Chapter 15: Neurocognitive Disorders

Delirium

it is characterized by impaired consciousness and cognition during the course of several hours or days.

Delirium

Many medical conditions that impair brain function have been linked to _, including intoxication by drugs and poisons

Ecstasy or “Molly”

The rise in the use of designer drugs such as _ or _ (methylene-dioxymethamphetamine) and more recently “bath salts” (methylenedioxypyrovalerone) is of particular concern because of such drugs’ potential to produce delirium

Diagnostic Criteria for Delirium

A disturbance in attention (i.e., reduced ability to direct, focus, sustain, and shift attention) and awareness (reduced orientation to 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 intoxica tion or withdrawal (i.e., due to a drug of abuse or to a medica tion), or exposure to a toxin, or is due to multiple etiologies.

Psychosocial Intervention

The recommended first line of treatment for a person experiencing Delirium is __

Major Neurocognitive Disorder

___ (previously labeled dementia) is a gradual deterioration of brain functioning that affects memory, judgment, language, and other advanced cognitive processes.

Mild Neurocognitive Disorder

it is a new DSM-5 disorder that was created to focus attention on the early stages of cognitive decline.

Diagnostic Criteria for Major Neurocognitive Disorder

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)

Diagnostic Criteria for Mild Neurocognitive Disorder

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)

Agnosia

the inability to recognize and name objects, persons, or sounds

Facial Agnosia

the inability to recognize even familiar face

delusions (irrational beliefs), depression, agitation, aggression, and apathy

Common side effects are _______

1. Alzheimer’s disease

2. Vascular Injury

3. Frontotemporal Degeneration

4. Traumatic Brain Injury

5. Lewy Body Disease

6. Parkinson’s Disease

7. HIV Infection

8. Substance Use

9. Huntington’s Disease

10. Prion Disease

11. another medical condition

DSM-5 identifies classes of neurocognitive disorder based on etiology: (

Neurocognitive Disorder due o Alzheimer’s Disease

The DSM-5 diagnostic criteria for ___ include multiple cognitive deficits that develop gradually and steadily.

Neurocognitive Disorder due to Alzheimer’s Disease

Predominant are impairment of memory, orientation, judgment, and reasoning. The inability to integrate new information results in failure to learn new associations.

Neurocognitive Disorder ue To Alzheimer’s Disease

People with ___ also display one or more other cognitive disturbances, including aphasia (difficulty with language), apraxia (impaired motor functioning), agnosia (failure to recognize objects), or difficulty with activities such as planning, organizing, sequencing, or abstracting information.

Aphasia

loss of ability to understand or express speech, caused by brain damage

• difficulty with language

Apraxia

a neurological condition that makes it difficult or impossible to make certain movements

• impaired motor functioning

Agnosia

a rare disorder whereby patients cannot recognize and identify objects, persons, or sounds

• failure to recognize objects

Diagnostic Criteria for Major Neurocognitive Disorder due to Alzheimer’s Disease

Probable Alzheimer’s disease is diagnosed if either of the following is present; otherwise, possible Alzheimer’s disease should be diagnosed. (Two domains must be impaired)

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).

Diagnostic Criteria for Mild Neurocognitive Disorder due to Alzheimer’s Disease

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).

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.

Vascular Neurocognitive Disorder

__ is a progressive brain disorder that is a common cause of neurocognitive deficits

Blood Vessels

The word vascular refers to __.

Diagnostic Criteria for Major or Mild Vascular 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. 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 (neuroimaging-supported).

2. 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

• Normal Pressure Hydrocephalus (excessive water in the cranium, resulting from brain shrinkage)

• Hypothyroidism (an underactive thyroid gland)

• Brain Tumor

• Vitamin B12 deficiency.

Other medical conditions that can lead to neurocognitive disorder include __

Normal Pressure Hydrocephalus

excessive water in the cranium, resulting from brain shrinkage

Hypothyroidism

an underactive thyroid gland

Chronic Traumatic Encephalopathy (CTE)

a neurocognitive disorder caused by repetitive head trauma, leading to distinctive neurodegeneration.

Chronic Traumatic Encephalopathy (CTE)

Previously known as dementia pugilistica (associated with boxers), it is now recognized in various athletes.

Frontotemporal Neurocognitive Disorder

an overarching term used to categorize a variety of brain disorders that damage the frontal or temporal regions of the brain—areas that affect personality, language, and behavior

Appropriate Behavior; Language

DSM-5 identifies two variants of frontotemporal neurocognitive disorder—through declines in __ (e.g., socially inappropriate actions, apathy, making poor judgments) or __ (e.g., problems with speech, finding the

Pick’s Disease

a rare neurological condition—occurring in about 5% of those people with neurocognitive impairment—that produces symptoms similar to that of Alzheimer’s disease.

40s; 50s

Pick’s Disease usually occurs relatively early in life—during a person’s _ or _

Traumatic Brain Injury

Severe trauma to the head causes the brain to sustain lasting injuries, also called as, _ which can lead to neurocognitive disorder

Neurocognitive Disorder due to Traumatic Brain Injury

__ includes symptoms that persist for at least a week following the trauma, including executive dysfunction (e.g., difficulty planning complex activities) and problems with learning and memory.

Neurocognitive Disorder due to Lewy Body Disease

The second most common type of neurocognitive disorders (after Alzheimer’s disease) is ____

Lewy Bodies

__ are microscopic deposits of a protein that damage brain cells over time.

Neurocognitive Disorder due to Lewy Body Disease

The signs of this disorder come on gradually and include impairment in alertness and attention, vivid visual hallucinations, and motor impairment as seen in Parkinson’s disease.

Parkinson’s Disease

It is a degenerative brain disorder that affects about 100 to 300 people in every 100,000 people worldwide, though estimates vary widely due to challenges in diagnosing the disorder

• Low Dopamine

Dopamine

Parkinson’s Disease

The changes in motor movements are the result of damage to _ pathways.

Dopamine

Parkinson’s Disease

_ is involved in complex movement, a reduction in this neurotransmitter makes affected individuals increasingly unable to control their muscle movements, which leads to tremors and muscle weakness.

Human Immunodeficiency Virus type 1 (HIV-1)

The ____, which causes AIDS, can also cause neurocognitive disorder (called neurocognitive disorder due to HIV infection)

Neurocognitive Disorder resulting from HIV

The early symptoms of __ are cognitive slowness, impaired attention, and forgetfulness.

Neurocognitive Disorder resulting from HIV

Affected individuals also tend to be clumsy, to show repetitive movements such as tremors and leg weakness, and to become apathetic and socially withdrawn.

Huntington’s Disease

it is a genetic disorder that initially affects motor movements, typically in the form of chorea, involuntary limb movements

Diagnostic Criteria for Neurocognitive Disorder due to Parkinson’s Disease

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 probably due to Parkinson’s Disease

__ should be diagnosed if 1 and 2 are both met. this disorder 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 neurocognitive disorder

Neurocognitive Disorder due to Prion Disease

it is a rare progressive neurodegenerative disorder caused by “prions”—proteins that can reproduce themselves and cause damage to brain cells, leading to neurocognitive decline

Prions

On the positive side, _ are not contagious in humans and have only been contracted through cannibalism (causing kuru) or accidental inoculations

Creutzfeldt-Jakob Disease (CJD)

A new variant of _ has been found in at least 10 cases, possibly linked to bovine spongiform encephalopathy (BSE), also known as mad cow disease.

This highlights the potential for prion diseases to be transmitted from animals to humans

Alzheimer’s Disease

In __, neurofibrillary tangles and amyloid plaques cause the brain to atrophy (shrink) more than in normal aging. However, since brain shrinkage can have many causes, a proper diagnosis requires the presence of tangles and plaques.

Neurofibrillary Tangles

Alois Alzheimer identified a “strange disease of the cerebral cortex” during an autopsy, finding __—twisted strands inside brain cells. This type of brain cell damage is found in everyone with Alzheimer’s disease.