medical or drug use or withdrawal

Question 2

Brain location based damage

Answer 2

1. Damage to temporal lobe: associated with defects in memory and attention
2. Damage to occipital lobe: visual-spatial deficits

Question 3

3 Categories of disorders of Cognitive Functioning

Answer 3

1. Delirium
2. Major Neurocognitive Disorder
3. Mild Neurocognitive Disorder

Question 4

Case of Dr. P

Answer 4

1. Documented in The Man Who Mistook His Wife for a Hat (Oliver Sacks): Diagnosed with agnosia
2. Musician and teacher lost ability to visually recognize objects, including faces
3. Sometimes perceived faces where none existed
4. His music and health remained intact
5. Upon leaving his exam with Dr. Sacks, he tried to take off his wife’s head to put it on as a hat
6. Case illustrates how psychological and environmental factors determine the impact and range of disabling symptoms as well as the individual’s ability to cope with them

Question 5

Delirium

Answer 5

1. Extreme mental confusion in which people have difficulty focusing their attention, speaking clearly and coherently, and orienting themselves to the environment
2. Find it difficult to to tune out irrelevant stimuli or shift their attention to new tasks
3. Severity of symptoms tends to fluctuate during the course of the day

Question 6

Prevalence/Occurrence of Delirium

Answer 6

1. 1 to 2% in the general community, but rises to 14% among people over the age of 85
2. Most often affects hospitalized patients, especially elderly hospitalized patients following surgery (between 15% and 50% elderly experience it after major surgery)
3. Among young people, delirium is most commonly the result of abrupt withdrawal from psychoactive drugs, especially alcohol.
4. Among older patients, it is often a sign of a life-threatening medical condition

Question 7

Features of Delirium with levels of severity (1)Mild, (2)Moderate and (3) Severe

Answer 7

1. Emotion: (1) Apprehension (2) Fear (3) Panic
2. Cognition and perception: (1)Confusion, racing thoughts (2)Disorientation, delusions (3)Meaningless mumbling, vivid hallucinations
3. Behavior (1) Tremors (2) Muscle spams (3) seizures
4. Autonomic activity (1) Abnormally fast heartbeat (2) Perspiration (3) Fever

Question 8

Major Neurocognitive Disorder

Answer 8

1. Commonly called Dementia (no longer used as a diagnostic label, DSM-V also believes its a pejorative term)
2. Most frequent cause is AD
3. The great majority of cases, including dementia due to AD, follow a progressive and irreversible course
4. Senile dementia: begins after 65
5. Presenile dementia: begins at or before 65
6. Not a consequence of normal aging, but a sign of a degenerative brain disease

Question 9

General Paresis

Answer 9

1. Dementia resulting from neurosyphilis, STD from bacterium Treponema pallidum.
2. Was the basis for development of the medical model for mental disorders
3. Once accounted for upwards of 30% of admissions to psychiatric hospitals
4. Development of antibiotics have greatly reduced the incidence of late-stage syphilis and the development of general paresis (but cannot restore people to original levels of functioning when damage is extensive)

Question 10

Cognitive Deficits associated with Dementia

Answer 10

1. Sensory/receptive aphasia: people have difficulty understanding written or spoken language, but can speak. Motor aphasia: can’t speak, but can understand spoken language
2. Apraxia: Impaired ability to perform purposeful movements despite an absence of any defect in motor functioning (e.g. can’t tie a shoe, but can describe process and nothing is wrong with arm or hand)
3. Agnosia: Inability to recognize objects despite an intact sensory system (case of Dr. P)
4. Disturbance in Executive Functioning: Deficits in planning, organizing, or sequencing activities or in engaging in abstract thinking

Question 11

Mild Neurocognitive Disorder

Answer 11

1. New in DSM-V and new name for Mild Cognitive Impairment (MCI)
2. Suffer a mild or modest decline in cognitive functioning from prior level
3. Not severe enough to warrant Major NC Disorder, but must be confirmed by formal tests of cognitive functioning (memory, attention, and problem solving)
4. Frequently occurs in the early stages of neurogenerative diseases like AD, but the majority of people with MCI do not develop AD
5. Inclusion in DSM-V is important because it targets cases of MCI for early intervention before it gets worse and enables researchers to identify possible participants to find ways to prevent mild to severe progression

Question 12

Alzheimer’s Disease Prevalence

Answer 12

1. More than 99% of cases occur in people over the age of 65
2. Affects 1 in 8 people over 65 years and 1 in 3 people over the age of 85 (4.7 millions Americans in total)
3. Prevalence rate is expected to more than double to 13.8 million by 2050
4. AD accounts for more than half of the cases of dementia in gen pop
5. Women have higher risk of developing disease, but may be due to women living longer

Question 13

Sign of AD

Answer 13

Cognitive impairments are more sever and pervasive, affecting the individual’s ability to meet the ordinary responsibilities of daily work and social roles

Question 14

History of AD

Answer 14

1. First described in 1907 by German physician Alois Alzheimer
2. During an autopsy of a 56 year old woman who had suffered from severe dementia, he found two brain abnormalities, now cardinal signs of the disease:
   (1) plaques: deposits of fibrous protein fragments composed of a material called beta amyloid
   (2) neurofibrillary tangles: twisted bundles of fibers of a protein called tau

Question 15

Early Stages of AD

Answer 15

1. Early stages are marked by limited memory problems and subtle personality changes: signs of withdrawal in people otherwise outgoing or irritability in otherwise gentle individuals
2. People generally appear neat and well groomed and are generally cooperative and socially appropriate

Question 16

Moderately severe AD

Answer 16

1. Require assistance in managing everyday tasks
2. Unable to select appropriate clothes or recall addresses or names of family members
3. Mistakes while driving, failing to stop at stop signs, accelerating when should be braking
4. Difficulties in toileting and bathing
5. Trouble recognizing themselves in mirrors
6. May no longer be able to speak in full sentences, verbal responses limited to a few words
7. Agitation: may act out in response to the threat of having to contend with an environment that no longer seems controllable

Question 17

Advanced AD

Answer 17

1. May start talking to themselves or experience visual hallucinations or paranoid delusions
2. May believe someone is attempting to harm them or is stealing their possessions or that their spouses are unfaithful to them or spouses are actually other people

Question 18

Most Severe AD

Answer 18

1. Cognitive functions decline to where people become essentially helpless
2. May lose the ability to speak or control body movement
3. Become incontinent, unable to communicate, walk, sit up and require assistance in toileting and feeding
4. End state: seizures, coma and death result

Question 19

AD affecting families

Answer 19

1. Attending a “funeral that never ends”
2. Imposes high levels of stress on caregivers
3. Caregivers experience more health-related problems and higher levels of stress hormones than do noncaregivers
4. Caretaking burden falls disproportionately on the adult daughters (sandwiched between their children and affected parents)

Question 20

Causal Factors of AD

Answer 20

1. Don’t know what causes it
2. Clues lie in understanding the process by which steel-wool-like placques and tangled nerve fibers form in the brain
3. Not sure of plaques and tangles are a cause of AD or a symptom of it
4. Number of genes linked to AD have been identified
5. Some forms of AD are associated with genes linked to the production of beta amyloid or abnormal buildup of amyloid plaques and neurofibrillary tangles
6. People with a genetic variant called the ApoE4 gene stand a much higher risk of developing AD (up to 3x greater)
7. Stress may be a possible culprit

Question 21

Treatment and Prevention of AD

Answer 21

1. Present drugs offer at best only modest benefits
2. Donepezil (Aricept) increases levels of NT acetylcholine. AD patients show lower levels of ACh.
3. Memantine (Axura) blocks NT glutamate- abnormally high levels of glutamate are found in AD: high levels may damage brain cells. Recent studies fail to show benefits of drug over placebo in mild forms of AD
4. Antipsychotics are used to help aggressive and agitated behavior, but carry significant safety risks
5. Inflammation appears to play a key role in development of AD: looking to see if anti-inflammatory drugs have preventative effects
6. Suspect that biological processes leading to AD start 20 years before dementia develops, so looking to treat it at its early stages

Question 22

Brain Networks in AD

Answer 22

1. Stanford study compared networks of interconnected neurons or hubs in AD brains.
2. fMRI scans showed less well-connected neural networks in AD: had fewer working hubs
3. Consequently, more difficult for neurons in the brain to communicate

Question 23

Vascular Neurocognitive Disorder (VND)

Answer 23

1. Cerebrovascular accident (CVA) or stroke: occurs when part of the brain becomes damaged because of a disruption in its blood supply, usually as the result of a blood clot that becomes lodged in an artery and obstructs circulation
2. VND (formerly called vascular dementia or multi-infarct dementia): form of major or mild neurcog disorder from strokes
3. Vascular Dementia is 2nd most common form of dementia after AD, affects people later in life, but somewhat earlier than dementia due to AD
4. Can cause aphasia, but the dementia that develops usually is a result of multiple strokes and their cumulative effects
5. Similar symptoms of dementia to AD dementia, but AD is characterized by an insidious onset and gradual decline, whereas Vascular dementia typically occurs abruptly

Question 24

Frontotemporal Neurocognitive Disorder

Answer 24

1. Characterized by deterioration of brain tissue in the frontal and temporal lobes of the cerebral cortex
2. Similar in progression to symptoms of AD dementia and include memory loss and social inappropriateness
3. Originally known as Pick’s disease: abnormal structures called Pick’s bodies found in the brain
4. Diagnosis is confirmed only upon autopsy by the absence of the neurofibrillary tangles and plaques found in AD and presence of Pick’s bodies
5. Accounts for 6 to 12% of all dementias. Men are more likely than women to have Pick’s disease and evidence points to a strong genetic component

Question 25

NC Disorder due to TBI

Answer 25

1. Results from multiple head injuries sustained than from a single incident
2. NFL study reports dementia and memory problems among retired players to be at a much higher rate than found in gen pop
3. Amnesia can occur
4. Case of patient H.M. experienced anterograde amnesia as complication of surgery to help control his epileptic seizures. Became unable to learn any new information
5. May experience disorientation to place and time more so than disorientation to self

Question 26

Substance/Medication-Induced NC Disorder

Answer 26

1. Korsakoff’s syndrome: irreversible memory loss due to brain damage from deficiency in vitamin B1 (thiamine). Associated with alcoholism because of malnutrition
2. Wernicke’s disease: Also from thiamine deficiency associated with alcoholism. Marked by confusion and disorientation, ataxia or difficult maintaining balance while walking, and paralysis of the muscles that control eye movements. Korsakoff’s can develop as a result, but can prevented if Wernicke’s is treated promptly with major doses of vitamin B1

Question 27

NC Disorder with Lewy Bodies

Answer 27

1. Accounts for about 10% of dementias in older adults
2. Has features of AD and Parkinson’s
3. Lewy bodies are abnormal protein deposits that form within the nucleus of cells in parts of the brain, disrupting memory and motor control.
4. Distinguishing feature of disorder is appearance of fluctuating alertness and attention