Neurocognitive disorders

Question 1

Neurocognitive disorders: A new category in dsm-5

Answer 1

• Previously “organic mental disorders” and “cognitive disorders”
• “Neurocognitive disorders” because of overlap between dementia and amnestic disorders
• All disorders influenced by brain -> these disorders are categorized by this influence
• Brain cell regeneration?

Question 2

Delirium:

Answer 2

often a temporary condition displayed as confusion and disorientation

Question 3

Mild or major neurocognitive disorder:

Answer 3

a progressive condition marked by gradual deterioration of a range of cognitive abilities

Question 4

Delirium: diagnostic criteria

Answer 4

• A. A disturbance in attention and awareness
• B. The disturbance develops over a short period of time, represents a change from baseline attention and awareness, and tends to fluctuate in severity during the course of a day
• C. An additional disturbance in cognition
• D. Disturbances in Criteria A and C are not better explained by another preexisting, established, or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal, such as coma
• E. There is evidence from the history, physical examination, or laboratory findings that the disturbance is a direct physiological consequence of another medical condition, substance intoxication, or withdrawal

Question 5

Delirium: demographics and aetiology

Answer 5

• Prevalence: 20% of older adults admitted into acute care facilities/ hospitals
• Course
  
  • Rapid onset
  • Symptoms may vary over course of day
  • Typically resides quickly
  • Effects may be more long-lasting
• Aetiology
  
  • Improper use of medications, high fever (in children), dementia, sign of end of life (in ¼ of cases), sleep deprivation, alcohol withdrawal, immobility, excessive stress
  • Older people more likely to suffer delirium

Question 6

Delirium: treatment and prevention

Answer 6

• Treatment will depend on identified cause
  
  • Substances or infection/injury
  • First line of treatment: psychosocial intervention
    
    • Provide reassurance to individual, give familiar personal belongings
  • Delirium brought on by withdrawal from alcohol or other drugs is usually treated with haloperidol or other antipsychotic medications
  • When case is unknown haloperidol or olanzapine are prescribed
• Prevention
  
  • Proper medical care for illnesses and drug monitoring

Question 7

Neurocognitive disorders

Answer 7

• Far more gradual decline in functioning
• Major neurocognitive disorder (previously labelled dementia)
  
  • Gradual deterioration of brain functioning that affects memory, judgment, language, other advanced cognitive processes
• Mild neurocognitive disorder
  
  • Early stages of cognitive decline

Question 8

Mild neurocognitive disorder: diagnostic criteria

Answer 8

• A. Evidence of modest decline from a previous level of performance in one or more cognitive domains
  
  • Concern of the individual, a knowledgeable informant, or the clinician that there has been a mild decline in functioning, and
  • A modest impairment in cognitive performance, preferably documented by standardized neuropsychological testing or, in its absence, another quantified clinical assessment
• B. Cognitive deficits do not interfere with capacity for independence in everyday activities
• C. Cognitive deficits do not occur exclusively in the context of a delirium
• D. Cognitive deficits are not better explained by another mental disorder
• Specify whether due to:
  
  • Alzheimer’s disease, frontotemporal lobe degeneration, etc.

Question 9

Major neurocognitive disorder: diagnostic criteria

Answer 9

• A. Evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains
  
  • Concern of the individual, a knowledgeable informant, or the clinician that there has been a significant decline in cognitive functioning
  • A substantial impairment in cognitive performance, preferably documented by standardized neuropsychological testing or, in its absence, another quantified clinical assessment
• B. Cognitive deficits interfere with independence in everyday activities
• C. The cognitive deficits do not occur exclusively in the context of a delirium
• D. Cognitive deficits not better explained by another mental disorder
• Specify whether due to:
  
  • Alzheimer’s disease, frontotemporal lobe degeneration, etc.

Question 10

Neurocognitive disorder: clinical description

Causes

Answer 10

• Will depend on which type person has
• Initial stages: impairment in memory for recent events, long-term still relatively intact
• Delusions can occur
• Emotional changes: depression, agitation, aggression, apathy
• Onset:
  
  • Can develop at any age, more frequently seen in older adults
• Causes (classes of neurocognitive disorders based on aetiology in DSM 5)
  
  • Alzheimer’s disease
  • Vascular disease
  • Frontotemporal degeneration
  • Traumatic brain injury
  • Lewy body disease
  • Parkinson’s disease
  • HIV infection
  • Substance use
  • Huntington’s disease
  • Prion disease
  • Other medical condition

Question 11

Agnosia:

Answer 11

common symptom of neurocognitive disorders where there is an inability to recognise and name objects

Question 12

Facial agnosia

Answer 12

the inability to recognise even familiar faces

Question 13

Neurocognitive disorder: Prevalence

Answer 13

• Will depend on which type, but in general prevalence increases with increasing age
  
  • At age 65, 5%
  • At age 85, 20% - 40%
  • At age 100, 100%
• Rate of new cases doubles every 5 years after age 75 (aging population)
• More prevalent among women (due to Alzheimer’s disease)

Question 14

Neurocognitive disorder due to Alzheimer’s disease: Diagnostic criteria

Answer 14

• A. The criteria are met for major or mild neurocognitive disorder
• B. There is insidious onset and gradual progression of impairment in one or more cognitive domains
• C. Criteria are met for either probable or possible Alzheimer’s disease as follows:
  
  • Major: Probable Alzheimer’s disease diagnosed if either one of following is present
    
    • Evidence of a causative Alzheimer’s disease genetic mutation from family history or genetic testing
  • All three of following present:
    
    • Clear evidence of decline in memory and learning and at least one other cognitive domain
    • Steadily progressive, gradual decline in cognition, without extended plateaus
    • No evidence of mixed aetiology
  • Mild:
    
    • Probable diagnosis if evidence of causative Alzheimer’s disease genetic mutation
    • Possible diagnosis if no evidence of genetic mutation and all three present:
      
      • Clear evidence of decline in memory and learning
      • Steadily progressive, gradual decline in cognition, without extended plateaus
      • No evidence of mixed aetiology
• D. Disturbance not better explained by cerebrovascular disease, another neurodegenerative disease, the effects of a substance, or another mental, neurological, or systemic disorder

Question 15

Neurocognitive disorder due to Alzheimer’s disease

Symptoms

Cognitive symptoms

Diagnosis

Answer 15

• Symptoms
  
  • Multiple cognitive deficits that develop gradually
  • Predominant presentation: impairments of memory, orientation, judgment, reasoning
  • Later stages: agitation, confusion, depression, anxiety, aggression
• Specific cognitive symptoms:
  
  • Aphasia (difficulty with language)
  • Apraxia (impaired motor functioning)
  • Agnosia (inability to recognise objects)
  • Difficulties with executive functioning tasks
• Diagnosis
  
  • Used to be possible only post-mortem, but now looking at brain scans and spinal fluid assessments as possibilities

Question 16

Neurocognitive disorder due to Alzheimer’s disease: demographics and course

Answer 16

• High prevalence in less educated persons
  
  • Cognitive reserve hypothesis
• Higher prevalence in women
• Roughly same prevalence across ethnic groups
• Course:
  
  • Cognitive deterioration slow during early and later stages
  • Rapid during middle stages
  • Average survival time is 8 years from diagnosis
  • Onset typically in 60s or 70s, but can be earlier

• Aprox. 50% of neurocognitive disorders are a result of Alzheimer’s*
• Research confirms that that greater educational level may predict a delay in the observation of Alzheimer’s symptoms (suggests that education doesn’t prevent Alzheimer’s but creates buffer period of better functioning)*

Cognitive reserve hypothesis suggest that the more synapses a person develops throughout life, the more neuronal death must take place before the signs of dementia are obvious

Question 17

Major or Mild Vascular neurocognitive disorder: Diagnostic criteria

Answer 17

• A. The criteria are met for major or mild neurocognitive disorder
• B. The clinical features are consistent with a vascular aetiology as suggested by either of the following:
  
  • Onset of the cognitive deficits is temporally related to one or more cerebrovascular events
  • Evidence for decline is prominent in complex attention
• C. There is evidence of the presence of cerebrovascular disease from history, physical examination, and/or neuroimaging considered sufficient to account for the neurocognitive deficits
• D. Symptoms are not better explained by another brain disease or systemic disorder. Probable vascular neurocognitive disorder is diagnosed if one of the following is present (otherwise diagnose “possible”)
  
  • Clinical criteria are supported by neuroimaging evidence of significant parenchymal injury attributed to cerebrovascular disease (neuroimaging-supported)
  • Neurocognitive syndrome is temporally related to one or more documented cerebrovascular events
  • Both clinical and genetic evidence of cerebrovascular disease is present

Question 18

Cerebrovascular

Answer 18

relating to the brain and its blood vessels

Question 19

Vascular neurocognitive disorder

Answer 19

• Blood vessels in brain are blocked/damaged
• Lower incidence rates than Alzheimer’s disease
  
  • 70 – 75 years of age: 1.5%
  • Over 80: 15%
• Aetiology
  
  • Stroke, cardiovascular disease
• Higher prevalence in men
• Symptoms will depend on site of damage in brain
  
  • Often includes decline in speed of information processing, executive functioning
• Onset is typically more sudden than Alzheimer’s type, probably because the disorder is result of a stroke, which inflicts brain damage immediately

Question 20

Other Types of neurocognitive disorder

• Alzheimer’s disease
• Vascular disease
• Frontotemporal degeneration
• Traumatic brain injury
• Lewy body disease
• Parkinson’s disease
• HIV infection
• Substance use
• Huntington’s disease
• Prion disease
• Other medical condition

Answer 20

• Traumatic brain injury
  
  • Including chronic traumatic encephalopathy
• Frontotemporal neurocognitive disorder
  
  • An overarching term to categorise a variety of brain disorders that damage the frontal or temporal regions of the brain- areas that affect personality, language and behaviour
• Pick’s disease
  
  • Produces symptoms similar to that of Alzheimer’s disease
  • Early onset (40s and 50s) last 5-10 years
• Lewy body disease
  
  • Microscopic deposits of protein that damage the brain cells over time
  • Gradual onset including motor impairment
• Parkinson’s disease
  
  • Estimated that about 75% of people who survive more than 10 years with Parkinson’s disease develop neurocognitive disorder
  • Primarily motor symptoms, stooped posture, speech soft and monotone
• HIV
• Huntington’s disease
  
  • Genetic disorder that initially affects motor movements
  • Depression, anxiety, aphasia
• Prion disease
  
  • Caused by “prions”, proteins that can reproduce themselves and cause damage to brain cells leading to neurocognitive decline
  • Can only be contracted through cannibalism or accidental inoculations from an infected person’s blood
  • No known treatment, always fatal
• Creutzfeldt-Jakob disease
  
  • A type of prions disease
  • Associated with mad cow’s disease
• Substance/medication induced
  
  • 7% of people dependent on alcohol meet the criteria for a neurocognitive disorder
  • prolonged drug use and poor diet

Question 21

Aetiology of neurocognitive disorder

Biological

Psychological and social

Answer 21

• Biological
  
  • Alzheimer’s disease
    
    • Neurofibrillary tangles, amyloid plaques, and brain atrophy (examined after death)
      
      • Brain atrophy itself cannot be deterministic if Alzheimer’s because it happens to many brains of older people
    • Multiple genes seem to be involved
    • Exercise may help reduce likelihood of disease, but only for some people
  • Head trauma
  • Other causes: diabetes, high blood pressure, herpes
• Psychological and social
  
  • Lifestyle issues associated with cardiovascular pathology
  • Lack of certain vitamins (B9 and B12)
  • Occupational hazards contributing to head injury

Question 22

Treatment of neurocognitive disorder

Answer 22

• Treatment prospects not good
• Brain cell regeneration?
• Goals of treatment:
  
  • Try to prevent certain conditions that bring on neurocognitive disorder (substance abuse or strokes)
  • Try to delay onset of symptoms to provide better quality of life
  • Attempt to help affected individuals and caregivers to cope
  • Intervention MUST target caregivers as well as afflicted persons
    
    • High rates of depression and stress in this population
    • Higher rates of neurocognitive disorders in caregivers

Question 23

Biological treatments neurocognitive disorder

Answer 23

• Treatments available for some known causes (known infectious diseases, nutritional deficiencies and depression) if caught early
• Blood thinning meds to reduce blood clotting
• No known treatment for neurocognitive disorder caused by stroke, Parkinson’s, or Huntington’s diseases
• Alzheimer’s disease
  
  • Cholinesterase inhibitors (prevent breakdown of acetylcholine)
    
    • Can have modest impact, but only in short-term
  • Treat associated depression
  • Vaccination in future?

Question 24

Psychosocial treatments neurocognitive disorders

Answer 24

• Target both individual and caregivers
• Earlier stages
  
  • Teach skills to compensate for lost abilities
  • Cognitive stimulation
• Later stages
  
  • Severe impairment and dysregulated behaviour
  • May not be able to engage in basic functions of living, may display inappropriate sexual and/or aggressive behaviour
  • Teach communication skills?
• Caregivers should be taught how to deal with situation
• Bottom line:
  
  • Best medications provide some recovery but do not prevent eventual decline
  • Psychological interventions may help people cope with loss of cognitive abilities
  • Provide psychological interventions to caregivers in early and late stages of decline

Question 25

Other

Answer 25

• Overall, the outlook for slowing, but not stopping, the cognitive decline characterised by neurocognitive disorder is optimistic*
• Managed care and patient counselling have been successful in preventing delirium in older adults*
• Treatment for delirium depends on the cause of the episode and can include medications, psychosocial interventions or both*
• Delirium severely affects people’s memory, making tasks such as recalling ones own name difficult*
• The elderly population is at greatest risk of experiencing delirium resulting in improper use of medications*
• Various types of brain trauma, such as head injury or infection, have been linked to delirium*
• People who suffer from delirium appear to be confused or out of touch with their surroundings*
• Timmy’s elderly grandmother does not recognise her home any more (agnosia)*
• She can no longer form complete, coherent sentences (aphasia)*
• She no longer recognises Timmy when he visits, even though he is her only grandchild (facial agnosia)*
• Julian is a recovering alcoholic. When asked about his wild adventures as a young man, his stories usually end quickly because he can’t remember the whole tale. He even has to write down things he has to do in a notebook, otherwise, he’s likely to forget (substance-induced neurocognitive disorder)*
• Mr. Brown has suffered from a number of strokes but can still care for himself. His ability to remember important things, however, has been declining steadily for the past few years (vascular neurocognitive disorder)*
• A decline in cognitive functioning that is gradual and continuous and has been associated with neurofibrillary tangles and amyloid plaques (neurocognitive disorder due to Alzheimer’s disease)*