Major Neurocognitive Disorder PDF Notes

Major Neurocognitive Disorder Module Module-5 Neurocognitive Status Not Started References DSM-5-TR pp. 591-603; Neurocognitive Disorders Chapter Important Points Early vs. Late on...

Major Neurocognitive Disorder Module Module-5 Neurocognitive Status Not Started References DSM-5-TR pp. 591-603; Neurocognitive Disorders Chapter Important Points Early vs. Late onset distinction, importance of neuroimaging Delirium Other Specified Delirium Unspecified Delirium Major Neuro-Cognitive Disorder Mild Neuro-Cognitive Disorder Major or Mild Neuro-Cognitive Disorder Due to Alzheimer’s Disease Major or Mild Frontotemporal Neurocognitive Disorder Major or Mild Neurocognitive Disorder with Lewy Bodies Major or Mild Vascular Neurocognitive Disorder Major or Mild Neurocognitive Disorder due to Traumatic Brain Injury Substance/Medication Induced Major or Mild Neurocognitive Disorder Major or Mild Neurocognitive Disorder due to HIV Infection Major or Mild Neurocognitive Disorder due to Prion Disease Major or Mild Neurocognitive Disorder due to Parkinson’s Disease Major or Mild Neurocognitive Disorder due to Huntington's Disease Major or Mild Neurocognitive Disorder due to Another Medical Condition Major or Mild Neurocognitive Disorder due to Multiple etiologies Unspecified Neuro-Cognitive Disorder Etiology Alzheimer’s Vascular Dementia FTD Lewy Bodies Parkinson’s Disease Traumatic Brain Injury Major Neurocognitive Disorder 1  Substance/Medication-Induced NCD HIV related NCD Prion Disease Interventions Cognitive Stimulation and Training Reminiscence and Reality Orientation Behavioural therapy for Challenging Behaviours Psychotherapy Design of Living Spaces Sensory and Activity Cues Daily Routine Structuring Caregiver to Psycho-Social Support Psycho-Education and Skills Training Support groups and Counselling Computerized Cognitive Training Assistive Devices and Apps Delirium A. 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. Major Neurocognitive Disorder 2  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 intoxication or withdrawal (i.e., due to a drug of abuse or to a medication), or exposure to a toxin, or is due to multiple etiologies. Specify whether: Substance intoxication delirium: This diagnosis should be made instead of substance intoxication when the symptoms in Criteria A and C predominate in the clinical picture and when they are sufficiently severe to warrant clinical attention. Substance withdrawal delirium: This diagnosis should be made instead of substance withdrawal when the symptoms in Criteria A and C predominate in the clinical picture and when they are sufficiently severe to warrant clinical attention. Medication-induced delirium: This diagnosis applies when the symptoms in Criteria A and C arise as a side effect of a medication taken as prescribed. Delirium due to another medical condition: There is evidence from the history, physical examination, or laboratory findings that the disturbance is attributable to the physiological consequences of another medical condition. Delirium due to multiple etiologies: There is evidence from the history, physical examination, or laboratory findings that the delirium has more than one etiology (e.g., more than one etiological medical condition; another medical condition plus substance intoxication or medication side effect). Specify if: Acute: Lasting a few hours or days. Persistent: Lasting weeks or months. Specify if: Hyperactive: The individual has a hyperactive level of psychomotor activity that may be accompanied by mood lability, agitation, and/or refusal to cooperate with medical care. Hypoactive: The individual has a hypoactive level of psychomotor activity that may be accompanied by sluggishness and lethargy that approaches stupor. Major Neurocognitive Disorder 3  Mixed level of activity: The individual has a normal level of psychomotor activity even though attention and awareness are disturbed. Also includes individuals whose activity level rapidly fluctuates. Other Specified Delirium This category applies to presentations in which symptoms characteristic of delirium that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for delirium or any of the disorders in the neurocognitive disorders diagnostic class. The other specified delirium category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for delirium or any specific neuro cognitive disorder. This is done by recording “other specified delirium” followed by the specific reason (e.g., “attenuated delirium syndrome”). An example of a presentation that can be specified using the “other specified” designation is the following: Attenuated delirium syndrome: This syndrome applies in cases of delirium in which the severity of cognitive impairment falls short of that required for the diagnosis, or in which some, but not all, diagnostic criteria for delirium are met. Unspecified Delirium This category applies to presentations in which symptoms characteristic of delirium that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for delirium or any of the disorders in the neurocognitive disorders diagnostic class. The unspecified delirium category is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for delirium, and includes presentations for which there is insufficient information to make a more specific diagnosis (e.g., in emergency room settings). Major Neuro-Cognitive Disorder Major Neurocognitive Disorder 4  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 cog functions, and 2. A substantial impairment in cog performance, documented by standardized neuropsychological testing (NIMHANS battery) or in its absence - another quantified clinical assessment B. The cognitive deficits interfere with independence in everyday activities. C. The cog deficits do not occur exclusively in the context of a delirium D. The cog deficits are not better explained by another mental disorder Specify without behaviour disturbance: If the cognitive disturbance is not accompanied by any clinically significant behavioral disturbance. with behavioural disturbances: If the cognitive disturbance is accompanied by a clinically significant behavioral disturbance (e.g., psychotic symptoms, mood disturbance, agitation, apathy, or other behavioral symptoms). Specify current severity: Mild: difficulties with instrumental activities of daily living Moderate: difficulties with basic activities Severe: fully dependent Mild Neuro-Cognitive Disorder Major Neurocognitive Disorder 5  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). Major or Mild Neuro-Cognitive Disorder Due to Alzheimer’s Disease A. The criteria fits major or mild neurocognitive disorder B. There is insidious onset gradual progression of impairment in one or more cognitive domains (for major neurocognitive disorder, at least two domains must be impaired). Major Neurocognitive Disorder 6  C. Criteria are met for either probable or possible Alzheimer’s disease as follows: 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 Probable Alzheimer’s or Possible Alzheimer’s For major neurocognitive disorder: Probable is diagnosed if either of the following is present; otherwise it is possible alzheimer’s. evidence of a causative alzheimer’s disease genetic mutation from family history or genetic testing all three of the following are present a. clear evidence of decline in memory and learning and at least one other cog domain 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 cog decline) For mild: probable alzheimer’s disease 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). Major Neurocognitive Disorder 7  Major or Mild Frontotemporal Neurocognitive Disorder A. The criteria are met for major or mild neurocognitive disorder. B. The disturbance has insidious onset and gradual progression. C. Either (1) or (2): 1. Behavioral variant: a. Three or more of the following behavioral symptoms: i. Behavioral disinhibition. ii. Apathy or inertia. iii. Loss of sympathy or empathy. iv. Perseverative, stereotyped or compulsive/ritualistic behavior. v. Hyperorality and dietary changes. b. Prominent decline in social cognition and/or executive abilities. 2. Language variant: a. Prominent decline in language ability, in the form of speech production, word finding, object naming, grammar, or word comprehension. D. Relative sparing of learning and memory and perceptual-motor function. E. The disturbance is not better explained by cerebrovascular disease, another neurodegenerative disease, the effects of a substance, or another mental, neurological, or systemic disorder. Probable frontotemporal neurocognitive disorder is diagnosed if either of the following is present; otherwise, possible frontotemporal neurocognitive disorder should be diagnosed: 1. Evidence of a causative frontotemporal neurocognitive disorder genetic mutation, from either family history or genetic testing. Major Neurocognitive Disorder 8  2. Evidence of disproportionate frontal and/or temporal lobe involvement from neuroimaging. Possible frontotemporal neurocognitive disorder is diagnosed if there is no evidence of a genetic mutation, and neuroimaging has not been performed. Major or Mild Neurocognitive Disorder with Lewy Bodies A. The criteria are met for major or mild neurocognitive disorder. B. The disorder has an insidious onset and gradual progression. C. The disorder meets a combination of core diagnostic features and suggestive diagnostic features for either probable or possible neurocognitive disorder with Lewy bodies. For probable major or mild neurocognitive disorder with Lewy bodies, the individual has two core features, or one suggestive feature with one or more core features. For possible major or mild neurocognitive disorder with Lewy bodies, the individual has only one core feature, or one or more suggestive features. 1. Core diagnostic features: a. Fluctuating cognition with pronounced variations in attention and alertness. b. Recurrent visual hallucinations that are well formed and detailed. c. Spontaneous features of parkinsonism, with onset subsequent to the development of cognitive decline. 2. Suggestive diagnostic features: a. Meets criteria for rapid eye movement sleep behavior disorder. b. Severe neuroleptic sensitivity. 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. Major Neurocognitive Disorder 9  Major or Mild Vascular Neurocognitive Disorder A. The criteria are met for major or mild 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. 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. Major Neurocognitive Disorder 10  Major or Mild Neurocognitive Disorder due to Traumatic Brain Injury A. The criteria are met for major or mild neurocognitive disorder. B. There is evidence of a traumatic brain injury—that is, an impact to the head or other mechanisms of rapid movement or displacement of the brain within the skull, with one or more of the following: 1. Loss of consciousness. 2. Post-traumatic amnesia. 3. Disorientation and confusion. 4. Neurological signs (e.g., neuroimaging demonstrating injury; a new onset of seizures; a marked worsening of a pre-existing seizure disorder; visual field cuts; anosmia; hemiparesis). C. The neurocognitive disorder presents immediately after the occurrence of the traumatic brain injury or immediately after recovery of consciousness and persists past the acute post-injury period. Substance/Medication Induced Major or Mild Neurocognitive Disorder A. The criteria are met for major or mild neurocognitive disorder. B. The neurocognitive impairments do not occur exclusively during the course of a delirium and persist beyond the usual duration of intoxication and acute withdrawal. Major Neurocognitive Disorder 11  C. The involved substance or medication and duration and extent of use are capable of producing the neurocognitive impairment. D. The temporal course of the neurocognitive deficits is consistent with the timing of substance or medication use and abstinence (e.g., the deficits remain stable or improve after a period of abstinence). E. The neurocognitive disorder is not attributable to another medical condition or is not better explained by another mental disorder. (study the dsm v tr and icd-11 criteria for later) (go through the ppt and add examples if u can) (take revisions Major or Mild Neurocognitive Disorder due to HIV Infection A. The criteria are met for major or mild neurocognitive disorder B. There is documented infection with HIV C. The neurocognitive disorder is not better explained by non-HIV conditions, including secondary brain diseases such as progressive multifocal leukoencephalopathy or cryptococcal meningitits D. The neurocognitive disorder is not attributable to another medical condition and is not better explained by a mental disorder Major or Mild Neurocognitive Disorder due to Prion Disease Prion diseases, a group of disorders caused by abnormally shaped proteins called prions, occur in sporadic, genetic, and acquired forms. A. The criteria are met for major or mild neurocognitive disorder. Major Neurocognitive Disorder 12  B. insidious onset, rapid progression of impairment C. There are motor features of prion disease, such as myoclonus (brief, involuntary muscle jerks or twitches) or ataxia (gait), or biomarker evidence. 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 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. Major or mild neurocognitive disorder possibly due to Parkinson’s disease 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 the neurocognitive disorder. if there is only 1 present - possible, 2 criteria are met - propable → parkinson’s → cognitive decline → dementia 1. The criteria are met for major or mild neurocognitive disorder Major Neurocognitive Disorder 13  2. insidious onset, gradual progression of impairment Major or Mild Neurocognitive Disorder due to Huntington's Disease Huntington's disease is a progressive neurodegenerative disorder that causes a decline in movement, thinking, and behavior. It is inherited in an autosomal dominant manner, meaning a person only needs to inherit one copy of the mutated gene to develop the disease. The disease is caused by a mutation in the HTT gene on chromosome 4, which leads to an abnormal huntingtin protein that accumulates in the brain. 1. The criteria are met for major or mild neurocognitive disorder 2. insidious onset, gradual progression of impairment 3. clinically established Huntington’s disease or risk for Huntington’s disease based on family history or genetic testing. 4. not attributed to any other medical condition Major or Mild Neurocognitive Disorder due to Another Medical Condition a. the criteria are met for major or mild neurocognitive disorder b. evidence from history, physical examination that is not supported to any specific disease c. not attributed to any other medical condition Major or Mild Neurocognitive Disorder due to Multiple etiologies a. the criteria are met for major or mild neurocognitive disorder b. evidence from history, physical examination that is not supported to any specific disease due to more than one etiology excluding substance use c. not attributed to any other medical condition and not exclusively limited to the period of delirium Unspecified Neuro-Cognitive Disorder Major Neurocognitive Disorder 14  This category applies to presentations in which symptoms characteristic of a neurocognitive disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the neurocognitive disorders diagnostic class. The unspecified neuro-cognitive disorder category is used in situations in which the precise etiology cannot be determined with sufficient certainty to make an etiological attribution. Etiology Alzheimer’s extracellular amyloid plaques and intracellular tau neuro-fibrillatary tangles leading to synapse loss and cortical atrophy AD is sporadic with advanced age at the greatest risk factor - familial - early onset - deterministic mutations env and comorbid factors coincide with cardiovascular disease controlling vascular risks - can slow progression, underscoring the role of vascular and metabolic factors in this dementia subtype. Vascular Dementia arises from cumulative cerebrovascular injury brain imaging shoes ischemic lesions or white matter hyperintensities - chronic small-vessel disease or strokes. pathologically, brain have multifocal infarcts, lacunes and gliosis in critical regions (periventricular white matter, thalamus, basal ganglia) lifestyle and env FTD genetic - 20 to 50% are familial, with mutations in MAPT (tau gene), GRN (progranulin) with Cgorf72 ( a hexanucleotide repeat) accounting for 60% familial FTD middle age Major Neurocognitive Disorder 15  Lewy Bodies cortical accumulation of misfolded brain vulnerability plaques/tangles fluctuating cognition and visual hallucination Parkinson’s Disease PDD occurs when PD progresses to involve cortical regions widespread Lewy bodies and dopamine production Traumatic Brain Injury TBI from severe or repetitive concussions can produce chronic neurocognitive disorder epidemiological studies - moderate to severe TBI doubles to quadruples later dementia risk mild TBI (concussion) on its own has uncertain risk, but repeated mild injuries (contact sports) cause chronic traumatic encephalopathy Substance/Medication-Induced NCD neurotoxicity of substances or medications chronic alcohol abuse - thiamine deficiency leads to wernicke-kosakoff syndrome with profound memory loss and causes nutritional deficits - alcoholic dementia other toxins or illicit drugs may also impair cognition, many have anticholinergic or sedating effects, prolonged bensodiazepine use is discouraged in the elderly due to risk of cog impairment HIV related NCD HIV enters CNS early infecting microglia and macrophages, viral proteins (Tat, gp120) induce chronic neuroinflammation and neural injury even with effective ART, latent HIV reservoirs in brain sustain inflammation Before ART, full blown dementia was common in late stage AIDS, now severity is rare Major Neurocognitive Disorder 16  risk factors- high viral load or low CD4 count (poorly controlled HIV), older age, HCV coinfection and substance abuse Suppressive ART dramatically reduces HIV dementia incidence Prion Disease eg: cruetzfeldt-jacob disease - misfolding of the normal prion protein into a pathogenic form that spreads by seeded aggregation misfolded prions trigger rapid neuronal loss and spongiform change throughout the brain no traditional modifiable risk factors - infections or genetic result is v rapid - with characteristic sharp-wave EEG changes and diffusion MRI abnormalities Interventions Primary treatment is pharmological, however, skipped Cognitive Stimulation and Training structured activities - thinking and memory. Ex: CST - cog stimulation therapy in groups for mild to moderate randomized trials - small significant gains FINGER trial (multidomain lifestyles - cog training) found that tailored cog exercises helped maintain cog function in at-risk order adults benefits limited to early stages cog training - not effective in severe impairment and standard programs are not recommended for late-stage Reminiscence and Reality Orientation reminiscence therapy - reviewing personal past, reality orientation - using clocks and calenders can improve mood and orientation in mild to moderate build on preserved long-term memory and social skills Major Neurocognitive Disorder 17  clinical trials - improve mood and social engagement most apt in early to mid stages, since they require some communicative skills Behavioural therapy for Challenging Behaviours address agitations, wandering, repitive questioning by identifying triggers and reinforcing desirable favours behavioural management therapy - ABC - antecedent behaviour consequence analysis and tailored activities studies report that individualised activity programs and structured schedules can reduce agitation first line for beh symptoms before considering drugs limitations: success depends on careful assessment of triggers and consistent implementation by trained staff, efficacy varies and requires family involvement Psychotherapy help to adjust to diagnosis and cope with mood symptoms - CBT can reduce anxiety and depression and aid for planning for the future requires insight and verbal ability, conventional therapy not practical caregivers/family receives CBT training to manage stress and patient beh issues Design of Living Spaces a safe, predictable env helps in orientation and reduce stress - clear signage, consistent routines, adequate lighting, minimizing clutter or noise placing multiple clocks and calendars - cue memory reducing env stress - minimizing bg noise can reduce agitation env “dementia-friendly” design - contrasting colours for steps, handles, secure outdoor areas for physical safety - fall risk and wandering evidence for specific modifications comes from practice and small studies, systematic reviews confirm changing the home or care setting can reduce beh problems Major Neurocognitive Disorder 18  limitations: feasability, resources, care givers, therapy resources Sensory and Activity Cues sensory therapy can sooth beh symptoms music therapy - meta analysis to moderately reduce agitation in dementia exposure to familiar scents or hand massages can collaborate with other therapies and pharma Daily Routine Structuring consistent scheduling of meals, hygience, activities reduce anxiety and confusion Caregiver to Psycho-Social Support Psycho-Education and Skills Training educating families/caregivers about the disorder and care techniques guidelines strongly recommend offering carers structured training that covers dementia symptoms, beh management, communication strategies, stress coping, self-care such programs often group based improve skills and well-being systematic reviews show that multicompenent caregiver training reduces caregiver burden and delays patient institutionalization ex: some guidelines notes s group formats are often most effective limitations: access to programs varies by region. carer education has most impact when begun at the diagnosis Support groups and Counselling peer support groups and counselling can provide emotional support and coping strategies for both the parties Major Neurocognitive Disorder 19  feeling understood by others in similar situations can reduce isolation and depression social activities resilience for care givers Computerized Cognitive Training software and apps can deliver cognitive exercises with adaptive difficulty systematic reviews report that technology based cognitive training procedures improvements in memory, attention and executive function in people with mild cognitive impairment or mild dementia limitations: need tech savvy care givers and even understanding from the patient, feasibility, resources Assistive Devices and Apps personal technology can support memory and safety ex: digital calendars, medication reminders, GPS trackers for wandering, voice-activated home assistants more advanced assistive robots or telepresence devices are emerging, evidence is still preliminary Major Neurocognitive Disorder 20