Neurocognitive Disorders

Question 1

Delirium DSM-5 Criteria

Answer 1

• Disturbance in attention/awareness (un-oriented)
• Acute onset (usually hours to a few days), clear change from previous functioning and fluctuates in severity during course of day
• Additional cognitive deficit (memory, language, visuospatial ability)
• Not better explained by chronic/pre-existing neurocognitive condition
• Evidence of an organic cause

Question 2

Delirium Prevalence

Answer 2

• High: 14-56% older hospitalized patients, 30% ER, 15-53% who have had surgery
• More common among men
• Women often misdiagnosed as depressed

Question 3

Delirium Etiology

Answer 3

• Serious Illnesses: AIDS, congestive heart failure, infection, toxic effects of medication (40%)
• Metabolic disorders: hypothyroidism, hypoglycemia…
• Neurological disorders (head trauma, stroke, seizure, meningitis)
• Malnutrition, dehydration
• Alcohol/drug intoxication/withdrawal
• Sometimes first sign of major neurocog disorder

Question 4

Delirium Environmental Correlates

Answer 4

• Increased risk with hospitalization, use of physical restraints, sleep deprivation, and lack of food/water

Question 5

Major Neurocognitive Disorder DSM-5 Criteria

Answer 5

• Sig decline in one or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition); based on concern of patient/informant/clinician and neuropsych testing
• Interference with independence in everyday activities (IADLs at minimum)
• Not delirium or another mental disorder

Question 6

Major Neurocognitive Disorder Specifiers

Answer 6

• Whether due to: AD, Frontotemporal lobar degeneration, Lewy body disease, Vascular disease, TBI, substance/medication use, HIV, Prion disease, Parkinson’s, Huntington’s, another medical condition, multiple etiologies, unspecified
• With or without behavioral disturbance
• Mild/Moderate/Severe

Question 7

Mild Neurocognitive Disorder DSM-5 Criteria

Answer 7

• Modest decline in one or more cognitive domains
• Deficits do not interfere with capacity for independence in everyday activities
• Not delirium or other mental disorder
• Same specifiers as major neurocog. disorder

Question 8

Alzheimer’s Disease DSM-5 Criteria

Answer 8

• Must meet criteria for major/mild, cognitive impairment
• Insidious onset and gradual progression of impairment in one or more cognitive domains
• Code whether probable or possible

Question 9

Probable vs Possible AD - Major Neurocog

Answer 9

1) Evidence of a causative AD genetic mutation
2) All three present: clear evidence of decline in memory and learning; steadily progressive, gradual decline in cognition, without extended plateaus; no evidence of mixed etiology
If both: probable, If not: possible

Question 10

Probable vs Possible AD - Minor Neurocog

Answer 10

• Probable: evidence of a causative AD genetic mutation
• Possible: no evidence of causative AD genetic mutation and all 3 of following present: clear evidence of decline in memory and learning; steadily progressive, gradual decline in cognition, without extended plateaus; no evidence of mixed etiology

Question 11

Major or Mild Frontotemporal NCD Criteria

Answer 11

• Criteria met for major/mild NCD
• Disturbance has insidious onset and gradual progression
• Either behavioral variant or language variant
• Behavioral variant: 3 or more of following - behavioral disinhibition; apathy or inertia; loss of sympathy/empathy; perseverative; stereotyped or compulsive behavior; hyperorality and dietary changes - and a prominent decline in social cognition and/or executive abilities
• Language variant: prominent decline in language ability, in the form of speech production, word finding, object naming, grammar, or word comprehension

Question 12

Major/Mild NCD with Lewy Bodies

Answer 12

• Probable or possible NCD with Lewy Bodies
• Core diagnostic features: fluctuating cognition with pronounced variations in attention and alertness, recurrent visual hallucinations that are well-formed and detailed, spontaneous features of parkinsonism with onset subsequent to the development of cognitive decline
• Suggestive diagnostic features: meets criteria for rapid eye movement sleep behavior disorder, severe neuroleptic sensitivity

Question 13

Vascular NCD

Answer 13

• Clinical features consistent with vascular etiology, suggested by either 1) onset of cognitive deficits is temporally related to one or more cerebrovascular events, 2) evidence of decline is prominent in complex attention (including processing speed) and frontal-executive function
• There is evidence of the presence of cerebrovascular disease…considered sufficient to account for the neurocog deficits

Question 14

NCD due to TBI

Answer 14

• Evidence of TBI: impact to the head or other rapid movement/displacement of brain in skull
• One of following: loss of consciousness, posttraumatic amnesia, disorientation and confusion, neurological signs (e.g., neuroimaging, seizures, etc.)
• Disorder presents immediately after TBI or after recovery of consciousness

Question 15

Substance/medication-induced NCD

Answer 15

• Not due to delirium
• Duration and extent of use capable of producing impairment (long history)
• Temporal course is consistent with timing of use and abstinence (use more = worse functioning, abstinence = plateau)
• Deficits remain stable or improve with abstinence

Question 16

Prion disease

Answer 16

• Insidious onset, rapid progression of impairment
• Motor features of prion disease or biomarker evidence
• Symptoms: Neurocog deficits, ataxia, abnormal movements (twitching, jerky movements)
• E.g., Mad Cow Disease but human form
• Contact with spinal matter/brain
• Misfolded proteins

Question 17

Major/Mild NCD due to Parkinson’s Disease

Answer 17

• Criteria are met for major/mild NCD
• “The disturbance occurs in the setting of established Parkinson’s disease”
• Insidious onset and gradual progression of impairment
• Motor symptoms: tremors, slowness of movement (bradykinesia), problems with balance, rigidity
• Associated symptoms: memory problems, depression/anxiety, sleep problems, loss of sense of smell, constipation, speech and swallowing problems, drooling, low blood pressure

Question 18

Epidemiology of NCD

Answer 18

• Dementia: 1-2% by age 65 but 30% by age 85
• Mild NCD: 5-25% by age 85
• Alzheimer’s most common (up to 75%)

Question 19

NCD Etiology

Answer 19

• Increasing age is major risk factor
• Specific mutation (e4) on the APOE gene (neither necessary nor sufficient)
• Alzheimer’s: neurofibrillary tangles, amyloid plaques
• Protective factors: advanced education, diet, moderate use of alcohol, nonsteroidal anti-inflammatory drugs, increased engagement in mental activities

Question 20

Crowe article

Answer 20

• DSM-5: dementia and amnestic disorders now subsumed under major NCD
• Presence and effect of the term “dementia” significantly reduced
• Mild NCD: less severe form of cognitive impairment
• NCD different than neurodevelopmental disorders, where deficits present from birth
• Progressive disorders like AD, Parkinson’s, Huntington’s, and vascular disease: minor and major NCD viewed as earlier and later stages of the disorder
• Importance of neuropsych testing emphasized
• DSM-5 field trials: very good kappa for major NCD and good kappa for mild NCD

Question 21

Looi and Velakoulis article

Answer 21

• Dementia and MCI now major and minor NCD
• Key distinction of major NCD is interference in independence of ADLs
• Hard to classify minor NCD’s by subtypes because not fully manifested
• Authors argue that not enough focus on specification of patterns of neuropsychological impairment, neuropsychiatric features, neuroimaging or other clinical biomarkers

Question 22

Delirium Specifiers

Answer 22

• Substance intoxication delirium
• Substance withdrawal delirium
• Medication-induced delirium
• Delirium due to another medical condition
• Delirium due to multiple etiologies
• Acute (lasting a few hours/days) or persistent (lasting weeks/months)
• Hyperactive, hypoactive, mixed level of activity