Neurocognitive Disorders

Overview

  • Neurocognitive disorders (NCDs) include two major syndromes:
    • Delirium – acute, short-term, fluctuating disturbance of attention + cognition.
    • Dementia (Major/Mild NCD) – chronic, progressive decline in ≥ one cognitive domain that interferes with independence.

Delirium vs Dementia

  • Onset: Delirium hrs–days\text{hrs–days}; Dementia mo–yrs\text{mo–yrs}.
  • Consciousness: Delirium altered; Dementia usually clear.
  • Course: Delirium reversible when cause treated; Dementia gradually worsens.
  • Common delirium precipitants: infection, dehydration, polypharmacy, substance intox/withdrawal, metabolic derangements.

DSM-5 Dementia Categories (key examples)

  • Alzheimer’s disease (AD)
  • Vascular NCD
  • Lewy body disease
  • Frontotemporal lobar degeneration
  • TBI-related, Substance/Medication-induced, HIV, Prion, Parkinson’s, Huntington’s

Etiology Highlights

  • AD: amyloid plaques; strongest risk = age; ↑ in women; risks – TBI, Down syndrome, vascular disease.
  • Vascular: cerebrovascular events, hypertension → reduced cerebral blood flow; risk rises sharply > 6565 yr.
  • Lewy body: abnormal α-synuclein deposits.
  • Frontotemporal: ≈ 40%40\% familial; MAPT, GRN, C9ORF72 mutations.
  • Other causes: TBI, HIV, Prion (contaminated meat / genetic), Huntington (autosomal dominant), Parkinson (basal ganglia loss).

Core Cognitive Domains Affected

  • Executive function: planning, decision-making.
  • Complex attention: sustain, divide, switch attention.
  • Learning & memory: new info, short-term recall.
  • Language: naming, fluency, comprehension.
  • Perceptual-motor: visuospatial, navigation.
  • Social cognition: recognition of social norms, empathy.

Alzheimer’s Diagnostic Criteria (DSM-5)

  • Insidious onset + gradual progression.
  • ≥ 22 impaired domains (one must be memory/learning).
  • No extended plateaus; no mixed etiology.
  • Genetic evidence (mutation or family history) strengthens diagnosis.

Alzheimer’s Manifestations by Stage

  • Mild: subtle memory lapses, misplacing items, neologisms, ↓ planning/organization.
  • Moderate: disorientation to time/place, ADL assistance, confabulation, wandering, sundowning.
  • Severe: profound communication & motor loss, atypical behaviors (hostility), agraphia, hyperorality, hypermetamorphosis.

Key Features of Other Dementias

  • Frontotemporal: early personality/behavior change (disinhibition, apathy), or progressive aphasia.
  • Lewy body: fluctuating cognition, visual/tactile hallucinations, spontaneous parkinsonism, REM sleep behavior disorder, neuroleptic sensitivity.
  • Vascular: stepwise decline, slowed processing, executive dysfunction.
  • TBI: LOC, post-traumatic amnesia, neuro signs; severity graded by Glasgow Coma Scale, duration of LOC & amnesia.

Safety Essentials

  • Home: supervise, secure exits, remove hazards/weapons, stove/temperature controls, ID & GPS devices.
  • Inpatient: ensure sensory aids, adequate lighting, minimal mirrors, hallway rails, ID bracelets; avoid restraints, use anxiolytics judiciously.

Nursing Assessment (Recognize Cues)

  • Screen mood (depression, hostility, suicidality), cognition (hallucinations, confabulation), ADLs, communication (word-finding, neologisms), vitals, labs.
  • Focus patterns: sundowning (AD), risky behaviors (frontotemporal), REM sleep disorder (Lewy body), stroke signs (vascular), seizures (TBI), psychomotor slowing (drug-induced).

Diagnostics

  • MMSE scores: 22–2622–26 mild, 18–2018–20 moderate, 0–100–10 severe.
  • AD: PET for amyloid; functional staging (eight-stage scales).
  • Vascular/TBI: CT or MRI.
  • Frontotemporal: CT/MRI.
  • Lewy body: clinical hx.
  • Huntington: genetic test.

Nursing Interventions

  • Person-centered planning; involve family early; connect to resources (Alzheimer’s Association, respite care, hospice).
  • Communication: calm voice, reality reinforcement, short phrases, limit choices.
  • Non-pharmacologic: orientation aids, music/reminiscence, safe environment, ADL support, MIND diet rich in flavanols & ω\omega-33.
  • Complementary: massage, aromatherapy (lemon, rosemary, lavender), research on turmeric, ginkgo.

Pharmacologic Overview

  • Delirium: treat cause; benzodiazepines for DTs.
  • Alzheimer’s symptoms: cholinesterase inhibitors (donepezil, rivastigmine, galantamine, tacrine); disease-modifying – aducanumab.
  • Lewy body: antipsychotics with caution (↑ sensitivity); treat parkinsonism.
  • Vascular: antiplatelets/anticoagulants, statins, BP control.
  • Parkinson’s dementia: levodopa, COMT inhibitors.
  • HIV: antiretrovirals.
  • Huntington’s chorea: tetrabenazine.

Evaluation

  • Reassess cognition & behavior regularly.
  • Monitor medication adherence/effectiveness & side effects.
  • Evaluate caregiver burden; recommend respite/support services.