psych 223 - ch 15 neurocognitive disorders

neurocognitive disorders: an overview

• Most neurocognitive disorders develop much later in life whereas intellectual disability and specific learning disorder are believed to be perfect from birth

• Affect learning, memory, and consciousness

• Types of neurocognitive disorders 

  • Delirium

  • Major or mild neurocognitive disorder

• Shifting DSM perspectives

  • From “organic” mental disorders (due to brain injury/dysfunction) to "cognitive" disorders

  • Broad impairments in cognitive functioning 

  • Cause profound changes in behavior and personality

delirium

•  rapid-onset reduced clarity of consciousness and cognition, with confusion, disorientation, and deficits in memory and language; temporary

• nature of delirium

  • Central features - impaired consciousness and cognition

  • Develops rapidly over several hours or days

  • Appear confused, disoriented, and inattentive

  • Marked memory and language deficits

  • Drugs such as ecstasy, “Molly” and “bath salts” can cause substance- induced delirium 

delirium facts and statisitcs

• Affects up to 20% of adults in acute care facilities (e.g. ER)

• More prevalent in certain populations, including:

  • Older adults

  • Those undergoing medical procedures

  • People with AIDS or cancer

  • People in hospitals / critical care

• Full recovery often occurs within several weeks

medical conditions related to delirium

• Dementia (50% of cases involve temporary delirium)

• Drug intoxication, poisons, withdrawal from drugs

• Infections

• Head injury and several forms of brain trauma

• Sleep deprivation, immobility, and excessive stress

treatment of delirium

• attention to underlying causes

• psychosocial interventions

  • reassurance/comfort, coping strategies, inclusion of patients in treatment decisions

prevention of delirium

• address proper medical care for illnesses, proper use of, and adherence to, therapeutic drugs

Major neurocognitive disorder

• previously labeled as dementia, gradual deterioration of brain functioning that affects memory, judgement, language, and other advanced cognitive processes 

Mild neurocognitive disorder

• modest impairment in cognitive abilities that can be overcome with accommodations such as extensive lists or elaborate schedules. 

• Has many causes and may be irreversible

neurocognitive disorder statisitcs

• New case identified every 7 seconds

• 5% prevalence in adults 65+; 20% prevalence in adults 90+

• Five million people with major neurocognitive disorder in US

• Methodology for estimating number of those suffering from major neurocognitive disorder has resulted in diverging numbers

• dramtic rise in alzheimer’s disease cases predicted through 2050; more people expected to live to > 85 years

DSM-5 Types of major and mild neurocognitive disorder

• Due to Alzheimer's disease

• Frontotempeoral 

• Vascular

• With lewy bodies

• Due to traumatic brain injury

• substance/medication induced

• Due to hiv infection

• Due to prion disease

• Due to Parkinson's disease

• Due to another medical condition

• Due to multiple etiologies

• Unspecified

neurocognitive disorder due to alzheimer’s disease

• condition resulting from a disease that develops most often in people 50 and older, characterized by multiple cognitive defects that develop gradually and steadily 

• Clinical features

  • Typically develops gradually and steadily

  • Memory, orientation, judgment, and reasoning deficits

  • Additional symptoms may include

    • Agitation, confusion, or combativeness

    • Depression and/or anxiety

Neurocognitive disorder due to alzheimer’s disease - stats

• Statistics

  • Prevalence

    • More common in less educated individuals

      • People who attain a higher level of education decline more rapidly once the symptoms become more severe

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

    • Slightly more common in women

      • Possibly because women lose estrogen as they age; estrogen may be protective

  • Post diagnosis survival = 8 years

  • Onset = 60s or 70s (“early onset” = 40s to 50s)

  • 60 to 70% of the cases of neurocognitive disorder result from Alzheimer's disease

Alzheimer's disorder: extent of deficits

• Range of cognitive deficits 

  • Aphasia- diffculty w language

  • Apraxia - impaired motor functioning

  • Agnosia - the inability to recognize and name objects; may be a symptom of major neurocognitive disorder or other brain disorders

    • Facial agnosia - type of agnosia specific to the inability to recognize even familiar faces

  • Difficulties with planning, organizing, sequencing, abstracting information

  • Negative impact on social and occupational functioning

aphasia

Impairment or loss of language skills resulting from brain damage caused by stroke, Alzheimer’s disease, or other illness or trauma.

apraxia

impaired motor functioning

agnosia

Inability to recognize and name objects; may be a symptom of major neurocognitive disorder or other brain disorders.

facial agnosia

• type of agnosia specific to the inability to recognize even familiar faces

vascular neurocognitive disorder

• Progressive brain disorder involving loss of cognitive functioning, caused by blockage of blood flow/vessels to the brain, that appears concurrently with other neurological signs and symptoms

  • Caused by blockage or damage to blood vessels

  • Second leading cause of neurocognitive disorder after alzheimer’s disease

  • Onset is often sudden (e.g. stroke)

  • Patterns of impairment are variable

  • Most require formal care in later stages

  • Prevalence 1.5% in people 70 to 75% and 15% for people over 80

  • Risk slightly higher in men

what is the leading cause of neurocognitive disorder?

alzheimer’s

what is the second leading cause of neurocognitive disorder

vascular neurocognitive disorder

frontotemporal neurocognitive disorder

• condition that damages the frontal or temporal regions of the brain; behavior or language or personality is negatively affected

• two types of impairment

  • declines in appropriate behavior

  • declines in language

picks’s disease

• rare condition that results in early onset neurocognitive disorder

  • Produces a cortical dementia like alzheimer’s

  • Occurs relatively early in life (around 40s or 50s)

Neurocognitive disorder due to traumatic brain injury

• neurocognitive disorder due to traumatic brain injury - condition resulting from jarring of the brain caused by a blow to the head or other impact; symptoms persist for at least a week after the initial trauma

  • accidents are leading cause

  • symptoms last for at least one week after head injury, including problems with executive function, learning, memory

  • Risk factors include age (most common among teens and young adults), excessive alcohol use, and lower socioeconomic status

head trauma

• injury to the head and, therefore, to the brain, typically caused by accidents; can lead to cognitive impairments, including memory loss

traumatic brain injury

• brain damage caused by a blow to the head or other trauma that injures the brian and results in diminished neurocognitive capacity

Neurocognitive disorder due to lewy body disease

• neurological impairment that affects people with Lew body disease, in which protein deposits damage brain cells and gradually cause motor impairments and loss of alertness

• Lewy bodies are microscopic protein deposits that damage brain over time

• Symptoms onset gradually

• Symptoms include impaired attention and alertness, visual hallucinations, motor impairment

Neurocognitive disorder due to parkinson’s disease

• disorder characterized by progressive decline in motor movements; results from damage to dopamine pathways

parkinson’s disease

• degenerative brain disorder principally affecting motor performance (for example, tremors and stooped posture) associated with reduction in dopamine. Major neurocognitive disorder may be a result as well

• Parkinson’s disease

  • Degenerative brain disorder

  • Dopamine pathway damage

  • 1 out of 1,000 people are affected worldwide

  • Chief difficulty: motor problems

    • Tremors, posture, walking, speech

  • Not all with PD will develop dementia

  • 75% survive 10+ years after diagnosis

Human Immunodeficiency virus type 1 (HIV-1)

•  disease that causes AIDS

Neurocognitive disorder due to HIV infections

• less common type of neurocognitive disorder that affects people who have HIV; may lead to impaired thinking in advanced stages

• HIV-1 can cause neurological impairments and dementia in some individuals

  • Cognitive slowness, impaired attention, and forgetfulness

  • Apathy and social withdrawal

  • Typically occurs in later disease stages

  • Now occurs in <10% of individuals with HIV

    • Highly active antiretroviral therapy (HAART) decreases risk

Neurocognitive disorder due to Huntington's disease

• neurological disorder that follows a subcortical pattern and is notable for causing involuntary limb movements

• Huntington’s disease = genetic autosomal dominant disorder

  • Caused by a gene on chromosome 4

• Manifests initially as involuntary limb movements (chorea), usually later in life

• Somewhere between 20% to 80% display neurocognitive disorder

• Dementia follows a subcortical pattern

huntington’s disease

• genetic disorder marked by involuntary limb movements and progressing to major neurocognitive disorder

• Huntington’s disease = genetic autosomal dominant disorder

  • Caused by a gene on chromosome 4

aphasia

• impairment or loss of language skills resulting from brain damage caused by stroke, Alzheimer's disease, or other illness or trauma

neurocognitive disorder due to prion disease

• rare progressive neurodegenerative disorder caused by prions, proteins that can reproduce themselves and cause damage to brain cells

• No known treatment, always fatal

• Can only be acquired through cannibalism or accidental transmission (e.g., contaminated blood transfusion)

ex: creutzfeldt-jakob disease

Creutzfeldt- jakob disease

• extremely rare type of prion disease that may result from a number of sources, including the consumption of beef from cattle with “mad cow disease”

  • Affects 1 out of 1,000,000

  • Linked to mad cow disease

substance/medication induced neurocognitive disorder

•  brain damage caused by prolonged use of drugs, often in combination with a poor diet

• 50 to 70% of chronic heavy alcohol users show some cognitive impairment, 7% of those meet criteria for neurocognitive disorder

• May be caused by alcohol, sedative, hypnotic, anxiolytic, or inhalant drugs

• Brian damage may be permanent 

• Symptoms similar to Alzheimer's

• Deficits may include

  • Memory impairment

  • Aphasia, apraxia, agnosia

  • Disturbed executive functioning 

causes of neurocognitive disorder: the example of alzheimer’s disease

• Features of brains w alzheimer’s disease

  • Neurofibrillary tangles (strand-like filaments)

  • Amyloid plaques (gummy deposits between neurons)

  • Brains of people with Alzheimer's tend to atrophy(shrink)

• Multiple genes are involved in Alzheimer's disease

  • Include genes on chromosomes 12,14,19,21

    • Chromosome 14

      • Associated with early onset alzheimer’s

    • Chromosome 19

      • Associated with late onset alzheimer’s

• Deterministic genes

• Susceptibility genes

deterministic genes

•  rare genes that lead to nearly a 100% chance of developing Alzheimer's. 

  • Beta-amyloid precursor gene

  • Presinilin-1 and presenilin-2 genes

susceptibility genes

• make it more likely but not certain to develop alzheimer’s

  • More common in the general population

  • ApoE4 gene is located on chromosome 18 and associated with late onset alzheimer’s 

the contributions of psychosocial factors in neurocognitive disorders

• Psychosocial factors such as education, coping skills, and social support do not cause dementia directly

  • May influence onset and course

• Lifestyle factors include drug use, diet, exercise, stress 

• Risk for certain conditions vary by ethnicity

medical treatment of neurocognitive disorders

• Few primary treatments exist

• Most treatments attempt to slow progression of deterioration, but cannot stop it

• Future directions

  • Glial cell-derived neurotrophic factor, stem cells: may slow deterioration

• Some drugs target cognitive deficits

  • Cholinesterase-inhibitors

  • Long-term effects not well demonstrated

psychosocial treatment of neurocognitive disorders

• Aims of psychosocial treatments

  • Enhance lives of patients and their families

  • Teach compensatory skills

  • Use memory enhancement devices, if needed

    • Example: “memory wallets” containing statements about one’s life

• Cognitive stimulation can delay onset of more severe symptoms 

Psychosocial treatment of neurocognitive disorders: caregivers

• Caregivers get instructions on how to handle problematic behavior including:

  • Wandering

  • Socially inappropriate behavior

  • Aggressive or rebellious behavior 

  • Impact of care on their own health

• Caregivers also under great deal of stress, may need mental health treatment

prevention of neurocognitive disorders

•  Reducing risk in older adults

  • Control blood pressure

  • Don’t smoke

  • Lead active physical and social life