Neurocognitive Disorders (NCDs)

Neurocognitive Disorders (NCDs)

• Conditions where a person experiences a significant decline in cognitive abilities compared to their previous level of functioning
• Cognitive abilities include thinking, memory, and reasoning

Historical Classifications

• DSM-IV-TR referred to these disorders as "Dementia, Delirium, Amnestic, and Other Cognitive Disorders"

DSM-5-TR Classification

• Groups these conditions under the umbrella term "NCDs"
• NCDs can be further classified

Types of NCDs

• Delirium: A state of acute confusion and disorientation
• Major NCD: Significant cognitive decline
  • Previously referred to as dementia
• Minor NCD: Mild cognitive decline
  • Also called mild cognitive impairment (MCI)
• Underlying cause: Specified based on factors like Alzheimer's disease (AD) or Parkinson's disease

Clinical Findings and Course of Delirium

• Definition: A condition characterized by a sudden disturbance in attention, awareness, and cognitive function

Symptoms of Delirium

• Attention and Focus: Difficulty maintaining and shifting focus, easily distracted, needs constant reminders to pay attention
• Disorganized Thinking and Speech: Rambling, irrelevant, pressured, and incoherent speech
• Impaired Reasoning and Behavior: Diminished reasoning skills and ability to engage in goal-oriented behavior
• Disorientation and Memory: Disorientation to time and place is typical, recent memory is often impaired
• Perception Changes: Misperceptions of the environment, illusions or hallucinations
• Sleep-Wake Cycle Disruption: Disturbed normal sleep-wake cycle
• Altered State of Awareness: Level of awareness varies from hypervigilance to stupor or semi-coma
• Sleep Disturbances: Fluctuations between excessive sleepiness (hypersomnolence) and insomnia, vivid dreams and nightmares are common
• Psychomotor Changes: Fluctuations between agitation with purposeless movements and a vegetative state resembling catatonic stupor, tremors may be observed
• Emotional Lability: Rapid shifts in emotions, including fear, anxiety, depression, irritability, anger, euphoria, or apathy manifested as crying, cursing, or aggression
• Autonomic Symptoms: Changes in the autonomic nervous system, such as rapid heart rate (tachycardia), sweating, flushed face, dilated pupils, and elevated blood pressure

Onset, Duration, and Resolution of Delirium

• Abrupt Onset: Delirium symptoms typically start suddenly, like after a head injury or seizure
• Prodromal Symptoms: Delirium may be preceded by restlessness, difficulty thinking clearly, insomnia, excessive sleepiness, and nightmares
• Slower Onset: More likely when the underlying cause is a systemic illness or metabolic imbalance
• Brief Duration: Delirium is usually brief, lasting about a week and rarely more than a month
• Symptom Resolution: Symptoms typically subside within 3 to 7 days after addressing the underlying cause; sometimes up to 2 weeks
• Factors Affecting Resolution: Age and duration of delirium can affect how quickly symptoms resolve
• High Mortality Rate: Delirium is associated with a high mortality rate due to the severity of underlying medical conditions
• Potential Shift to NCD: Delirium may transition into a more permanent neurocognitive disorder (NCD)

Predisposing and Precipitating Factors for Delirium

• Predisposing Factors: Conditions that make individuals more susceptible to developing delirium
  • Serious medical, surgical, or neurological conditions
  • Older adults (age 65 and older)
  • Depression, falls, and elder abuse
• Precipitating Factors: Triggers that can directly lead to an episode of delirium in vulnerable individuals
  • Systemic infections
  • Febrile illness or hyperthermia (high fever)
  • Metabolic disorders like electrolyte imbalances or hypercarbia
  • Hypoxia (low oxygen levels) and chronic obstructive pulmonary disease (COPD)
  • Hepatic (liver) or kidney failure
  • Head trauma
  • Seizures
  • Migraine headaches
  • Brain abscess or brain neoplasms (tumors)
  • Stroke
  • Nutritional deficiency
  • Uncontrolled pain
  • Burns
  • Heat stroke
  • Orthopedic and cardiac surgeries
  • Social isolation, emotional stress, physical restraints, and admission to an intensive care unit

Substance-Related Delirium

• Substance Intoxication Delirium: Caused by the toxic effects of certain substances on the brain, including:
  • Alcohol
  • Amphetamines
  • Cannabis
  • Cocaine
  • Hallucinogens
  • Inhalants
  • Opioids
  • Phencyclidine
  • Sedatives, hypnotics, or anxiolytics
• Substance Withdrawal Delirium: Occurs with abrupt cessation of certain substances after prolonged use, including:
  • Alcohol
  • Opioids
  • Sedatives, hypnotics, or anxiolytics

Medication-Induced Delirium

• Medication-Induced Delirium: Certain medications can trigger delirium as a side effect
• Common Medications: Known to potentially cause delirium, including:
  • Anticholinergics
  • Antihypertensives
  • Corticosteroids
  • Anticonvulsants
  • Cardiac glycosides
  • Analgesics
  • Anesthetics
  • Antineoplastic agents
  • Antiparkinson drugs
  • H2-receptor antagonists (e.g., cimetidine)
• Polypharmacy: Taking multiple medications at the same time increases the risk of developing delirium

Delirium Due to Other Medical Conditions or Multiple Etiologies

• Delirium due to an underlying medical condition, a combination of factors or neurocognitive disorders
  • UTI is strongly linked to delirium, especially in older adults(65+)
  • Increased levels of interleukin-6 might contribute to delirium
• Delirium often the result of multiple combined factors rather than a single cause

Neurocognitive Disorder (NCD)

• Classified based on the DSM-5-TR, according to the severity of symptoms
• Mild NCD: Sometimes referred to as mild cognitive impairment (MCI)
  • Early intervention is key
• Major NCD: Encompasses what was previously known as dementia in the DSM-IV-TR
• Diagnoses (mild and major NCD) can represent different stages of the same condition
  • Appropriate diagnosis depends on severity, presentation, and may be reversible

Dementia Definition

• Also known as major neurocognitive disorder
• Dementia is a general term for the impaired ability to remember, think, or make decisions that is severe enough to interfere with social, behavioral, occupational, and emotional functioning
• Decline is significant enough to disrupt a person's social, behavioral, occupational, and emotional well-being, and can be caused by different diseases

Gradual Progression of Dementia

• Unlike delirium, which has a rapid onset, dementia develops gradually over time
• Reversibility: In some instances, dementia can be reversible, depending on the underlying cause

Prevalence of Alzheimer's Disease (AD)

• Approximately 6.5 million people in the United States have Alzheimer's disease (AD)
• AD is the most prevalent form of neurocognitive disorder (NCD)

Age-Related Increase in AD

• The number of people with AD increases significantly with age
• 5% of individuals between 65 and 74 years old
• 13.1% of individuals between 75 and 84 years old
• 33.2% of individuals 85 years and older
• 80% of those with AD are over 75, although some are under 65
• Growing older is the biggest risk factor for AD, but it's not a normal part of aging

Gender and Race Factors of AD

• Almost two-thirds of Americans with AD are women
• There is a disproportionately higher prevalence in Black/African American and Hispanic/Latino people
• Projected Increase: By 2050, the number of people aged 65 and older with Alzheimer's dementia is projected to reach 12.7 million, increase due to growing population
• Survival: People typically live for 4 to 8 years with AD but can live as long as 20 years
• Recent Trends: Dementia, including newly developing AD cases, has been declining which may be due to improved treatment/risk factors/awareness

Mild and Major Neurocognitive Disorders (NCDs)

General Explanation:

• NCDs characterized by decline in cognitive functions
  • Classified based on degree to which deficits affect a person's ability to function in daily life
  • Decline determined from a prior level of cognitive ability in one or more cognitive areas
  • Cognitive areas include complex attention, executive function, learning and memory, language, perceptual-motor, social cognition

Mild Neurocognitive Disorder:

• Involves a modest cognitive decline from a previous level of performance
  • Cognitive deficits do not interfere with independence in everyday activities
  • Greater effort, compensatory strategies, or accommodation may be required

Etiologies

• Possible causes for both Mild and Major NCDs include
  • Substance/medication use, HIV infection, prion disease, Parkinson's disease, Huntington's disease
  • Another medical condition, multiple etiologies, unknown etiology

Specifying Behavioral Disturbances in NCD

• Explains how to classify NCDs based on presence or absence of accompanying behavioral disturbances
  • Without Behavioral Disturbance: If the cognitive decline occurs without any significant behavioral or psychological symptoms
  • With Behavioral Disturbance: The cognitive decline is accompanied clinically significant behavioral or psychological symptoms
    • Psychotic symptoms (delusions or hallucinations)
    • Mood disturbances, agitation, apathy, aggression, disinhibition
    • Disruptive behaviors or vocalizations, sleep or appetite/eating disturbance

Diagnostic Criteria

• Irrespective of behavioral disturbances
  • Key criterion for NCD diagnosis is evidence of significant cognitive decline from a previous level of performance
  • Concern from individual, knowledgeable informant, or a clinician that there has been a significant decline in cognitive function

Cognitive and Behavioral Changes in NCD

• Impaired Thinking: Abstract thinking, judgment, and impulse control are impaired
• Social Disregard: Individuals may disregard social norms, exhibiting uninhibited or inappropriate behavior
• Neglect of Hygiene: Personal appearance and hygiene are often neglected
• Language Difficulties: Language can be affected, with difficulty naming objects or vague and imprecise speech
  • Aphasia may occur
• Personality Changes: Common, either as an alteration or exaggeration of previous traits
• Socially active person may become apathetic or isolated
• Tidy person may become unkempt
• Distrustful person may exhibit extreme fear and paranoia

Reversibility and Progression

• Reversible NCD: True reversibility is rare and may be temporary
  • Caused by brain tumors, subdural hematomas, medication reactions, vitamin deficiencies, poisoning, anoxia, CNS infections
• Irreversible NCD: Progressive and irreversible

Later-Stage Symptoms and Complications

• Apraxia: The inability to perform purposeful motor acts despite intact motor function
• Emotional Changes: Irritability, moodiness, and sudden outbursts can occur
• Loss of Independence: The ability to work or manage personal care independently diminishes
• Wandering: Wandering away from home or care settings becomes a concern
• Advanced Dementia: Advanced stages include profound memory deficits, minimal verbal communication, loss of ambulatory ability and incontinence
• Common Complications: Common clinical complications include eating problems and infections

Causes and Stages of Alzheimer's Disease (AD)

• Causes of NCD: Alzheimer's Disease (AD) is the most common, accounting for 60-80% of all cases
• Five Stages of AD: The progression of AD is characterized by five stages
  • Stage 1: Preclinical AD, no noticeable symptoms or decline in memory
    • Brain changes detectable, don't always lead to progressive disease
  • Stage 2: MCI due to AD (Mild Cognitive Impairment)
    • Subtle symptoms such as memory loss and language
    • Brain can no longer compensate for neuron damage and death caused by AD
  • Stage 3: Mild Dementia due to AD
    • Individuals need assistance with more complex tasks
    • May deny problems and try to cover up memory loss
    • Depression and social withdrawal are common
  • Stage 4: Moderate Dementia due to AD
    • This stage is often the longest
    • Symptoms interfere with completing activities of daily living (ADLs), such as bathing and dressing
    • increasing confusion and incontinence
  • Stage 5: Severe Dementia due to AD
    • Memory and motor skills are greatly diminished
    • Inability to recognize family members and loved ones
    • Likely to require 24-hour care

Predisposing risk factors and different categories of NCDs

• Etiology: NCDs are categorized and distinguished based on their underlying cause but all have similar symptoms
• AD (Alzheimer's Disease)
• Frontotemporal degeneration
• Lewy body disease
• Vascular disease
• Traumatic brain injury
• Substance/medication use
• HIV infection
• Prion disease
• PD (Parkinson's disease)
• Huntington's disease
• Another medical condition Multiple etiologies
• Unspecified(cause is unknown)

Characterized by NCD Symptoms:

• Alzheimer's Disease (AD) manifests as the symptoms associated with either mild or major Neurocognitive Disorder (NCD) -Progressing through the five stages previously outlined
• Gradual Onset: AD is gradual and subtle
• Diagnostic Tools: Refined diagnostic criteria and tools allow clinicians to identify AD with greater accuracy.

Diagnostic tools

CT and MRI Scans: Computed tomography (CT) scans and magnetic resonance imaging (MRI) show degenerative changes in the brain.

Microscopic Examination: Examination of brain tissue reveals neurofibrillary tangles and senile plaques

Role of MARK4

• Recent Research suggests that a mutation in microtubule affinity regulating kinase (MARK4) which is an enzyme involved in cell functions contributes to accumulation and toxicity of tau proteins which leads to neurodegeneration and the development of AD

Multiple Factors

• The development and progression of AD involve multiple risk factor that affects different areas of the brain

Neurotransmitters effected by AD

Acetylcholine

• A decrease in acetylocholine linked to the development of AD and the cholinergic neurons start in basal forebrain to areas including basal ganglia, cerebral cortex, etc

Serotonin

• Cell bodies for serotonin pathways are in the raphe nuclei of the brainstem

Norepinephrine

• Pathways originate in the locus coeruleus and project through the forebrain, prefrontal cortex etc

Dopamine

• Pathways originate in the midbrain to the frontal cortex and dopamine neurons are in the hypothalamus near the posterior pituitary

Glutamate

• Excitatory neurotransmitter and found in the cerebral cortex, hippocampus, thalamus, hypothalamus, cerebellum and the spinal cord with high concentrations

Areas of the Brain affected by AD

Frontal Lobe

• Damage causes impaired reasoning ability, judgements and the inability to solve problems

Parietal Lobe

• Damage leads to impaired orientation ability and visuospatial skills

Occipital Lobe

• Damage causes issues and impaired language interpretation

Temporal Lobe

• Damage leads to delusions and hallucinations

Hippocampus

• Damage causes impaired memory

Amygdala

• Damage causes impaired emotions like fear, anxiety and depression

Neurotransmitters

• Alterations in Neurotransmitters contributes to restlessness, mood states, sleep impairments.etc

Medications to treat Alzheimer's Disease

• Cholinesterase Inhibitors: Inhibits the action of acetylcholinesterase to make more acetylcholine in the brain
• NMDA Receptor Antagonist: Blocks NMDA receptors to prevent CA influx.
• Human Monoclonal Antibody:Binds to aggregate amyloid-beta to reduce amyloid in the brain

Redefinition of AD and related research

• Redefinition of AD (2018): Shift from cognitive symptoms to presence of specific Biommackers for early prevention measures. Biomarkers include: Amyloid beta (AB) plaques, Tau neurofibrillary tangles and Neuronal Damage
• Inflamation and AD: High levels of certain inflammations is suggested to increase the risk of AD and the body has a certain responce to it

Etiological Theories behind Alzheimer’s Disease (AD)

• Unknown Exact Cause: The precise cause of AD remains unknown and it is thought to be by multiple genetic causes.
• Neurotransmitter Alterations: Abnormal levels of the enzyme that created acetylcholine. Also the neurotransmitters like Serotonin are disrupted.

Research

Blood test for Early Detection

• A study suggests blood test and presence of the APOE 4 gene variants can help detect this up to 2 decades before.

Ketone and Brain Health

• Use of ketones protects healthy neurons and reduces the build up of amyloid plaque

Cause from Vascular Neurocognitive Disorder

• Problems caused by blood vessels in the brain which leads to decreased blood flow which causes progressive intellectual and functional declines

Location of Damage

• Damage may be in larger blood vessels or smaller microvascular

Prevalence

• Vascular NCD Is common in men
• Onset and progression
• Symptoms can fluctuate
• Mechanism
• Small strokes that damage the brain at different patterns
• Common Signs and Symptoms
• Athetotic Gate, Balance issues and muscle weakness

Cause due to interrupted blood flow

Nerve Cell Death- Lack of oxygen and nutrients will cause it

Condition affecting: Various diseases that affect blood flow.

High Blood Pressure: High blood pressure damages the vessels linings.

Emboli: Particulate matter

Types of Frontotemporal Neurocognitive

Cause: Shrinking of frontal and temporal lobes of the brain

Etiology: Genetic Factors

Two Symptom Patterns

• Speech and language problems and the inpairment with speech
• Skills like spatial and memory and are preserved

DSM 5 Criteria to be diagnosed with traumatic brain injury

Impact to Head

One or more of the following

• Loss of conciousness
• Post traumatic amnesia(memory loss)
• Disorientation and Contusion

*Symptom Duration:

• Depending of symptoms may subside over time

Chronic Traumatic Encephalopathy (CTE)

• Repeated Head trauma can result in it. Emotional problems and Lack of impulsivity characterize it

Prevalence from LBD

After AD, LBD is second most common

Similarities and differences

Clinical simiularirties to AD But progresses quickly will cause visual hallucinations

Features

Disorder is identified by Lewy Bodies

• levels in the Brain Patients are super sensitive to antipsychotics causes side effects

NCD from Parkinson’s

####### Very high and can cause involuntary movements

HIV-Associated NCD

Associated with HIV complexes

Less severe form

• Less Severe forms could be HIV-Associated minor complexes.

Severity

• Correlates extent of brain to disease of the HIV infection
• Early Symptoms
• Neuropsychiatric symptoms causes changes
• Latter symptoms
• Severe cognition can also cause psychosis

Substance use or medication induced

Causes: Can often result from reactions of substances or abuse. Symptoms: Major symptoms and can be long lasting Substance and medication induced causes, Huntington Disease Can cause Huntington Disease by a DNA Error

Area of the brain affected

Straitum gets major damage

• Onset: Happens at 30/50 and involuntary twitching
• Progression: Decline and cognitive inpariment.
• Medical condition
• Can results with diseases in other other regions or the Brian

Neurocognitive Disorder Due To Prion Disease and Another Medical Condition

• Neurocognitive Disorder Due To Prion Disease
• Cause: Prio Diseases are caused by infectious agents called prions
• Characteristics: characterized by an insidious onset (gradual a subtle) and rapid progression
• Manifestations: Problems with the coordination and disturbances
• Diagnosis:Prion disease c an only be Defectively confirm with brain autopsy
• Age Of Onset: Symptoms typically occur between the ages 40/60

Assessment

Nursing is a specific symptom

• Patient History Nurses are key

Mood swings and Emotional Reactions

• Type and severity can cause issues
• Cognitive: the problem from attention
• Social: Appropriate if behavior
• Biologiccal Factors
• Lead mercury and organic

Goal and Pyschological Testing

• Physical Assessment focus on the Damage due to the nervous system .

Purpose of lab test

• Purpose of Lab Test: This test us ed to out out an associated to find out if the patient if actually has the given disease

Test used

Thyroid function

Vitamin B 12: Test too out malnutrition

Drug And Alcohol screening

• Pet Scan can do so metabolism and damage to the brain
• RPR and HIV Testing a test should b e perforce is the patient has had a higher issue

Nursing diagnosis

• identify relevance. Provides standardized is provided
• Outcome Criteria: To measure the long/ short term goal

Planning and implementation if safety is the main concern

Patient Goals:

• IntervationTailoring: Should be short and all the time
• Benifets-physical activity: Should be a slow process and a deliteration

Wandering is a safety problem

• Problems for caregiver
• Increased risk from the stress
• Stages of cognitive decline: can result in them forgetting why there were what they were doing

Goal and interventions

• Disturbed ThoughtProcess:
• Inpaired memory: Can reduce or eliminate skill if not practiced.
• Patient coals-short term goal/ long term goal Goal and interventions-Disturbed ThoughtProcess: Short term is to provide clocks and reality

Controversary

• Controverary About reality is that it can negatively inpect mood and self esteem is better

Intervention

_minimize focus on delisuibal thinking

Dont ignore report of haliuations: Validate

Acess for side effects

• Impaired communication skills patient coals

Patient is able to make needs known

Interventions

• Use a call

Always Identfy Self

Importance of Independence

nterventions

-Provide a stimple

Guidence

-Caregiver Roles

-Minimize confusion

If patient in dischaged must assess.

And inform about awareness

Concempt Care MAP - patient evulation

• Evaluation is on based short term goals and can vary Quality andsafety of the QSEN

Objectives of care for Chronic progressive disorder

• To provide

Caregiver

• Learning Capiing.

General Support and medical

Security and nutriaition

Mrtication:

-Find the Right medication for you.

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