DSM-5-TR Neurocognitive Disorders

Complex attention Cognitive domain

Sustained Attention: Maintenance of attention over time (e.g., pressing a button every time a tone is heard, and over a period of time).

Selective Attention: Maintenance of attention despite competing stimuli or distractors: hearing numbers and letters read and asked to count only letters.

Divided Attention: Attending to two tasks within the same time period: rapidly tapping while learning a story being read. Processing speed can be quantified on any task by timing it (e.g., time to put together a design of blocks; time to match symbols with numbers; speed in responding, such as counting speed or serial 3 speed).

Complex attention MILD

Normal tasks take longer than previously. Begins to find errors in routine tasks; finds work needs more double-checking than previously. Thinking is easier when not competing with other things (radio, TV, other conversations, cell phone, driving).

Complex attention MAJOR

Has increased difficulty in environments with multiple stimuli (TV, radio, conversation); is easily distracted by competing events in the environment. Is unable to attend unless input is restricted and simplified. Has difficulty holding new information in mind, such as recalling phone numbers or addresses just given, or reporting what was just said. Is unable to perform mental calculations. All thinking takes longer than usual, and components to be processed must be simplified to one or a few.

Executive function Cognitive Domain

Planning: Ability to find the exit to a maze; interpret a sequential picture or object arrangement. Decision-making: Performance of tasks that assess process of deciding in the face of competing alternatives (e.g., simulated gambling).

Working memory: Ability to hold information for a brief period and to manipulate it (e.g., adding up a list of numbers or repeating a series of numbers or words backward). Feedback/error utilization: Ability to benefit from feedback to infer the rules for solving a problem.

Overriding habits/inhibition: Ability to choose a more complex and effortful solution to be correct (e.g., looking away from the direction indicated by an arrow; naming the color of a word's font rather than naming the word).

Mental/cognitive flexibility: Ability to shift between two concepts, tasks, or response rules (e.g., from number to letter, from verbal to keypress response, from adding numbers to ordering numbers, from ordering objects by size to ordering by color).

Executive function MILD

Increased effort required to complete multistage projects. Has increased difficulty multitasking or difficulty resuming a task interrupted by a visitor or phone call. May complain of increased fatigue from the extra effort required to organize, plan, and make decisions. May report that large social gatherings are more taxing or less enjoyable because of increased effort required to follow shifting conversations.

Executive function MAJOR

Abandons complex projects. Needs to focus on one task at a time. Needs to rely on others to plan instrumental activities of daily living or make decisions. Mild: Increased effort required to complete multistage projects. Has increased difficulty multitasking or difficulty resuming a task interrupted by a visitor or phone call. May complain of increased fatigue from the extra effort required to organize, plan, and make decisions. May report that large social gatherings are more taxing or less enjoyable because of increased effort required to follow shifting conversations.

Learning and Memory Cognitive Domain

Immediate memory span: Ability to repeat a list of words or digits. Note: Immediate memory sometimes subsumed under "working memory" (see "Executive Function").

Recent memory: Assesses the process of encoding new information (e.g., word lists, a short story, or diagrams). The aspects of recent memory that can be tested include 1) free recall (the individual is asked to recall as many words, diagrams, or elements of a story as possible); 2) cued recall (examiner aids recall by providing semantic cues such as "List all the food items on the list" or "Name all of the children from the story"); and 3) recognition memory (examiner asks about specific items— e.g., "Was 'apple' on the list?" or "Did you see this diagram or figure?"). Other aspects of memory that can be assessed include semantic memory (memory for facts), autobiographical memory (memory for personal events or people), and implicit (procedural) learning (unconscious learning of skills).

Learning and Memory MAJOR

Repeats self in conversation, often within the same conversation. Cannot keep track of short list of items when shopping or of plans for the day. Requires frequent reminders to orient to task at hand.

Learning and Memory MILD

Has difficulty recalling recent events, and relies increasingly on list making or calendar. Needs occasional reminders or re-reading to keep track of characters in a movie or novel. Occasionally may repeat self over a few weeks to the same person. Loses track of whether bills have already been paid.

Language Cognitive Domain

Expressive language: Confrontational naming (identification of objects or pictures); fluency (e.g., name as many items as possible in a semantic [e.g., animals] or phonemic [e.g., words starting with "f"] category in 1 minute).

Grammar and syntax (e.g., omission or incorrect use of articles, prepositions, auxiliary verbs): Errors observed during naming and fluency tests are compared with norms to assess frequency of errors and compare with normal slips of the tongue.

Receptive language: Comprehension (word definition and object-pointing tasks involving animate and inanimate stimuli): performance of actions/activities according to verbal command.

Language MAJOR

Has significant difficulties with expressive or receptive language. Often uses general-use phrases such as "that thing" and "you know what I mean," and prefers general pronouns rather than names. With severe impairment, may not even recall names of closer friends and family. Idiosyncratic word usage, grammatical errors, and spontaneity of output and economy of utterances occur. Stereotypy of speech occurs; echolalia and automatic speech typically precede mutism.

Language MILD

Has noticeable word-finding difficulty. May substitute general for specific terms. May avoid use of specific names of acquaintances. Grammatical errors involve subtle omission or incorrect use of articles, prepositions, auxiliary verbs, etc.

Perceptual-motor Cognitive Domain

Visual perception: Line bisection tasks can be used to detect basic visual defect or attentional neglect. Motor-free perceptual tasks (including facial recognition) require the identification and/or matching of figures—best when tasks cannot be verbally mediated (e.g., figures are not objects); some require the decision of whether a figure can be "real" or not based on dimensionality.

Visuoconstructional: Assembly of items requiring hand-eye coordination, such as drawing, copying, and block assembly.

Perceptual-motor: Integrating perception with purposeful movement (e.g., inserting blocks into a form board without visual cues; rapidly inserting pegs into a slotted board). Praxis: Integrity of learned movements, such as ability to imitate gestures (wave goodbye) or pantomime use of objects to command ("Show me how you would use a hammer").

Gnosis: Perceptual integrity of awareness and recognition, such as recognition of faces and colors.

Perceptual-motor MAJOR

Has significant difficulties with previously familiar activities (using tools, driving motor vehicle), navigating in familiar environments; is often more confused at dusk, when shadows and lowering levels of light change perceptions.

Perceptual-motor MILD

May need to rely more on maps or others for directions. Uses notes and follows others to get to a new place. May find self lost or turned around when not concentrating on task. Is less precise in parking. Needs to expend greater effort for spatial tasks such as carpentry, assembly, sewing, or knitting.

Social Cognition Cognitive Domain

Recognition of emotions: Identification of emotion in images of faces representing a variety of both positive and negative emotions.

Theory of mind: Ability to consider another person's mental state (thoughts, desires, intentions) or experience—story cards with questions to elicit information about the mental state of the individuals portrayed, such as "Where will the girl look for the lost bag?" or "Why is the boy sad?"

Social Cognition MAJOR

Recognition of emotions: Identification of emotion in images of faces representing a variety of both positive and negative emotions. Theory of mind: Ability to consider another person's mental state (thoughts, desires, intentions) or experience—story cards with questions to elicit information about the mental state of the individuals portrayed, such as "Where will the girl look for the lost bag?" or "Why is the boy sad?"

Social Cognition MILD

Has subtle changes in behavior or attitude, often described as a change in personality, such as less ability to recognize social cues or read facial expressions, decreased empathy, increased extraversion or introversion, decreased inhibition, or subtle or episodic apathy or restlessness.

Delirium CRITERIA

A. A disturbance in attention (i.e., reduced ability to direct, focus, sustain, and shift attention) accompanied by reduced awareness of the environment.

B. The disturbance develops over a short period of time (usually hours to a few days), 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 (e.g., memory deficit, disorientation, language, visuospatial ability, or perception). D. The 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 (i.e., due to a drug of abuse or to a medication), or exposure to a toxin, or is due to multiple etiologies.

Delirium Specifiers...

Acute: Lasting a few hours or days.

Persistent: Lasting weeks or months.

Hyperactive: The individual has a hyperactive level of psychomotor activity that may be accompanied by mood lability, agitation, and/or refusal to cooperate with medical care.

Hypoactive: The individual has a hypoactive level of psychomotor activity that may be accompanied by sluggishness and lethargy that approaches stupor.

Mixed level of activity: The individual has a normal level of psychomotor activity even though attention and awareness are disturbed. Also includes individuals whose activity level rapidly fluctuates.

Substance intoxication delirium: This diagnosis should be made instead of substance intoxication when the symptoms in Criteria A and C predominate in the clinical picture and when they are sufficiently severe to warrant clinical attention.

Substance withdrawal delirium: This diagnosis should be made instead of substance withdrawal when the symptoms in Criteria A and C predominate in the clinical picture and when they are sufficiently severe to warrant clinical attention.

Major Neurocognitive Disorder CRITERIA

A. Evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition) based on: 1. Concern of the individual, a knowledgeable informant, or the clinician that there has been a significant decline in cognitive function; and 2. A substantial impairment in cognitive performance, preferably documented by standardized neuropsychological testing or, in its absence, another quantified clinical assessment.

B. The cognitive deficits interfere with independence in everyday activities (i.e., at a minimum, requiring assistance with complex instrumental activities of daily living such as paying bills or managing medications).

C. The cognitive deficits do not occur exclusively in the context of a delirium.

D. The cognitive deficits are not better explained by another mental disorder (e.g., major depressive disorder, schizophrenia).

Mild Neurocognitive Disorder CRITERIA

A. Evidence of modest cognitive decline from a previous level of performance in one or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition) based on: 1. Concern of the individual, a knowledgeable informant, or the clinician that there has been a mild decline in cognitive function; and 2. A modest impairment in cognitive performance, preferably documented by standardized neuropsychological testing or, in its absence, another quantified clinical assessment.

B. The cognitive deficits do not interfere with capacity for independence in everyday activities (i.e., complex instrumental activities of daily living such as paying bills or managing medications are preserved, but greater effort, compensatory strategies, or accommodation may be required).

C. The cognitive deficits do not occur exclusively in the context of a delirium.

D. The cognitive deficits are not better explained by another mental disorder (e.g., major depressive disorder, schizophrenia).

BOTH Neurocognitive Disorder Specifiers...

Without behavioral disturbance: If the cognitive disturbance is not accompanied by any clinically significant behavioral disturbance.

With behavioral disturbance (specify disturbance): If the cognitive disturbance is accompanied by a clinically significant behavioral disturbance (e.g., psychotic symptoms, mood disturbance, agitation, apathy, or other behavioral symptoms).

MAJOR Neurocognitive Disorder SEVERITY Specifiers...

Mild: Difficulties with instrumental activities of daily living (e.g., housework, managing money).

Moderate: Difficulties with basic activities of daily living (e.g., feeding, dressing).

Severe: Fully dependent.

Major or Mild Neurocognitive Disorder Due to Alzheimer's Disease CRITERIA

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 (for major neurocognitive disorder, at least two domains must be impaired).

C. Criteria are met for either probable or possible Alzheimer's disease

D. The disturbance is not better explained by cerebrovascular disease, another neurodegenerative disease, the effects of a substance, or another mental, neurological, or systemic disorder.

Major or Mild Neurocognitive Disorder Due to Alzheimer's Disease PROBABLE vs. POSSIBLE

For major neurocognitive disorder:

Probable Alzheimer's disease is diagnosed if either of the following is present; otherwise, possible Alzheimer's disease should be diagnosed.

1. Evidence of a causative Alzheimer's disease genetic mutation from family history or genetic testing.

2. All three of the following are present:

a. Clear evidence of decline in memory and learning and at least one other cognitive domain (based on detailed history or serial neuropsychological testing).

b. Steadily progressive, gradual decline in cognition, without extended plateaus.

c. No evidence of mixed etiology (i.e., absence of other neurodegenerative or cerebrovascular disease, or another neurological, mental, or systemic disease or condition likely contributing to cognitive decline).

For mild neurocognitive disorder:

Probable Alzheimer's disease is diagnosed if there is evidence of a causative Alzheimer's disease genetic mutation from either genetic testing or family history. Possible Alzheimer's disease is diagnosed if there is no evidence of a causative Alzheimer's disease genetic mutation from either genetic testing or family history, and all three of the following are present:

1. Clear evidence of decline in memory and learning.

2. Steadily progressive, gradual decline in cognition, without extended plateaus.

3. No evidence of mixed etiology (i.e., absence of other neurodegenerative or cerebrovascular disease, or another neurological or systemic disease or condition likely contributing to cognitive decline).

Major or Mild Frontotemporal Neurocognitive Disorder CRITERIA

A. The criteria are met for major or mild neurocognitive disorder.

B. The disturbance has insidious onset and gradual progression.

C. Either (1) or (2):

1. Behavioral variant: a. Three or more of the following behavioral symptoms: i. Behavioral disinhibition. ii. Apathy or inertia. iii. Loss of sympathy or empathy. 696 iv. Perseverative, stereotyped or compulsive/ritualistic behavior. v. Hyperorality and dietary changes. b. Prominent decline in social cognition and/or executive abilities.

2. Language variant: a. Prominent decline in language ability, in the form of speech production, word finding, object naming, grammar, or word comprehension.

D. Relative sparing of learning and memory and perceptual-motor function.

E. The disturbance is not better explained by cerebrovascular disease, another neurodegenerative disease, the effects of a substance, or another mental, neurological, or systemic disorder.

Major or Mild Frontotemporal Neurocognitive Disorder PROBABLE vs. POSSIBLE

Probable frontotemporal neurocognitive disorder is diagnosed if either of the following is present; otherwise, possible frontotemporal neurocognitive disorder should be diagnosed: 1. Evidence of a causative frontotemporal neurocognitive disorder genetic mutation, from either family history or genetic testing.

2. Evidence of disproportionate frontal and/or temporal lobe involvement from neuroimaging.

Possible frontotemporal neurocognitive disorder is diagnosed if there is no evidence of a genetic mutation, and neuroimaging has not been performed.

Major or Mild Neurocognitive Disorder With Lewy Bodies CRITERIA

A. The criteria are met for major or mild neurocognitive disorder.

B. The disorder has an insidious onset and gradual progression.

C. The disorder meets a combination of core diagnostic features and suggestive diagnostic features for either probable or possible neurocognitive disorder with Lewy bodies.

D. The disturbance is not better explained by cerebrovascular disease, another neurodegenerative disease, the effects of a substance, or another mental, neurological, or systemic disorder.

Major or Mild Neurocognitive Disorder With Lewy Bodies PROBABLE vs. POSSIBLE

For probable major or mild neurocognitive disorder with Lewy bodies, the individual has two core features, or one suggestive feature with one or more core features.

For possible major or mild neurocognitive disorder with Lewy bodies, the individual has only one core feature, or one or more suggestive features.

1. Core diagnostic features:

a. Fluctuating cognition with pronounced variations in attention and alertness.

b. Recurrent visual hallucinations that are well formed and detailed.

c. Spontaneous features of parkinsonism, with onset subsequent to the development of cognitive decline.

2. Suggestive diagnostic features:

a. Meets criteria for rapid eye movement sleep behavior disorder.

b. Severe neuroleptic sensitivity.

Major or Mild Vascular Neurocognitive Disorder CRITERIA

A. The criteria are met for major or mild neurocognitive disorder.

B. The clinical features are consistent with a vascular etiology, as suggested by either of the following:

1. Onset of the cognitive deficits is temporally related to one or more cerebrovascular events.

2. Evidence for decline is prominent in complex attention (including processing speed) and frontal-executive function.

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. The symptoms are not better explained by another brain disease or systemic disorder.

Major or Mild Vascular Neurocognitive Disorder PROBABLE vs. POSSIBLE

Probable vascular neurocognitive disorder is diagnosed if one of the following is present; otherwise possible vascular neurocognitive disorder should be diagnosed:

1. Clinical criteria are supported by neuroimaging evidence of significant parenchymal injury attributed to cerebrovascular disease (neuroimagingsupported).

2. The neurocognitive syndrome is temporally related to one or more documented cerebrovascular events.

3. Both clinical and genetic (e.g., cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy) evidence of cerebrovascular disease is present.

Possible vascular neurocognitive disorder is diagnosed if the clinical criteria are met but neuroimaging is not available and the temporal relationship of the neurocognitive syndrome with one or more cerebrovascular events is not established.

Major or Mild Neurocognitive Disorder Due to Traumatic Brain Injury CRITERIA

A. The criteria are met for major or mild neurocognitive disorder.

B. There is evidence of a traumatic brain injury—that is, an impact to the head or other mechanisms of rapid movement or displacement of the brain within the skull, with one or more of the following:

1. Loss of consciousness.

2. Posttraumatic amnesia.

3. Disorientation and confusion.

4. Neurological signs (e.g., neuroimaging demonstrating injury; visual field cuts; anosmia; hemiparesis; hemisensory loss; cortical blindness; aphasia; apraxia; weakness; loss of balance; other sensory loss that cannot be accounted for by peripheral or other causes).

C. The neurocognitive disorder presents immediately after the occurrence of the traumatic brain injury or immediately after recovery of consciousness and persists past the acute post-injury period.

Substance/Medication-Induced Major or Mild Neurocognitive Disorder CRITERIA

A. The criteria are met for major or mild neurocognitive disorder.

B. The neurocognitive impairments do not occur exclusively during the course of a delirium and persist beyond the usual duration of intoxication and acute withdrawal.

C. The involved substance or medication and duration and extent of use are capable of producing the neurocognitive impairment.

D. The temporal course of the neurocognitive deficits is consistent with the timing of substance or medication use and abstinence (e.g., the deficits remain stable or improve after a period of abstinence).

E. The neurocognitive disorder is not attributable to another medical condition or is not better explained by another mental disorder.

Major or Mild Neurocognitive Disorder Due to HIV Infection CRITERIA

A. The criteria are met for major or mild neurocognitive disorder.

B. There is documented infection with human immunodeficiency virus (HIV).

C. The neurocognitive disorder is not better explained by non-HIV conditions, including secondary brain diseases such as progressive multifocal leukoencephalopathy or cryptococcal meningitis.

D. The neurocognitive disorder is not attributable to another medical condition and is not better explained by a mental disorder.

Major or Mild Neurocognitive Disorder Due to Prion Disease CRITERIA

A. The criteria are met for major or mild neurocognitive disorder.

B. There is insidious onset, and rapid progression of impairment is common.

C. There are motor features of prion disease, such as myoclonus or ataxia, or biomarker evidence.

D. The neurocognitive disorder is not attributable to another medical condition and is not better explained by another mental disorder.

Major or Mild Neurocognitive Disorder Due to Parkinson's Disease CRITERIA

A. The criteria are met for major or mild neurocognitive disorder.

B. The disturbance occurs in the setting of established Parkinson's disease.

C. There is insidious onset and gradual progression of impairment.

D. The neurocognitive disorder is not attributable to another medical condition and is not better explained by another mental disorder.

Major or Mild Neurocognitive Disorder Due to Parkinson's Disease PROBABLE vs POSSIBLE

Major or mild neurocognitive disorder probably due to Parkinson's disease should be diagnosed if 1 and 2 are both met.

Major or mild neurocognitive disorder possibly due to Parkinson's disease should be diagnosed if 1 or 2 is met:

1. There is no evidence of mixed etiology (i.e., absence of other neurodegenerative or cerebrovascular disease or another neurological, mental, or systemic disease or condition likely contributing to cognitive decline).

2. The Parkinson's disease clearly precedes the onset of the neurocognitive disorder.

Major or Mild Neurocognitive Disorder Due to Huntington's Disease CRITERIA

A. The criteria are met for major or mild neurocognitive disorder.

B. There is insidious onset and gradual progression.

C. There is clinically established Huntington's disease, or risk for Huntington's disease based on family history or genetic testing.

D. The neurocognitive disorder is not attributable to another medical condition and is not better explained by another mental disorder.