Differentiating Neurocognitive Disorders Transcript PDF

Differentiating Neurocognitive Disorders Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2533795-dt-... Di!erentiating Neurocognitive Disorders Disorders Well, welcome to week 7. Gosh, we're getting so close to the end. So...

Differentiating Neurocognitive Disorders Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2533795-dt-... Di!erentiating Neurocognitive Disorders Disorders Well, welcome to week 7. Gosh, we're getting so close to the end. So this week, we're going to talk about a couple of di!erent things. The "rst slide set is about neurocognitive disorders, not just di!erentiating them, but we're also going to dip into the six neurocognitive domains. This is an important discussion for you. I guess I think everything's important. So it's almost kind of pointless to say that. But this really is-- what's best way to put it? Everybody still calls it dementia, even clinicians. I mean, most of the population still refers to cognitive impairment as dementia. And dementia isn't really the terminology that we should be using anymore. Now, we have neurocognitive disorders. Neurocognitive disorders are a collection of disorders that can be caused by any number of things that we used to call dementing disorders. Like, you know how we used to call Alzheimer's dementia Alzheimer's dementia? Well, now, we call it Alzheimer's disease. And Alzheimer's disease is one potential cause of neurocognitive disorder. So my job is to teach you the right way. So that's what we're going to talk about in this slide set. And I guess that's all I have to say about that. Let's talk about neurocognitive disorders. All right, so I think this is going to be a fairly straightforward and comparatively brief slide set for which I'm sure you'll be grateful. But it really is about new versus old terminology and what it means, and how we now characterize disorders of cognitive function. These two are their own chapter in the DSM-5. And so now since you will be the expert, you will be the one that gets consulted by the generalist. You certainly want to use the right terms and know what you're talking about, which is always a plus as well. So in this slide set, we introduce the terms, and then you will explore further as you do your assignments this week. So the old and new terminology. Yeah, for the longest time, in fact, as long as I can remember, and I think I told you in another slide set, in the '90s, I did a fellowship at 1 of 15 12/8/24, 4:28 PM Differentiating Neurocognitive Disorders Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2533795-dt-... the Philadelphia Geriatric Center. I don't think it even exists anymore. I think it was consumed by some bigger entity. But in its day, it really was a premiere geriatric center in that part of the country. And it was a#liated with Einstein Hospital. So they had this Philadelphia Geriatric Center, which was both obviously a patient care facility and an academic center. So they really were like on the newer at the time cutting-edge contributing to the science. And at the Philadelphia Geriatrics Center, we did dementia assessments. I mean, that was the biggest part of my fellowship all day long learning how to do true detailed dementia assessments, and then making rounds in the entire living continuum. There was independent apartment living, there was assisted living, and then there was long- term care facility. And so that was for that entire period of nine months or something, that was how I spent my clinical day. And these are the terms that we used then, delirium, mild cognitive impairment, and dementia. And they were speci"c terms. Delirium is still its own entity. It is considered a neurocognitive disorder, but it is distinct from the other two. And we'll break them out in a few minutes. But delirium is kind of its own thing. And then we used to have this condition we called mild cognitive impairment, and then dementia. And the di!erence between the two really was the level of impairment. Mild cognitive impairment, just like the name implied, there was clear, objective, measurable, cognitive impairment that was not just consistent with some of the normal age-related declines in memory and function, but it didn't interfere with independent living. People with mild cognitive impairment could still live independently. So many times they would avail themselves of prompts and reminders, pillbox, maybe knowing that a relative could check in regularly. And if not, maybe a social services, like somebody from the o#ce on aging or whatever you call it in your state would check in on them, but they could live independently. And then patients with dementia had cognitive impairment to the extent that they could not live without support of their day-to-day functions, not that they didn't try. Dementia disorders has always been really di#cult to get your hands around because as patients develop more severe dementia, they know it, they recognize what's going on, and will "nd ways to manage it so that it's not readily apparent to their family and to the general population. 2 of 15 12/8/24, 4:28 PM Differentiating Neurocognitive Disorders Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2533795-dt-... And in some circumstances where patients live primarily alone, dementia can be well- advanced before it really comes to the attention of somebody. I remember one patient at the Philadelphia Geriatric Center, she had been living alone and she really was progressing down the dementia road. And her family wanted her to have some sort of supervised living. And the starting point was her driver's license. She was still driving. And the family kept trying to get her to have an assessment and she kept resisting it. And "nally-- so "nally she agreed. She agreed to have a dementia evaluation. And the day of her appointment, she purposely, because she was angry, drove her car into the building. And so that prompted a whole conversation about how people with dementing disorders are driving, and at what point you can suspend the driver's license. And even that is a di#cult call. So anyway, I know I'm getting o! the beaten path here. Old terms, delirium, mild cognitive impairment, and dementia. The di!erences among the three are that delirium is separate. It is acute, it is a symptom of something else. And it is treatable and curable. Mild cognitive impairment and dementia really were a continuum. Most people with mild cognitive impairment were expected to progress to a dementing disorder unless something in their world changed. And with mild cognitive impairment, you could still live independently. And with a dementing disorder, you couldn't. And then in 2013 when DSM-5 came out, they totally rede"ned all of this. It's all basically the same issues and the same things. It's just that we have di!erent terms for them now. Now, we have a family of disorders called the neurocognitive disorders, a.k.a. NCG. And there are three types. And so while there are some distinct di!erences among the three, the transition, just like it was before, is fairly linear. So delirium is still known as delirium. And delirium is reversible the majority of the time. Now, we have mild and major neurocognitive disorder, mild NCG and major NCG. Mild NCG is what we used to call mild cognitive impairment and major neurocognitive disorder is what we used to call dementia. And so now when you evaluate a patient who presents with altered mental status, what we are doing is evaluating them for a neurocognitive disorder and we are di!erentiating among delirium, mild neurocognitive disorder, and major neurocognitive disorder. So those are the three: delirium, mild neurocognitive disorder, 3 of 15 12/8/24, 4:28 PM Differentiating Neurocognitive Disorders Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2533795-dt-... and major neurocognitive disorder. Every few years we have to get new terms so that we can write new books and new articles. And so that somebody can be a leader in that. Anyway, neurocognitive disorder number one, delirium. Delirium, like I said before, it is acute. It is acute, it is global, it is reversible. When somebody presents with an acute mental status change, the progression of evaluation really begins with di!erentiating delirium from neurocognitive disorder because delirium is a symptom. It's a symptom of some other underlying problem. And if we can identify the other underlying problem and treat it, then the delirium is resolved. This is the only one of the neurocognitive disorders that is reversible. And so by de"nition, it is a disturbance of attention awareness and a change in baseline cognition. And it needs to be evaluated, and then we can treat it. I mean, you can see this across the lifespan. The elderly don't have a particular hold on delirium. Although, it is more common in the elderly population because as a function of aging, the neurologic system just tends to be more vulnerable to insults or weaker. I might be getting ahead of myself here, let me go to the next slide. Yeah, so like I just said, delirium can occur at any age, but it does occur more often in the elderly. And the reason for it is that the elderly-- all body systems are on that downward age-related slow, steady decline. They just don't function as well. They don't heal themselves as well. They're just not at their peak performance, and they are readily susceptible to insult. And if the neurological system becomes insulted, it can produce delirium. Whereas in young people or middle-aged people, when your body systems are still pretty solid and at their prime, it's not as easy to become delirious. So if a patient presents to you with an acute mental status change-- and at this point, we don't know what it is. We don't know if it's delirium yet or a neurocognitive disorder yet because we haven't evaluated the patient. So when you're seeing somebody with a chief complaint of acute mental status change or altered mental status, your di!erentials include delirium and neurocognitive disorder. When you're considering delirium in the young and middle-aged population, since they aren't necessarily vulnerable to any level of insult, the overwhelming majority of delirium in the young and middle-aged population is going to be due to an intoxicating 4 of 15 12/8/24, 4:28 PM Differentiating Neurocognitive Disorders Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2533795-dt-... substance, some sort of organic disease, like a brain lesion or a bleed, or a psychosis, a psychotic episode, a manic episode. That's it. I mean, if you or I-- and again, I will bring myself with-- we're down there in middle age. If you or I present anywhere with an acute mental status change, we're getting a head CT, a tox screen, and a psych consult. Because the tox screen, obviously, we're looking for intoxicating substances, the head CT, we're looking for a bleed or a lesion, and the psych consult to evaluate if we are manic or psychotic, or whatever other acute psychotic reaction, pick your poison. Those are the three leading di!erentials of acute mental status change in the young and middle-aged population. In the elderly, though, delirium could be due to anything. We still consider those three. Now, basically we just have to consider the entire rest of the body. Don't worry. There is a diagnostic evaluation. You don't have to test patients for all 68,000 ICD-10 codes. But it is a workup in the elderly that really considers the fact that virtually anything can make you delirious. So I started to allude to this before, and then I pulled myself back in so that I'm consistent with your slides. So as a function of aging, every body system begins to decline. Again, I'm having like this deja vu. Like, I've had this conversation with you before, but I can't imagine in what circumstance that would have been. So if I did, just ignore me for the next few minutes. And if I didn't say this before, it's an important point here. From the time of conception, the human zygote, embryo, fetus, all the way up through the stages of development, neonate, infant, toddler, et cetera, from the time of conception, the human organism grows and develops and grows and builds reserves and is building, is like going uphill building. And they're building reserves from which to live the rest of our lives. So for the "rst 30 years, the biology of the human organism is that for the "rst 30 years of life, we grow, develop, grow, develop, and build strong reserves. And then in the third decade, we stop building, we stop growing, and we start living o! of those reserves. We start a slow, steady, downhill decline. There is no 40-year peak. We hit the top, and then we start on our way down. Don't worry. I mean, I know it's a distressing thought. But we have developed enough reserves to live for decades and decades. The human organism is designed to live for 5 of 15 12/8/24, 4:28 PM Differentiating Neurocognitive Disorders Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2533795-dt-... about 120 years. So absent accidents and wars and disease and whatever else kills us prematurely, the human organism is designed to live about 120 years. If you look at like the Guinness Book of Records or every now and then, you'll see something on the news or a news article, oh, the oldest lady in this community, she's 119 years old and still smokes Lucky Strikes. Or, she died today in her sleep with her family at her bedside, or something like that. When people live to that age, it's always the one teens, like never appreciably past that. And it's as if they just have protective mechanisms that protects them from all the things that can kill you prematurely. But nobody seems to live beyond that 120 point or maybe 121, I think. I don't know why I think this. I could be way o! base. But I think the oldest recorded life ever was estimated to be 122 years old. And even that is probably not accurate because precise recording of birth probably wasn't around 122 years ago whenever this patient was born that I'm thinking about. Anyway, the point is we are an organism. We have a design. And it's designed to grow, peak, grow, build, build, build, peak, and then slowly steadily decline. And it does. It's not disease, it's not illness, it's not a bad thing. It's just the nature of the beast. But as we experience that slow, steady, downward decline, things just don't function at their peak. They're "ne, but they're not at their peak. And the further time goes on, the more dramatic those age-related changes are. And certain body systems are more vulnerable to them than others. And so when those body systems, their vulnerabilities are receptive to any insult because the body is a series of interdependent systems. Nothing functions independently in the body. All the systems depend on each other. So if one of them is weaker, like the neurologic system, any insult to any body system is more likely to produce a neurologic symptom. That's what it really all comes down to. The neurologic system just as a function of normal age-related change is more vulnerable than some of the others. And so when you insult any body system, you're more likely to see neurologic systems-- or neurologic symptoms. And so when an elderly patient presents with delirium, the di!erential diagnosis is a whole lot more broad. And so if you work with the frail elderly, you know what I'm talking about. And if you 6 of 15 12/8/24, 4:28 PM Differentiating Neurocognitive Disorders Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2533795-dt-... don't work with the frail elderly, here is an important point for you to remember. If you see a frail-- like an elderly-- or I guess I'm supposed to say an older adult now, the correct terminology, an older adult who presents with an acute mental status change, the number one cause is UTI. In any long-term care facility, if a patient has an acute mental status change, the "rst thing somebody does is a UA. And if the urine is normal, then they get a chest X-ray because it's probably pneumonia. And if that's normal, if you haven't already done it, you want to look all over their skin for cellulitis. I mean, pick up the scrotum, pull the butt apart, look under the hairline, under the armpits, between the toes, like whatever because there's really probably infection somewhere. Infection hands down is the most common cause of delirium in the elderly, and the urinary tract is the most common and most vulnerable. If you or I get UTI, we get dysphoria, urgency, maybe some hematuria frequency. But in an older adult, mental status change is much more common. Electrolyte imbalances, hyponatremia, hypo-- oh, god, hypocalcemia. That fast I lost it. Hypocalcemia and hyponatremia are the two most common. Even retention of urine and feces can cause delirium in an older adult. Because when your bladder and your rectum "ll, they "ll passively all day long and they distend the smooth muscle of those cavities. And when the smooth muscle is distended to a certain point, stretch receptors are stimulated that sends a message to the brain that says, excuse me, brain, I'm full. Could you please go to the nearest bathroom, sit down or whatever you do, and relax your outlet sphincter so I can empty? Because while the bladder and the rectum "ll passively, we do thankfully have voluntary control over the outlet sphincters. And you need to be triggered to relax it. And you are triggered by neurologic stretch receptors. But in the elderly, because of normal age-related change, sometimes when those receptors are stimulated, it basically is a mis"re and they become confused and they need to have their bladder drained or their rectum disimpacted, or perhaps both. Also, hypoxemia. Believe me, none of this is a stretch. The older adult is very vulnerable to mental status changes from hypoxemia. It is not at all unusual to have an elderly patient be-- present to the emergency room from a long-term care facility with an acute mental status change and it's because they have a PE, or pneumonia, or anything else 7 of 15 12/8/24, 4:28 PM Differentiating Neurocognitive Disorders Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2533795-dt-... that could make you hypoxemic Ditto on the volume contraction. The older adult is very vulnerable to volume contraction and physiologic impact of that. And sometimes you have older adults like in the outpatient setting-- like, you might be doing more generalist outpatient psych and maybe you have 45-year-old patient, and you're treating them for depression or anxiety or whatever. And then one day they call you and say, oh, my gosh, my mom's visiting from out of town. And I think she has Alzheimer's disease. Can you see her? And you say, oh, why do you think that? And they're like, well, she's like, she didn't know my name this morning. And she's putting the keys in the refrigerator. And she just is really out of it. And you say, well, how long has this been going on? And they're like, like today. She was "ne yesterday. This is not Alzheimer's disease, right? This is acute UA. Bring her in. She needs a UA. That's the "rst thing you want to do. And if she doesn't have a urinary tract infection, you want to palpate the bladder. Conversely, I got o! on a tangent here, but I meant to talk about volume contraction. When you have these older adults that live at home and they're by themselves most of the week, and then sometimes the family unit comes over on the weekends and take them out to brunch or something like that. And they might show up and "nd that Mom is confused. And last week she was "ne. But the problem is maybe she didn't feel good. She had a day's worth of diarrhea. Then she was on the couch. And it became volume contracted. And now she's acutely confused and all she really needs is some $uid. And another common cause of delirium is a subdural hematoma. The elderly unfortunately will-- when they live alone, they do fear being required to go live with a relative or live, quote, "in a home." And so sometimes what happens is they will have some troubles at home or their memory is a problem. Or, they start having falls and they're afraid to tell anybody because they're afraid they're going to be forced to change their living environment. And so they have these falls and hit their head and just get little subdural hematoma that eventually accumulate to produce an acute mental status change. So all of this in the elderly-- like, nothing here is a stretch. These are very common causes of acute mental status change. And they're "xable. I mean, most of them are 8 of 15 12/8/24, 4:28 PM Differentiating Neurocognitive Disorders Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2533795-dt-... "xable. Subdural hematoma is not as easy. But things like treating infection, giving $uids, repairing retention, these are all very easy "xes and the mental status does return to normal. That's delirium. That's the "rst neurocognitive disorder. Now, numbers two and three are a little bit di!erent. These are not reversible. They are not acute. In some circumstances, you might be able to improve things a little bit. But even that's a stretch. Typically, if you have mild or major neurocognitive disorder, that's your baseline mental state. This isn't really a symptom of anything. This is your baseline mental state. Like delirium, they can occur at any point in the lifespan. But the elderly are at higher risk, frankly, because the elderly are at higher risk for everything. So these conditions now-- there is a departure here from the way we used to approach it. We used to say that dementing disorders virtually always had a memory problem. That there was some sort of short-term memory loss. Long-term memory was more intact. But memory problems were a classic hallmark feature of a dementing disorder. And that approach has changed a bit. Now, we recognize that neurocognitive disorders can occur at any point in the lifespan. But yes, the elderly are at higher risk. That these conditions present as de"cits in one or more of the cognitive domains. And this is what we used to think of as mild cognitive impairment or a dementing disorder. Now, it's really just about the level of dysfunction. There are six cognitive domains and de"cits in any one of them that interfere with some level of function is a neurocognitive impairment. And depending on the level of impact on day-to-day living, it may be a mild neurocognitive disorder or a major neurocognitive disorder. The di!erence between the two is the level of function. Just like patients with the old terminology of mild cognitive impairment were capable of functioning independently, patients with mild neurocognitive disorder are those who are symptomatic beyond normal age-related change but still have enough cognitive function to remain relatively independent. So new terminology is mild neurocognitive disorder, which is the artist formerly known as mild cognitive impairment. Confusing, right? Because the terms are so similar. But the proper terminology now is mild neurocognitive disorder. Patients with major neurocognitive disorder experience enough of a decline in function due to the insult in one or more cognitive domain that they cannot live independently. So it is just a continuum. And it doesn't always like start mild, and then progressively 9 of 15 12/8/24, 4:28 PM Differentiating Neurocognitive Disorders Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2533795-dt-... get bad. One of the things that can produce this is head trauma. And head trauma, you can go from 0 to 60, you can go from "ne yesterday-- you have a major traumatic event today and tomorrow you have major neurocognitive disorder. Or, you can be "ne today, and then have some other level of some other-- like acute incident happen, maybe an acute vascular event or an acute injury, and you develop mild neurocognitive disorder. But that's it. The event happened. It gets treated. There is some cognitive dysfunction, but there's no reason to think it will progress. So there are those who live with a state of mild neurocognitive disorder for a long time and others who bypass mild completely and go right to major neurocognitive disorder. That does happen. It just depends on the underlying cause and the domains that are a!ected. But on the $ip side, you certainly can have people that develop a condition that is progressive. And in its early stages, it produces mild neurocognitive disorder and then is not treatable, like Alzheimer's disease, and then can go on to lead to major neurocognitive dysfunction. So how we "gure this out is that we evaluate for symptoms among six neurocognitive domains. And so like I said a few slides ago, no longer is memory loss required for a diagnosis. It's not uncommon. It depends on what the underlying disease is and which cognitive domain or domains are a!ected. But unlike the older de"nition of dementia where memory loss was a core feature, with neurocognitive disorder, it is not. It may be there. It may not. Now, the most common cause of neurocognitive disorder is Alzheimer's disease. And the nature of Alzheimer's disease is such that memory loss is very common. So you'll see it frequently, but it is no longer a requirement of diagnosis. Now, what we are doing is evaluating function in six domains. And that's how we make our assessment. And this isn't typically something that the generalist does in the more general outpatient psych mental health practice. This is something that you usually refer for neuropsychiatric testing. And there are practices that this is all they do, and they do very detailed assessments of the cognitive domains and give you your impression. So I'm sure you're asking yourself, self, what are the six principal neurocognitive 10 of 15 12/8/24, 4:28 PM Differentiating Neurocognitive Disorders Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2533795-dt-... domains? And here they are. Learning and memory is one, perceptual-motor function, language, executive function, complex attention, and social cognition. And I know you can read those. I just violated my own rule and read them to you. But what I want to call out is these are the six domains. These are the six areas and there's detailed symptom assessment of each one. But these are the six neurocognitive domains that, when there is impairment in one or more, that leads to some trouble with day-to-day function, that's when you have a neurocognitive disorder. So as you look at these six di!erent domains, you can see how someone perhaps may not have a memory problem at all. Yes, if they have de"cits in the "rst domain, then they're going to have a memory problem. But maybe they're there neurocognitive impairment is language. It's about reception and expressive language. It's an impairment if it's signi"cant enough. It could be a major neurocognitive disorder, but it isn't about memory at all. It's about being able to process and express language. So six di!erent domains and the remainder of the slides in this slide set break down some examples of each of them for you. So "rst up, learning and memory. So in learning and memory, obviously, memory is an important part. But not just long-term memory. That's just one piece. Other aspects of learning and memory that are evaluated when looking at this domain include things like free recall, being able to recall without any prompting, cued recall where the name gives it away. This is like when you do a Mini-Mental status examination-- for so long the Folstein Mini-Mental was the one that everybody went to, everybody knew it. The Folstein Mini-Mental, by the way, I think I mentioned this in week 1 when we're talking about assessment. The Folstein Mini-Mental is an excellent tool because it very brie$y assesses many of these domains. And we used to always use it all the time except that then years ago, they, I don't know what you call it, copyrighted or patented or something. Anyways, now you're not supposed to use it without paying for it. It's no longer free access. So a couple of other, quote, "Mini-Mental" status exam-like things have hit the scene that don't cost money that aren't Folstein. But I guess Dr. Folstein really was the prototype in this one. And one of the classic questions was at the beginning of the exam you say to the patient, I'm going to give you three words, apple, ball, and car, or something like that. And you say, remember, 11 of 15 12/8/24, 4:28 PM Differentiating Neurocognitive Disorders Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2533795-dt-... apple, ball, and car. And the patient says, OK, apple, ball, and car. And then you go on and do a few more questions on the exam. And then go back and say, OK, what were those three words? And hopefully, the patient says apple, ball, and car. And that would be your cued recall as opposed to free recall is something that there is no cue for it. You just ask the patient to retrieve something. Recognition is a di!erent aspect of this domain, and also unintentional learning. Learning a skill just by way of repetition and exposure. There are certain things that we learn without anybody necessarily telling us what it is or what to do. We learn it by exposure, by trial and error. And that's another domain that's evaluated. So that's the "rst neurocognitive domain. And I'm just giving you a summary here. There's certainly more to it. But this is an introduction I guess like every other lecture. Perceptual-motor function is not the same as learning and memory. This is the ability to perceive sensory input, put together sensory input, and then express motor function. And so here some of the areas that are assessed are visual perception. When you put something in front of the patient, [coughs] excuse me, do they see it? Do they see it as you presented it to them? Visuoconstructional reasoning. This is the ability to put together a process and be able to express it on paper evaluating for spatial relationships, like the example that you see here, these two pentagons, right? 1, 2, 3, 4-- yeah, "ve-sided. These two pentagons, you see how they are interrelated. This is also part of any classic short o#ce-based Mini- Mental status exam. The patient is asked to copy that on a separate piece of paper. And that really does tell you a lot about this domain. It tells you about their ability to see it and perceive it appropriately, and then to be able to copy that and have the motor function to do it. They may see it and perceive it appropriately, but not be able to write it down. They just can't make their hands go in that way or make those lines intersect appropriately. These are all aspects of perceptual-motor function as well as coordination. So it's a di!erent domain, again, unrelated to memory. The language domain. So the language domain isn't just about talking, although, grammar and syntax are that, but also naming objects. There are those with de"cits where you show them the picture of a pen, and they can write down-- when you say what is it, they can write down pen but can't say it. They can't "nd the word. Fluency of language, and then also the ability to understand spoken language. Reception and 12 of 15 12/8/24, 4:28 PM Differentiating Neurocognitive Disorders Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2533795-dt-... perception, that's really what's going on here. Executive function. This is like higher order cognitive function. [coughs] Excuse me. So this is the ability-- this is multitasking. This is evaluating information and responding appropriately. Inhibition is an important aspect of executive function. The ability to know when a certain response is or isn't appropriate even if-- you know, if you see something or you hear something or something is presented to you, and you might have an instinctual response that is perhaps not socially acceptable or doesn't work to your advantage in that particular circumstance, and your brain recognizes that and keeps you from expressing that, that's inhibition. And that's important. We see a de"cit in that in a lot of mental health disorders. The ability to $ex immediately to a change in circumstances. So this stu! is higher order. It's its own domain. And this might be one that's a!ected. So complex attention is exactly that, being able to attend to a task at hand. It's not just one skill. It's not just, quote, "paying attention." You have to be able to attend to the thing that is most imperative at the moment, be able to perceive other stimuli, but recognize that that doesn't need your attention right now, how to change your attention, how to process the information. And sometimes people will have de"cits in one and not the other. There's a real strong relationship here with ADD. Like, I'm talking to you right now, but not really talking to you. I'm talking to my computer screen. So I'm just sitting in a room talking to my computer. And there's a window on either side of me and a couple of dogs laying around here. So as I'm having the conversation with you, from time to time, something will happen outside. Kid will ride by on a bike, the trash truck goes by or something. And I'm aware of it. I can see it. It's drawn to my attention. But I need to stay focused on you and this conversation and not respond to that. And from time to time, you'll see that I don't do a great job of it. Sometimes when I trip over a word or go o! on the wrong tangent, it's because the screen in front of me I just kind of zoned it out and my attention was directed to something that it shouldn't have been, something that wasn't my priority right now, and that I have to rein myself back in. So this, of course, does not necessarily mean I have a neurocognitive disorder, but that's just an example of how attention varies. There's di!erent types of attention. And when someone cannot sustain and focus attention appropriately, can't be selective 13 of 15 12/8/24, 4:28 PM Differentiating Neurocognitive Disorders Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2533795-dt-... about where and how and to what they attend to the extent that it interferes with day- to-day function, yes, then it becomes a cognitive impairment. And then, of course, we have social cognition. So this is described as theory of the mind. And the theory of the mind-- I mean, this is kind of esoteric for me. I struggle a bit with it. But as I understand it, theory of the mind is about the patient's capacity to understand other people by ascribing mental states to them that are di!erent from one's self. So I can recognize that you might have a di!erent belief system than I do. That your emotions at any given time are not the same as mine. Something that might make me very happy and exciting might be hurting you. I mean, that's the best I can do. Like I said, this is more esoteric for me. But it is about-- it is about recognizing emotions, mood, belief of others and recognizing that they can be separate from self. Like, maybe the classic example is you are in competition with your best friend for something really important, and you win it and your friend doesn't. Someone who has a de"cit in social cognition or impairment in social cognition, when they win that thing, they're happy, they're excited, and can't truly appreciate that their best friend isn't because the best friend-- I mean, yeah, I'm sure your friend will be happy for you. But you got the idea. Maybe that wasn't the best example, but hopefully you get what I'm trying to say. I told you I'm not really good with this esoteric stu!. But theory of mind, when you say words like theory of mind, I just kind of zone out. This is just more, oh, I don't know, more blurred lines than I am. But the skill set really is about having enough insight, being capable of recognizing that others feel, believe, and emote di!erently than you do in any given point. And some people do have a de"cit in this. And so as you might imagine, it really interferes with social or occupational function. So here are your more common causes of cognitive impairment. Number one, Alzheimer's disease. This is the most common cause of neurocognitive disorder. Right behind it is vascular disease, basically target organ damage from hypertension, or diabetes, or atherosclerosis. Organic brain disease or traumatic brain injury. Then less common, but still here, Parkinson's disease, which can cause a neurocognitive dysfunction. Lewy bodies, which cause a very speci"c type of cognitive impairment. Metabolic and endocrine disorders 14 of 15 12/8/24, 4:28 PM Differentiating Neurocognitive Disorders Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2533795-dt-... do tend to be more acute delirium than long-term neurocognitive impairment. Syphilis and normal pressure hydrocephalus, we have to consider them as well. In the world of neurocognitive disorders, Alzheimer's disease and vascular disease really are hands down the most common. Everything else is just like a very small slice of the dementia pie. So a patient presents to you with a new onset mental status change. First thing we do is rule out reversible and identi"able causes. So everybody, urinalysis, urine culture, like I said, if that's negative, the chest X-ray, blood culture. TSH, CBC, and CMP, you're looking for metabolic phenomenon, you're looking for infection, hypo or hyperthyroidism. A depression screening, because this can also-- severe depression can mimic neurocognitive impairment. And a 12-week ECG, you're looking for hypoxemic causes of delirium. I know it sounds like a lot, but it's just a couple of tubes of blood, a depression tool and a urine and an EKG. It can be done same day in the o#ce. And a lot of the time, you'll "nd your cause there. If not-- if that "rst sweep doesn't give you anything, then next-- everybody at this point typically gets a head CT, or depending on the presentation, maybe an MRI, but some sort of head imaging. Depending on patient history and your level of suspect, a tox screen. Syphilis screening. People could have been exposed to syphilis decades ago and are just now evidencing neurosyphilis. HIV screening, because there is HIV or AIDS encephalopathy. So again, depending on risk. And if you really cannot identify any underlying cause for the mental status change, then it's time to consider referring the patient for neuropsychiatric testing and true evaluation of the six cognitive domains. And I think that's that. So as always, I hope it was helpful. Enjoy your learning activities for the week. But you will come back and talk with me this week about, I believe, sleep-wake disorders. Print this page 15 of 15 12/8/24, 4:28 PM