Week 12: Neurocognitive Disorders

What are Neurocognitive Disorders?

Note the focus on “neurological.” This chapter was previously titled “Delirium, Dementia, and Amnestic and Other Cognitive Disorders.” The disorders’ core features are cognitive. They are characterized by: (the syndromes of delirium as well as by major or mild neurocognitive disorders and their etiological subtypes). All of which are caused by either a general medical condition, or substance use or a combination.

What do neurocognitive disorders represent?

a deficit in the person’s cognitive functioning and are acquired rather than developmental. We would see a clear decline from a previous level of functioning, prominent memory disturbances, and CNS damage. The disorders are progressive and degenerative marked by gradual deterioration of a broad range of cognitive abilities. The person experiences global deterioration - gradual but progressive. The have a great deal of difficulty performing tasks that require them to remember or learn things or to use information they once knew.

What are the delirium disorders?

Substance, Intoxication/Withdrawal, Medication-induced, Delirium due to Another Medical Condition.

What are the major or mild neurocognitive disorders?

(13) Alzheimer’s disease, Frontotemporal Lobar Degeneration, Lewy Body Disease, Vascular Disease, Traumatic Brain Injury, Substance/Medical Induced, HIV Infection, Prion Disease, Parkinson's Disease, Huntington’s Disease, Another Medical Condition, Multiple Etiologies, Unspecified. These are very medically based.

What is delirium?

One of the first mental disorders to be documented in history. It has many known causative factors: (Fevers, drug allergies, chemotherapy, anesthesia). The interplay between cognitive functioning and biological influences. Most of the medical conditions that cause this are potentially treatable. People may not remember what is happening. Temporary condition that often follows a short and fluctuating course. People with this cannot think or reason clearly and thus lose contact with the world around them. A person might be able to focus on one thing, but the focus only lasts a few moments. The person cannot relate their present situation to anything they experienced in their past. It can occur at any age. Its effects are almost always time-limited.

What would we would see in delirium?

Restlessness, Agitation, Constant moving around without purpose or goal-related activity. The person may suddenly change from interacting with the world to totally withdrawn.

What is Delirium Prevailing pattern?

Most commonly affects the frail and infirm. The presence of this varies depending on the characteristics of the individual, the setting of care - is it familiar to the person?, and sensitivity to detection. Can be found in (15% to 53% of older individuals postoperatively, 70% to 87% of those in ICU, 60% of those in nursing homes or post-acute care settings, and up to 83% of people at the end of life).

What is the Delirium differential assessment?

The disorder is characterized by impaired awareness and attention during the course of several hours or several days. Most prevalent in those who undergo general surgical procedures, cancer patients, and people with AIDS. Can also be caused by intoxication from drugs, toxins, and poisons; withdrawal from drugs; infections; head injuries; and various other types of trauma to the brain. Often signals the presence of a medical situation or a medical emergency!!! Tends to develop quickly, and its course can vary over the day - Symptoms tend to worsened during early evening or at night (known as “sundowning”).

What is a clouding of consciousness?

the inability to focus, sustain, or shift attention. Individuals appear confused, bewildered or alarmed. They may have difficulty concentrating and responding to reassurance of following directions. The person may be disoriented; speech may seem rambling or incoherent quality; and he/she/they may have trouble finding words - word retrieval problems, or identifying commonly recognized objects or people. Perceptual disturbances may also be present and include illusions and visual hallucinations. Persecutory delusions are fairly common.

What is the etiology of delirium?

Specify according to substance intoxication or withdrawal, medication-induced, due to another condition or due to multiple etiologies. Associated features include: (Symptom length: active (lasting a few hours or days) or persistent (lasting weeks or months). Activity level: The person may appear hyper/hypoactive or show mixed level of activity. Emotional disturbances: Periods of anxiety, fear, depression, irritability, belligerence, or euphoria). In schizophrenia we would see negative symptoms - not really in this. If caused by a medication, note then name of the medication when coding this. If this is caused by a medical condition, note the condition: E.g., Delirium Due to Congestive Heart Failure

What is complex attention?

the ability to sustain focus

What is the specific function of complex attention?

Includes sustained attention or the person’s ability to pay attention over time. Allocating and dividing attention; Selective attention or the ability to resist distractions; and processing speed or the ability to capture information, process it, and respond.

What is an example of major impairment of complex attention?

Increased difficulty in environments with multiple stimuli (TV, radio, conversation); easily distracted by competing events in the environment; and input must be restricted and simplified. 

What is an example of mild impairment of complex attention?

Normal tasks can take longer than before; others begin to find errors in routine tasks; work needs more double-checking than before; thinking is easier for the person when he/she/they are not competing with other things like listening to the radio.

What is executive function?

The ability to think abstractly and to plan initiate, sequence, monitor, and stop complex behavior, allows a person to access info, think about solutions, and to implement them.

What is the specific function of executive function?

This includes the ability to plan; make decisions; working memory or the ability to hold info for a brief period of time and to manipulate it. Responding to feedback: being able to benefit from feedback and correcting errors; overriding habits/inhibitions; and mental flexibility or being able to shift between thinking about two different concepts. Ex. don’t put your hand on the hot stove.

What is an example of major impairment of executive function?

Individual abandons complex projects, needs to focus on one task at a time; depends on others to plan significant activities of daily living even to make decisions.

What is an example of mild impairment of executive function?

Individual increases his/her efforts necessary to complete the multiple phases of projects; experiences difficulty returning to an interrupted task, for instance by a phone call; may complain about the extra effort needed to organize, plan, and make decisions; may avoid large gatherings finding them more taxing or less enjoyable due to increased effort to follow shifting conversations.

What is learning and memory?

The process in which info is encoded, stored, and retrieved

What is the specific function of learning and memory?

This addresses immediate memory; Recent memory (including the ability to freely recall, cued, recall, and recognition memory); and Very long-term memory. Note: Sometimes immediate memory is considered under the working memory seen as part of the persons’ executive functions

What is an example of a major impairment of learning and memory?

The person may now repeat himself/herself/themself in conversations; cannot keep track of a short list of items when going out shopping or planning the day; requires numerous reminders to attend to a task at hand.

What is an example of mild impairment of learning and memory?

The person shows difficulty recalling events; relies more on making lists or checking a calendar; occasionally repeats him/herself/themself over a few weeks to the same person; loses track of bills that have been paid. The situation is causing problems in social, occupational, or functional parts of life.

What is language?

Particularly expressive, or one’s ability to communicate with others using language or how one expresses his/her/their wants and needs and receptive language which is the understanding of language input or the understanding of both words and gestures.

What is the specific function of language?

This comprises naming: Word finding (proficiency in identifying objects or pictures); Fluencies (being able to name as many things as possible in a specific category); Grammar and Syntax or the rules of grammar that dictate how words are combined into phrases, sentences, and paragraphs.

What is an example of major impairment of language?

Significant difficulties expressing language and prefers general pronouns instead of names. Errors in grammar are evident; becomes echolalic.

What is an example of minor impairment of language?

Noticeable difficulties finding words; may substitute general terms for the specifics; may avoid using the particular names of acquaintances; shows grammatical errors involving subtle omission or incorrect use of parts of speech.

What is perceptual-motor?

the ability to receive, interpret, and respond successfully to info.

What is the specific function of perceptual-motor?

Includes visual – the abilities involving the coordination of fine motor skills with visuospatial abilities, usually in the reproduction of geometric figures. Ex. reaching for something across the table and knocking everything over or someone cannot draw a trapezoid. Perceptual-motor – any skill involving the interaction and integration of perceptual processes and voluntary movement. Praxis, which refers to the act of engaging, applying exercising, realizing, or practicing ideas; and Gnosis or perceptual awareness and recognition.

What is an example of major impairment of perceptual-motor?

The individual experiences significant difficulties with activities that were previously familiar to them (e.g., using cooking utensils, driving) or navigating in familiar environments; becomes confused more often at dusk.

What is an example of mild impairment of perceptual-motor?

May need to rely more on maps for travel to familiar places; may get lost or turned around when not concentrating; less precise parking abilities.

What is social cognition?

Focuses on how people process, store, and apply info about others and social situations.

What is the specific feature of social cognition?

Consists of recognition of emotions; and the ability to consider another person’s mental state, thoughts, desires.

What is a major example of impairment of social cognition?

The person’s behavior is clearly out of the ‘acceptable’ social range/ he/she/they are insensitive to social standards of modesty in dress, or in conversations around various topics, focuses excessively on a topic despite disinterest or direct feedback from others; displays behavioral intent without regard for safety for themselves or others. Maybe they’re saying things that are not tuned inot social cues.

What is a minor example of impairment of social cognition?

Subtle changes in a person’s behavior or attitude often characterized as changes in personality – the person is less able to read social cues, shows decreased empathy, becomes increasingly extraverted.

What is Neurocognitive Disorders Differential Assessment?

The primary feature of both disorders is an acquired cognitive decline in one or more cognitive domains. Attention, executive functions, learning and memory, language, perception and social cognition. The decline is not just a sense of loss of one’s cognitive abilities, but can also be observed by others.

What is “Mild” NCD impairment?

requires a “modest” cognitive decline to the extent that it doesn’t interfere with the person’s independence in everyday activities. They can still live alone.

What is “Major” NCD impairment?

is evident or reported by those who know the individual and interferes with independence to the extent that assistance is required. The distinction relies heavily on observable behavior but can also be tested by cognitive assessment.

What is major NCD impairment differential assessment?

The person shows evidence of significant cognitive decline in domains such as complex attention, executive function, or mental processes that help connect past with present such as learning, memory, language, perceptual-motor, or social cognitive domains. Significant decline: Considered by the individual or one who knows the individual such as a relative. Significant impairment: Considered by in impairment documented by standardized assessment.

What is mild NCD impairment differential assessment?

Evidence of modest decline from a previous level of performance in one (or more) domains such as complex attention, executive function, learning, memory, language, perceptual-motor, or social cognition. Modest decline: Considered by the individual or a close relative. Modest impairment: Noted by changes diagnosed via standardized tests

What does the DSM make a distinction of in NCD?

The DSM makes a distinction between a probable and a possible diagnosis. Only when there are tangible data known about the diagnosis is the diagnosis indicated as “probable.” Note the medical condition.

The SW uses the term “possible” when he/she/they are the first to recognize the disorder but does not have evidence to support the medical diagnosis.

• Mild NCD: Previously, the dx was cognitive d/o NOS. While this is a new dx, it is believed that it will help bridge a gap by highlighting those with a modest level of decline most commonly seen, in individuals with the early stages of Alzheimer’s.

• Major NCD: Considers more severe.

What is NCD Prevailing Pattern?

The disorder primarily affects the older population. Alzheimer’s disease is the most common disorder. People with AD will have about 60% to 90% developing major impairments. Approximately 7% of those diagnosed with AD are between 65 and 74, 53% are between 75 and 84 and 40% are over age 85. Vascular disease is the second most common NCD.

What are the NCD etiological subtupes?

Each subgroup can be further divided into mild or major degrees of cognitive impairment on the basis of cognitive decline, especially around the ability ADLs. The DSM makes a distinction between a probable and a possible diagnosis. Only when there are tangible data known about the diagnosis is the diagnosis indicated as “probable.” The SW uses “possible” when he/she/they are the first to recognize the disorder but does not have evidence to support the medical diagnosis.

What is NCD due to Alzheimer’s disease?

AD appears in individuals who are in the 60s and 70s. Of those who are older than 85, nearly one-half will have Alzheimer’s disease. More prevalent among women and can be found in all ethnic groups but slightly lower rates among American Indians. There is no foolproof way to diagnose AD. Amyloid proteins build up and cause cell death. Amyloid precursor protein (APP) is a normal protein produced by healthy neurons. These can build up in the fluid surrounding neurons to form plaques. In normal people, the fluids build up and dissolve, in others, the fluid sticks together to form plaques.

What is the NCD due to Alzheimer’s disease differential assessment?

We may see degeneration in many areas of the brain. We would also have to see Mild or Major NCD. There is an insidious/slow onset and gradual progression of cognitive impairment. For major NCD, two or more cognitive domains are impaired and impaired ADLs. For mild NCD, one or more cognitive domains are impaired. The disorder is not better explained by cerebrovascular disease or another neurological or systemic disease. We would also consider: Probable NCD where there is Evidence of AD genetic mutation or All three of the following: impaired memory, progressive gradual decline, and no evidence of other possible diagnoses at work.

What would we see in NCD due to AD?

Initially, we would see problems with short-term memory. The person may forget to turn off the stove, where they live, where they left their purse. Personality changes can become apparent. The person may neglect their ADLs. The person may wander aimlessly around the neighborhood. Once the person finds his/her/their keys they may not remember the purpose of the keys. The decision to institutionalize is usually made where there is excessive nighttime activity such as falls, injuries, restlessness, immobility or difficulty in walking, incontinence, and having someone – a spouse – who can’t take care of the person. The deterioration starts out slow, but then speeds up as the person gets to the middle or late stages of the disease. Deterioration starts slow but then speeds up.

What happens in the early stage of AD?

Memory loss, Loss of initiative, Mood or personality changes, Confusion, Difficulty performing chores

What happens in the middle stage of AD?

Increasing problems seen by family and/or friends, Escalating memory loss, Increase in making repetitive statements, Occasional muscle jerking, Difficulty in reading, writing or using numbers. Needs close supervision, Becomes suspicious, irritable, or restless. Difficulty with bathing and/or self-care. Changes become more marked and disabling.

What happens in the late stage of AD?

Difficulty swallowing, Does not recognize family or friends. Does not distinguish familiar daily activities. Becomes incontinent. Unable to care for self. Difficulty communicating. Personality deterioration.

What is NCD due to vascular disease?

After AD, this is the second most common NCD. Sometimes referred to as multi-infarct dementia - several or mini strokes, so parts of the brain does not have blood flow. Symptoms can vary depending on the specific brain areas where blood flow is reduced. We would see confusing, disorientation, trouble speaking or understanding speech, or vision loss. Symptoms may be the most obvious soon after a major stroke. We may also see a person having had several or a series of strokes. Risk factors include diabetes, HTN, heart disease. The person’s condition worsens in a series of small debilitating steps, or when there is prominent evidence for a decline in complex attention and executive functions. In AD, we would see a more gradual decline.

What is Vascular Disease?

defined a decline in thinking skills caused by conditions that block or reduce blood flow to the brain depriving the brain of vital oxygen and nutrients.

What is Frontotemporal NCD?

This NCD commonly seen in adults under age 65 and is the 3rd most common NCD in industrialized nations. Used to be referred to as Pick’s Disease. This NCD symptoms typically appear about a decade earlier than AD. Survival rates vary from between 2 to 8 years post onset - decline is quick. Characterized by progressive changes in personality and social conduct and associated with degeneration of prefrontal and anterior temporal cortex of the brain. Loss of interest in socializing, self-care, and personal responsibilities, or the person may show varying degrees of apathy or disinhibition. This is where a lot of our emotional areas are located - emotionally flat affect.

What is Neurocognitive D/O with Lewy Bodies?

Relatively new classification. Roughly half the frequency of AD. Age of onset is similar to AD with the mean of 68 years and a range of 50 to 85 years. The person experiences an insidious onset and gradual progression resulting in unrelenting dementia until death. Look for Mild or Major impairments.  May have variations in attention and alertness, recurrent visual hallucinations, and movement or spontaneous features looking like Parkinson's. We would also see disturbances in sleep, severe reactions to tranquilizers. The person may have repeated falls and fainting spells, loss of consciousness, autonomic dysfunction, hallucinations, visuospatial abnormalities, and other psychiatric disturbances like delusions, aggression, and depression.

What is NCD due to Traumatic Brain Injury?

Characterized by impact to the head or displacement of the brain within the skull. Estimated 2% of the US population lives with long-term disabilities due to a prior traumatic brain injury. If someone has a TBI in early to midlife, they are at increased risk of a NCD later in life.

What is Substance/Medication-Induced NCD?

Characterized by neurocognitive impairments that persist beyond the usual duration of intoxication and acute withdrawal. Sometimes can take months for functioning to return to normal. It is important for the SW to make sure that the person’s cognitive deficits were not present before the use of the substances or medications thought to be responsible for the impairment. The d/o is specifically coded for alcohol or the specific substance causing the neurocognitive symptoms. Korsakoff syndrome and Wernicke encephalopathy. People with the disorder may confabulate information. There may be striking memory problems while other thinking and social skills are relatively unaffected.

What is NCD due to HIV Infection?

This infection enters the CNS after initial infection and is responsible for various neuropsychiatric complications. This shows a more marked impairment in cognitive functioning. Signs and symptoms range from subtle cognitive and motor impairments to profound dementia. In the late stage we would see seizures, incontinence, and severe confusion. Early on, we would see mild interference in daily functioning; inefficiency in work, homemaking, or social functioning. In major NCD, slowing may be prominent. This can affect any part of the brain, so the person may show other patterns of cognitive dysfunction.

What is NCD due to Prion Disease?

Transmissible Spongiform Encephalopathies. Mad cow. We can see this disease in both humans and animals. The causative agent is believed to be prions, which cause abnormal folding of specific normal cellular proteins called prion proteins found in the brain. Once of the identified prion diseases is Creutzfeldt-Jakob disease. We would see rapid mental deterioration and is always fatal leading to death within 1 year of onset. Initial signs and symptoms typically include personality changes, anxiety, depression, memory loss, impaired thinking, blurred vision, sensory problems, insomnia, difficulty speaking and swallowing and sudden jerky movements.

What is NCD due to Parkinson’s Disease?

This is a slow and progressive neurological condition characterized by tremors, rigidity, involuntary and rhythmic movements of the extremities, motor restlessness, and posturing instability. Symptoms typically begin between 50 and 60 years of age. The development of symptoms often cause them to go unnoticed. As many as 70% to 80% of individuals with PD convert to NCD. In most instances, this occurs within the first 10 years after onset. Impairment in at least 2 of the 4 cognitive domains: attention, executive functioning, visuospatial processing, and verbal free recall. The person must show at least one behavioral symptoms; for example apathy, depression, hallucinations, delusions, or excessive daytime sleepiness.

What is NCD due to Huntington’s Disease?

The disease in inherited through a single dominant gene. Progressive and degenerative disease includes difficulties in cognition, emotion, and movement. Symptoms generally begin between 30 and 50 years of age, and death occurs within 10 to 20 years. We would see involuntary tremors and twitching or the head, torso, and extremities, a lurching gait, and explosive speech.