Neurocognitive Disorders PDF

Neurocognitive Disorders CHAPTER OUTLINE...

Neurocognitive Disorders CHAPTER OUTLINE Perspectives on Neurocognitive Disorders Delirium Clinical Description and Statistics Treatment Prevention Major and Mild Neurocognitive Disorders Clinical Description and Statistics Neurocognitive Disorder Due to Alzheimer’s Disease Vascular Neurocognitive Disorder Other Medical Conditions That Cause Neurocognitive Disorder Substance/Medication-Induced Neurocognitive Disorder Causes of Neurocognitive Disorder Treatment Prevention Christian MartÃ-nez Kempin/E+/Getty Images 8 15 Copyright 201 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  [ student learning outcomes* ] Use scientific reasoning to interpret behavior: Identify basic biological, psychological, and social components of behavioral explanations (e.g., inferences, observations, operational definitions and interpretations) (APA SLO 1.1a) (see textbook pages 557–560) Engage in innovative and integrative thinking and Describe problems operationally to study them problem solving: empirically. (APA SLO 1.3a) (see textbook pages 543–557) Describe applications that employ discipline-based Correctly identify antecedents and consequences of problem solving: behavior and mental processes (APA SLO 5.3c) (see textbook pages 560–564). Describe examples of relevant and practical applications of psychological principles to everyday life (APA SLO 5.3a) (see textbook pages 560–564) * Portions of this chapter cover learning outcomes suggested by the American Psychological Association (2012) in its guidelines for the undergraduate psychology major. Chapter coverage of these outcomes is identified above by APA Goal and APA Suggested Learning Outcome (SLO). R esearch on the brain and its role in psychopathology has disorders” category, however, covered so many disorders that the increased at a rapid pace, and we have described many of the distinction was meaningless. Consequently, the traditional organic latest advances throughout this book. All the disorders we disorders—delirium, dementia, and amnestic disorders—were kept have reviewed are in some way influenced by the brain. You have together, and the others—organic mood, anxiety, personality, hallu- seen, for example, that relatively subtle changes in neurotransmit- cinosis, and delusional disorders—were categorized with disorders ter systems can significantly affect mood, cognition, and behavior. that shared their symptoms (such as anxiety and mood disorders). Unfortunately, the brain is sometimes affected profoundly, and, Once the term organic was dropped, attention moved to devel- when this happens, drastic changes occur. In earlier editions of this oping a better label for delirium, dementia, and the amnestic dis- book, the tone of this chapter was quite dark given the lack of infor- orders. The label “cognitive disorders” was used in DSM-IV to mation on these cognitive disorders that impair all aspects of mental signify that their predominant feature is the impairment of such functioning. The typically poor prognosis of the people afflicted led cognitive abilities as memory, attention, perception, and think- to pessimistic conclusions. A great deal of new research is leading ing. Although disorders such as schizophrenia, autism spectrum us to be more optimistic about the future, however. For example, disorder, and depression also involve cognitive problems, cogni- we used to think that once neurons died there was no hope of any tive issues are not believed to be primary characteristics (Ganguli replacement, yet we now know brain cells can regenerate even in et al., 2011). Problems still existed with the “cognitive disorder” the aging brain (Stellos et al., 2010). In this chapter, we examine this label, however, because although the cognitive disorders usu- exciting new work related to the brain disorders that affect cognitive ally first appear in older adults, intellectual disability and specific processes such as learning, memory, and consciousness. learning disorder (which are apparent early) also have cognitive impairment as a predominant characteristic. Finally, in DSM-5, neurocognitive disorders is the new category name for the vari- Perspectives on Neurocognitive Disorders ous forms of dementia and amnestic disorders, with “major” or Most neurocognitive disorders develop much later in life, whereas “mild” subtypes; DSM-5 retains the “delirium” label (American intellectual disability and specific learning disorder are believed to Psychiatric Association, 2013). This new categorization was cre- be present from birth (see Chapter 14). In this chapter, we review ated because of the overlap of the different types of dementia (e.g., two classes of cognitive disorders: delirium, an often temporary Alzheimer’s disease) and amnestic disorder found in people such condition displayed as confusion and disorientation; and mild or that one person may actually suffer from multiple types of neuro- major neurocognitive disorder, a progressive condition marked by cognitive problems (Ganguli et al., 2011). gradual deterioration of a range of cognitive abilities. As with certain other disorders, it may be useful to clarify why The label “neurocognitive disorders” in DSM-5 reflects a shift in neurocognitive disorders are discussed in a textbook on abnormal the way these disorders are viewed (American Psychiatric Associa- psychology. Because they so clearly have organic causes, you could tion, 2013). In early editions of the DSM, they were labeled “organic argue that they are purely medical concerns. You will see, however, mental disorders,” along with mood, anxiety, personality, hallucino- that the consequences of a neurocognitive disorder often include sis (an abnormal mental state involving hallucinations), and delu- profound changes in a person’s behavior and personality. Intense sional disorders. The word organic indicated that brain damage anxiety, depression, or both are common, especially among people or dysfunction was believed to be involved. The “organic mental with major neurocognitive disorder. In addition, paranoia is often P e rspe ct i v e s on Ne u ro c o gni t i v e D i s order s 543 Copyright 201 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. reported, as are extreme agitation and aggression. Families and to be only a temporary problem, more recent work indicates that friends are also profoundly affected by such changes. Imagine your the effects of delirium may be more lasting (Cole, Ciampi, Belzile, & emotional distress as a loved one is transformed into a different Zhong, 2009). Some individuals continue to have problems on and person, often one who no longer remembers who you are or your off; some even lapse into a coma and may die. Concern by medical history together. The deterioration of cognitive ability, behavior, professionals is increasing—perhaps because of the increased num- and personality and the effects on others are major concerns for ber of adults living longer—leading some to recommend that delir- mental health professionals. ium be included as one of the “vital signs” (along with heartbeat, breathing rate, temperature, and blood pressure) that physicians routinely check when seeing older adults (Flaherty et al., 2007). Delirium Many medical conditions that impair brain function have The disorder known as delirium is characterized by impaired been linked to delirium, including intoxication by drugs and poi- consciousness and cognition during the course of several hours or sons; withdrawal from drugs such as alcohol and sedative, hypnot- days. Delirium is one of the earliest-recognized mental disorders: ic, and anxiolytic drugs; infections; head injury; and various other Descriptions of people with these symptoms were written more types of brain trauma (Meagher & Trzapacz, 2012). DSM-5 recog- than 2,400 years ago (Solai, 2009). Consider the case of Mr. J. nizes several causes of delirium among its subtypes. The diagnosis received by Mr. J.—substance-induced delirium—as well as delir- ium not otherwise specified all include disruptions in the person’s MR.J Sudden Distress ability to direct, focus, sustain, and shift attention. The rise in the use of drugs such as Ecstasy (methylene-dioxymethamphetamine) M r. J., an older gentleman, was brought to the hospital emergency room. He didn’t know his own name, and at times he didn’t seem to recognize his daughter, who was is of particular concern because of such drugs’ potential to pro- duce delirium (Solai, 2009). The last two categories indicate the often complex nature of delirium. with him. Mr. J. appeared confused, disoriented, and a little That delirium can be brought on by the improper use of agitated. He had difficulty speaking clearly and could not medication is a particular problem for older adults, because focus his attention to answer even the most basic questions. they tend to use prescription medications more than any other Mr. J.’s daughter reported that he had begun acting this way age group. The risk of problems among the elderly is increased the night before, had been awake most of the time since further because they tend to eliminate drugs from their systems then, was frightened, and seemed even more confused today. less efficiently than younger individuals. It is not surprising, She told the nurse that this behavior was not normal for then, that adverse drug reactions resulting in hospitalization are him and she was worried that he was becoming “senile.” She almost 6 times higher among elderly people than in other age mentioned that his doctor had just changed his hyperten- groups (Olivier et al., 2009). And it is believed that delirium is sion medication and wondered whether the new medication responsible for many of the falls that cause debilitating hip frac- could be causing her father’s distress. Mr. J. was ultimately tures in the elderly (Stenvall et al., 2006). Although there has diagnosed as having substance-induced delirium (a reaction been some improvement in the use of medication among older to his new medication); once the medication was stopped, he adults with physicians using more care with drug dosages and improved significantly over the course of the next 2 days. the use of multiple drugs, improper use continues to produce serious side effects, including symptoms of delirium (Olivier et al., 2009). Because possible combinations of illnesses and The preceding scenario is played out daily in most major medications are so numerous, determining the cause of delir- metropolitan hospital emergency rooms. ium is extremely difficult (Solai, 2009). Delirium may be experienced by children who have high fevers or who are taking certain medications and is often mistaken Clinical Description and Statistics for noncompliance (Smeets et al., 2010). It often occurs during People with delirium appear confused, disoriented, and out of the course of dementia; as many as 50% of people with dementia touch with their surroundings. They cannot focus and sustain their suffer at least one episode of delirium (Kwok, Lee, Lam, & Woo, attention on even the simplest tasks. There are marked impair- 2008). Because many of the primary medical conditions can be ments in memory and language (Meagher & Trzapacz, 2012). Mr. treated, delirium is often reversed within a relatively short time. J. had trouble speaking; he was not only confused but also couldn’t Yet, in about a quarter of cases, delirium can be a sign of the end remember basic facts, such as his own name. As you saw, the of life (Wise, Hilty, & Cerda, 2001). Factors other than medical symptoms of delirium do not come on gradually but develop over conditions can trigger delirium. Age itself is an important fac- hours or a few days, and they can vary over the course of a day. tor; older adults are more susceptible to developing delirium as a Delirium is estimated to be present in approximately 20% of result of mild infections or medication changes (Fearing & Inouye, older adults who are admitted into acute care facilities such as 2009). Sleep deprivation, immobility, and excessive stress can also emergency rooms (Meagher & Trzapacz, 2012). It is most preva- cause delirium (Solai, 2009). lent among older adults, people undergoing medical procedures, Researchers studying the brain functioning of persons cancer patients, and people with acquired immune deficiency syn- with and without delirium are beginning to understand the drome (AIDS). Delirium subsides relatively quickly. Once thought mechanisms underlying this disorder of attention. In one study, 544 C ha p ter 15 Neuro c o g n itive D isorde rs Copyright 201 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  nonmedical treatment is to DSM 5 TABLE 15.1 Diagnostic Criteria for Delirium reassure the individual to help him or her deal with the agi- tation, anxiety, and hallucina- A. A disturbance in attention (i.e., reduced ability to direct, tions of delirium. A person in focus, sustain, and shift attention) and awareness the hospital may be comforted (reduced orientation to the environment). by familiar personal belongings B. The disturbance develops over a short period of time such as family photographs ©Richard Hutchings/PhotoEdit (usually hours to a few days), represents a change from (Fearing & Inouye, 2009). Also, baseline attention and awareness, and tends to fluctuate a patient who is included in in severity during the course of a day. all treatment decisions retains C. An additional disturbance in cognition (e.g., memory a sense of control (Katz, 1993). deficit, disorientation, language, visuospatial ability, or This type of psychosocial treat- perception). ment can help the person D. The disturbances in Criteria A and C are not better manage during this disruptive Elderly patients with delirium explained by another preexisting, established, or period until the medical causes in care facilities are often com- evolving neurocognitive disorder and do not occur in are identified and addressed forted by having their personal the context of a severely reduced level of arousal, belongings nearby. (Breitbart & Alici, 2012). Some such as coma. evidence suggests that this type of support can also delay institu- E. There is evidence from the history, physical examina- tionalization for elderly patients (Rahkonen et al., 2001). tion, or laboratory findings that the disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal (i.e., due Prevention to a drug of abuse or to a medication), or exposure to a Preventive efforts may be most successful in assisting people who toxin, or is due to multiple etiologies. are susceptible to delirium. Proper medical care for illnesses and From American Psychiatric Association. (2013). Diagnostic and statistical therapeutic drug monitoring can play significant roles in prevent- manual of mental disorders (5th ed.). Washington, DC. ing delirium (Breitbart & Alici, 2012). For example, the increased number of older adults involved in managed care and patient counseling on drug use appear to have led to more appropriate use of prescription drugs among the elderly (U.S. General Accounting scientists assessed brain activity using fMRI scanning during Office, 1995). active episodes of delirium as well as after these episodes and found both lasting disruption of connectivity (between the dor- solateral prefrontal cortex with the posterior cingulate cortex) as well as reversible disruptions (such as between the thalamus Concept Check 15.1 with the reticular activating system) (S.-H. Choi et al., 2012). Although such research is potentially important for efforts to Match the terms with the following descriptions of delirium: both prevent and treat delirium, there are potential ethical (a) memory, (b) cause, (c) counseling, (d) confused, (e) elderly, concerns. For example, a person experiencing delirium is not and (f) trauma. capable of providing informed consent for participating in such research and therefore someone else (e.g., a spouse or relative) 1. Managed care and patient ____________ have been must agree. In addition, fMRI testing can be anxiety-provoking successful in preventing delirium in older adults. for many people and was possibly very frightening for some- 2. Treatment of delirium depends on the ____________ of one already so disoriented (Gaudreau, 2012). We discuss these the episode and can include medications, psychosocial issues in more detail in Chapter 16. intervention, or both. 3. Delirium severely affects people’s ____________, making Treatment tasks such as recalling one’s own name difficult. Delirium brought on by withdrawal from alcohol or other drugs is usually treated with haloperidol or other antipsychotic medica- 4. The ____________ population is at the greatest risk of tions, which help calm the individual. Infections, brain injury, and experiencing delirium resulting from improper use of tumors are given the necessary and appropriate medical interven- medications. tion, which often then resolves the accompanying delirium. The 5. Various types of brain ____________, such as head antipsychotic drugs haloperidol or olanzapine are also prescribed injury or infection, have been linked to delirium. for individuals in acute delirium when the cause is unknown (Meagher & Trzapacz, 2012). 6. People who suffer from delirium appear to be The recommended first line of treatment for a person ____________ or out of touch with their surroundings. experiencing delirium is psychosocial intervention. The goal of D el i ri um 545 Copyright 201 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Major and Mild Neurocognitive Disorders impairments in cognitive abilities but can, with some accommoda- tions (for example, making extensive lists of things to do or creat- Few things are more frightening than the possibility of one day not ing elaborate schedules), continue to function independently. recognizing those you love, not being able to perform the most Causes of neurocognitive disorders include several medi- basic of tasks and, worse yet, being acutely aware of this failure of cal conditions and the abuse of drugs or alcohol that produce your mind. When family members show these signs, initially adult negative changes in cognitive functioning. Some of these children often deny any difficulty, coming up with excuses (“I forget conditions—for instance, infection or depression—can cause things, too”) for their parents’ failing abilities. Major neurocogni- neurocognitive impairment, although it is often reversible tive disorder (previously labeled dementia) is a gradual deteriora- through treatment of the primary condition. Some forms of the tion of brain functioning that affects memory, judgment, language, disorder, such as Alzheimer’s disease, are at present irrevers- and other advanced cognitive processes. Mild neurocognitive dis- ible. Although delirium and neurocognitive disorder can occur order is a new DSM-5 disorder that was created to focus attention on the early stages of cognitive decline. Here the person has modest DSM 5 TABLE 15.3 Diagnostic Criteria for Mild DSM Neurocognitive Disorder 5 TABLE 15.2 Diagnostic Criteria for Major Neurocognitive Disorder A. Evidence of modest cognitive decline from a previous level of performance in one or more cognitive domains A. Evidence of significant cognitive decline from a previous (complex attention, executive function, learning and level of performance in one or more cognitive domains memory, language, perceptual motor, or social cognition) (complex attention, executive function, learning and based on: memory, language, perceptual-motor, or social cognition) 1. Concern of the individual, a knowledgeable infor- based on: mant, or the clinician that there has been a mild 1. Concern of the individual, a knowledgeable infor- decline in cognitive function; and mant, or the clinician that there has been a significant 2. A modest impairment in cognitive performance, decline in cognitive function; and preferably documented by standardized neuropsy- 2. A substantial impairment in cognitive performance, chological testing or, in its absence, another quanti- preferably documented by standardized neuropsy- fied clinical assessment. chological testing or, in its absence, another quanti- B. The cognitive deficits do not interfere with capacity fied clinical assessment. for independence in everyday activities (i.e., complex B. The cognitive deficits interfere with independence in instrumental activities of daily living such as paying bills everyday activities (i.e., at a minimum, requiring assis- or managing medications are preserved, but greater tance with complex instrumental activities of daily living effort, compensatory strategies, or accommodation may such as paying bills or managing medications). be required). C. The cognitive deficits do not occur exclusively in the C. The cognitive deficits do not occur exclusively in the context of a delirium. context of a delirium. D. The cognitive deficits are not better explained by an- D. The cognitive deficits are not better explained by other mental disorder (e.g., major depressive disorder, another mental disorder (e.g., major depressive schizophrenia). disorder, schizophrenia). Specify whether due to: Specify whether due to: Alzheimer’s disease Alzheimer’s disease Frontotemporal lobar degeneration Frontotemporal lobar degeneration Lewy body disease Lewy body disease Vascular disease Vascular disease Traumatic brain injury Traumatic brain injury Substance/medication use Substance/medication use HIV infection HIV infection Prion disease Prion disease Parkinson’s disease Parkinson’s disease Huntington’s disease Huntington’s disease Another medical condition Another medical condition Multiple etiologies Multiple etiologies Unspecified Unspecified From American Psychiatric Association. (2013). Diagnostic and statistical From American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC. manual of mental disorders (5th ed.). Washington, DC. 546 C ha p ter 15 Neuro c o g n itive D isorde rs Copyright 201 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. together, neurocognitive disorder has a gradual progression as to the brain such as stroke (which destroys blood vessels), the opposed to delirium’s acute onset; people with neurocognitive infectious diseases of syphilis and HIV, severe head injury, the disorder are not disoriented or confused in the early stages, introduction of certain toxic or poisonous substances, and dis- unlike people with delirium. Like delirium, however, neurocog- eases such as Parkinson’s, Huntington’s, and, the most common nitive disorder has many causes, including a variety of traumas cause of dementia, Alzheimer’s. Consider the personal account Pat Summitt: Grit and Determination Simon Bruty/Sports Illustrated/Getty Images chest and I said, “Hey, Tyler, I’ve been The doctor told me that given my waitin’ on you.” (pp. 6–7) diagnosis, frankly, he felt I could no Her memory for important longer work at all. I should step down experiences that occurred years ago immediately, because in his opinion remains intact. However, recent expe- the dementia would progress rapidly. I riences and facts are more elusive. needed to quit, and get myself out of She then goes on to describe some of the public eye as quickly as possible, the things she no longer remembers. or I would “embarrass” myself and A Sometimes, when I first wake up, ruin my legacy. As he spoke, I felt my t the age of 57, Pat Summitt was a I don’t remember where I am. For a fist clench. It was all I could do not to highly successful basketball coach moment I’m disoriented and uneasy, lunge across the desk and drop him and mother, but she was beginning to and I have to lie there until it comes with one punch. Who did he think he experience lapses in her memory. to me. was? Even if I had an irreversible brain Friends started asking, “Are you Occasionally when I’m asked a disease—even if I did—what right did having trouble with your memory?” question, I begin to answer it but then he have to tell me how to cope with Finally I admitted, “Sometimes I draw I forget the subject—it slips away like it? Quit? Quit? (pp. 17–18) blanks.” I grew uncertain, and then a thread through my fingers. She goes on to write about her unusu- a little frightened. I began staying in I struggle to remember directions. ally practical and optimistic perspective bed until late in the morning, which There are moments when I’m driving on having Alzheimer’s disease—a view was unlike me. I’d always been a to someplace I should know, and I of this degenerative disease that should bolter, the first person up and the have to ask, “Do I go left or right here?” serve as a role model for the millions of most energetic one, too, and I’d I tend not to remember what hotel people impacted by this disorder. always gone to work earlier than room I’m in. I don’t remember what anyone on my staff. But I began to times my appointments are. (p. 7) Above all, I know that Alzheimer’s dread going into the office. (p. 11) has brought me to a point that I was Many people who begin to have these going to arrive at someday anyway. Despite having cognitive difficulties, not cognitive difficulties retell these initial With or without this diagnosis, I was all of her memories are lost to her in this experiences as incredibly frightening. going to experience diminishment. initial stage of the disease. She begins her However, Pat Summitt is known for her We all do. It’s our fate. No, I can’t size memoir with the things she remembers. tough determination both on the basket- up a court of ten players anymore, ball court and now battling Alzheimer’s see the clock out of one eye and I remember a tiny saloon in the disease. Her reaction to her diagnosis and the shifting schemes of opposing Tennessee hills where the bartender her doctor’s recommendations show an players with the other, and order up squirted bourbon shots from a squeeze incredible level of courage and strength. a countermove by hollering “Five!” bottle, straight into the customers’ mouths. I remember teaching a clinic In my case, symptoms began to or “Motion!” But I can suggest that to other coaches and opening the floor appear when I was only 57. In fact, people with mild to moderate stages for questions, and a guy raised his hand the doctors believe early-onset of dementia have far more abili- and asked if I had any advice when it Alzheimer’s has a strong genetic ties than incapacities. I can suggest came to “coaching women.” I remem- predictor, and that it may have been that just because certain circuits of ber leveling him with a death ray stare progressing hidden in me for some memory or swiftness of synapses and then relaxing and curling up the years before I was diagnosed. I’d been may fail, thought and awareness and corner of my mouth and saying, “Don’t walking around with a slow-ticking, consciousness do not. (p. 375) worry about coaching ‘women.’ Just go slow-exploding bomb in my brain Source: Summitt, P. H. (2013). Sum it up: A home and coach ‘basketball.’” (p. 6) cells, and it only became apparent thousand and ninety-eight victories, a couple I remember the night my son was when it began to seriously interfere of irrelevant losses, and a life in perspective. born. The doctor placed him on my with my work. (p. 9) New York: Crown Archetype. Major and Mi l d Ne u ro c o gni t i v e D i s order s 547 Copyright 201 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. by Pat Summitt, the most successful NCAA basketball coach of Alzheimer’s disease—is alarming. Figure 15.1 illustrates how all time. She coached the Tennessee Lady Vols basketball team the prevalence of neurocognitive disorder due to Alzheimer’s from 1974 to 2012—winning a record setting 1,098 games— disease is projected to dramatically increase in older adults, until her symptoms of neurocognitive disorder due to Alzheim- partly as a result of the increase of baby boomers who will er’s disease prevented her from working with the team full-time. become senior citizens (Hebert, Weuve, Scherr, & Evans, 2013). She courageously writes of her experiences with this disorder Among the eldest of adults, research on centenarians (people (Summitt, 2013). 100 years and older) indicates that up to 100% showed signs After several evaluations, which included neurological evalu- of neurocognitive disorder (Imhof et al., 2007). Neurocogni- ations, magnetic resonance imaging (MRI) showing some dam- tive disorder due to Alzheimer’s disease rarely occurs in people age in several parts of her brain, and a spinal tap that showed under 45 years of age. the presence of beta amyloid protein, Pat Summitt’s neurologist A dramatic rise in Alzheimer’s disease is predicted through the concluded that she had early onset neurocognitive disorder due year 2050 as larger numbers of people are expected to live beyond to Alzheimer’s disease. People at the same stage of decline as she 85 years of age. will continue to deteriorate and eventually may die from compli- Estimates of the prevalence of the new DSM-5 diagnosis— cations of their disorder. mild neurocognitive disorder—have been studied by the Einstein Aging Study at Yeshiva University (Katz et al., 2012). Clinical Description and Statistics Researchers recruited 1,944 adults aged 70 or older and assessed them for mild neurocognitive disorder as well as mild amnestic Depending on the individual and the cause, the gradual pro- neurocognitive disorder in this group. This latter disorder— gression of neurocognitive disorder may have somewhat differ- in its more severe state—was previously a separate DSM ent symptoms, although all aspects of cognitive functioning are disorder (amnestic disorder) but has been folded into the gen- eventually affected. In the initial stages, memory impairment is eral neurocognitive disorder group. Almost 10% of those over typically seen as an inability to register ongoing events. In other 70 had mild neurocognitive disorder and 11.6% met the cri- words, a person can remember how to talk and may remember teria for mild amnestic neurocognitive disorder. Race also events from many years ago but will have trouble remembering seemed to be a factor with black men and women at higher risk what happened in the past hour. For example, Pat Summitt had for mild neurocognitive disorder than white men and women vivid recollections about her childhood but could not remember (Katz et al., 2012). which direction to drive in familiar places. Pat Summitt couldn’t find her way home because visuo- spatial skills are impaired among people with neurocognitive disorder. Agnosia, the inability to recognize and name objects, is one of the most familiar symptoms. Facial agnosia, the inabil- Aged 65-74 years ity to recognize even familiar faces, can be extremely distress- Aged 75-84 years ing to family members. A general deterioration of intellectual Aged 85 years or older function results from impairment in memory, planning, and Total abstract reasoning. 16 Perhaps partly because people suffering from neurocogni- tive disorder are aware that they are deteriorating mentally, 14 emotional changes often occur as well. Common side effects are delusions (irrational beliefs), depression, agitation, aggression, 12 and apathy (Lovestone, 2012). It is difficult, however, to estab- lish the cause-and-effect relationship. It is not known how much 10 behavioral change is caused by progressive brain deterioration Millions directly and how much is a result of the frustration and discour- 8 agement that inevitably accompany the loss of function and the 6 isolation of “losing” loved ones. Cognitive functioning contin- ues to deteriorate until the person requires almost total support 4 to carry out day-to-day activities. Ultimately, death occurs as the result of inactivity, combined with the onset of other illness- 2 es, such as pneumonia. Globally, it is estimated that one new case of major neurocog- 0 nitive disorder is identified every 7 seconds (Ferri et al., 2005). 2010 2015 2020 2030 2040 2050 Major neurocognitive disorder can develop at almost any age, Year although this disorder is more frequent in older adults. Estimates FIGURE 15.1 With the increasing numbers of persons living longer, in the United States suggest a prevalence of a little more than 5% the rate of Alzheimer’s disease is predicted to escalate dramatically through in people older than 65; this rate increases to 20%–40% in those the year 2050. (From Hebert, L. E., Weuve, J., Scherr, P. A., & Evans, D. A. older than 85 (Richards & Sweet, 2009). The increasing number (2013). Alzheimer disease in the United States (2010–2050) estimated using of people with just one form of neurocognitive disorder—due to the 2010 census. Neurology, 80(19), 1778–1783.) 548 C ha p ter 15 Neuro c o g n itive D isorde rs Copyright 201 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  A problem with confirming prevalence figures for neurocog- Neurocognitive Disorder Due to Alzheimer’s Disease nitive disorder is that survival rates alter the outcomes. Because In 1907 the German psychiatrist Alois Alzheimer first described adults are generally living longer and are therefore more at risk the disorder that bears his name. He wrote of a 51-year-old woman of developing neurocognitive disorder, it is not surprising that who had a “strange disease of the cerebral cortex” that manifested the disorder is more prevalent. Incidence studies, which count as progressive memory impairment and other behavioral and the number of new cases in a year, may thus be the most reliable cognitive problems, including suspiciousness (Richards & Sweet, method for assessing the frequency of neurocognitive disorder, 2009). He called the disorder an “atypical form of senile demen- especially among the elderly. Research shows that the rate for tia”; thereafter, it was referred to as Alzheimer’s disease. new cases doubles with every 5 years of age after age 75. Many studies find greater increases of neurocognitive disorder among Description and Statistics women (Carter, Resnick, Mallampalli, & Kalbarczyk, 2012). Neurocognitive disorder due to Alzheimer’s disease may, as we The DSM-5 diagnostic criteria for neurocognitive disorder due discuss later, be more prevalent among women. Together, results to Alzheimer’s disease include multiple cognitive deficits that suggest that neurocognitive disorder is relatively common develop gradually and steadily. Predominant are impairment of among older adults and the chances of developing it increase memory, orientation, judgment, and reasoning. The inability to rapidly after the age of 75. integrate new information results in failure to learn new associa- In addition to the human costs of neurocognitive disorder, the tions. Individuals with Alzheimer’s disease forget important events financial costs are staggering. Estimates of the costs of caring for and lose objects. Their interest in nonroutine activities narrows. people with neurocognitive disorder due to Alzheimer’s disease They tend to lose interest in others and, as a result, become more are often quoted to be about $100 billion per year in the United socially isolated. As the disorder progresses, they can become agi- States. One estimate indicates that the total worldwide societal tated, confused, depressed, anxious, or even combative. Many of cost of major neurocognitive disorder is more than $315 billion these difficulties become more pronounced late in the day—in a (Wimo, Winblad, & Jonsson, 2007). These numbers do not, how- phenomenon referred to as “sundowner syndrome”—perhaps as ever, factor in the costs to businesses for health care in the form of a result of fatigue or a disturbance in the brain’s biological clock insurance and for those who care for these individuals—estimated (Lemay & Landreville, 2010). to be more than $140 billion in the United States alone (Weiner et People with neurocognitive disorder due to Alzheimer’s al., 2010). Many times, family members care for an afflicted person disease also display one or more other cognitive disturbances, around the clock, which is an inestimable personal and financial including aphasia (difficulty with language), apraxia (impaired commitment (Lovestone, 2012). motor functioning), agnosia (failure to recognize objects), or DSM-5 identifies classes of neurocognitive disorder based on difficulty with activities such as planning, organizing, sequencing, etiology: (1) Alzheimer’s disease, (2) vascular injury, (3) fronto- or abstracting information. These cognitive impairments have a temporal degeneration, (4) traumatic brain injury, (5) Lewy body serious negative impact on social and occupational functioning, disease, (6) Parkinson’s disease, (7) HIV infection, (8) substance and they represent a significant decline from previous abilities. use, (9) Huntington’s disease, (10) prion disease, and (11) another Research using brain scans is being conducted on people with medical condition. We emphasize neurocognitive disorder due to mild neurocognitive disorder to see whether changes in brain Alzheimer’s disease because of its prevalence (almost half of those structure early in the development of Alzheimer’s disease can be with neurocognitive disorder exhibit this type) and the relatively detected, which could lead to early diagnosis. In the past, a defini- large amount of research conducted on its etiology and treatment. tive diagnosis of Alzheimer’s disease could be made only after an autopsy determined that certain characteristic types of damage were present in the brain. There is now growing evidence, how- ever, that the use of sophisticated brain scans along with new chemical tracers may soon be able to help clinicians identify the presence of Alzheimer’s disease before the significant declines in cognitive abilities (through a project called the Alzheimer’s Dis- ease Neuroimaging Initiative [ADNI]) or death (Douaud et al., 2013; Weiner et al., 2012b). In addition, research on the presence of certain markers for Alzheimer’s (e.g., beta amyloid—the sub- stance in the amyloid plaques found in the brains of persons with this disease) in spinal fluid also appears to increase the accuracy of a diagnosis (Vanderstichele et al., 2012). Currently, to make a ©Francisco Cruz/SuperStock diagnosis without direct examination of the brain, a simplified version of a mental status exam is used to assess language and memory problems (see Table 15.1). In an interesting, somewhat controversial study—referred to as the “Nun Study”—the writings of a group of Catholic nuns People with facial agnosia, a common symptom of neurocognitive collected over several decades appeared to indicate early in life disorder, are unable to recognize faces, even of their closest friends which women were most likely to develop Alzheimer’s disease and relatives. later (Snowdon et al., 1996). Researchers observed that samples Major and Mi l d Ne u ro c o gni t i v e D i s order s 549 Copyright 201 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  Table 15.1 Testing for Neurocognitive Disorder due to Alzheimer’s Disease Type* Maximum Score† Question Orientation 5 Ask the patient, “What is the (year) (season) (date) (day) (month)?” 5 Ask the patient, “Where are we—(state) (country) (town) (hospital) (floor)?” Registration 3 Name three objects, using 1 second to say each. Then ask the patient all three after you have said them. (Give one point for each correct answer.) Then repeat them until the patient learns all three. (Count and record the number of trials.) Attention and Calculation 5 Count backward from given number (like 100) by subtracting 7s. (Give one point for each correct answer; stop after five answers.) Alternatively, spell “world” backward. Recall 3 Have the patient name the three objects learned previously. (Give one point for each correct answer.) Language 9 Have the patient name a pencil and a watch. (1 point) Have the patient repeat the following: “No ifs, ands, or buts.” (1 point) Have the patient follow a three-stage command: “Take a piece of paper in your right hand, fold it in half, and put it on the floor.” (3 points) Have the patient read and obey the following: “Close your eyes.” (1 point) Have the patient write a sentence. (1 point) Have the patient copy a design. (1 point) Note: One part of the diagnosis of the neurocognitive disorder due to Alzheimer’s disease uses a relatively simple test of the patient’s mental state and abilities, like this one, called the Mini Mental State Inpatient Consultation Form. A low score on such a test does not necessarily indicate a medical diagnosis of the disorder. *The examination also includes an assessment of the patient’s level of consciousness: alert, drowsy, stupor, or coma. † Total maximum score is 30. Adapted from the Mini Mental State Inpatient Consultation Form (Folstein, Folstein, & McHugh, 1975). from the nuns’ journals over the years differed in the number of or 70s. Approximately 50% of the cases of neurocognitive dis- ideas each contained, which the scientists called “idea density.” In order are found to be the result of Alzheimer’s disease, which is other words, some sisters described events in their lives simply: “I believed to afflict more than 5 million Americans and millions was born in Eau Claire, Wis, on May 24, 1913 and was baptized more worldwide (Alzheimer’s Association, 2010). in St. James Church.” Others were more elaborate in their prose: Some early research on prevalence suggested that Alzheimer’s “The happiest day of my life so far was my First Communion Day disease may occur more often in people who are poorly educated which was in June nineteen hundred and twenty when I was but (Fratiglioni et al., 1991; Korczyn, Kahana, & Galper, 1991). Great- eight years of age, and four years later in the same month I was er impairment among uneducated people might indicate a much confirmed by Bishop D. D. McGavich” (Snowdon et al., 1996, pg., earlier onset, suggesting that Alzheimer’s disease causes intellec- 530). When findings of autopsies on 14 of the nuns were correlated tual dysfunction that in turn hampers educational efforts. Or there with idea density, the simple writing (low idea density) occurred could be something about intellectual achievement that prevents among all 5 nuns with Alzheimer’s disease (Snowdon et al., 1996). or delays the onset of symptoms of the disorder. Later research This is an elegant research study, because the daily lives of the nuns seems to confirm the latter explanation. It appears that educational were similar, which ruled out many other possible causes. There level may predict a delay in the observation of symptoms (Pernec- is some concern, however, about overgeneralizing from this one zky et al., 2009). Unfortunately, people who attain a higher level study and we must be cautious about depending too much on of education also decline more rapidly once the symptoms start these observations, because only a small number of people were to occur (Scarmeas, Albert, Manly, & Stern, 2006), suggesting that examined. It is not yet clear that neurocognitive disorder due to education does not prevent Alzheimer’s disease but just provides Alzheimer’s disease has such early signs, but research continues a buffer period of better functioning. Educational attainment may in the hope of early detection so that early intervention can be somehow create a mental “reserve,” a learned set of skills that help developed (Farias et al., 2012; Tyas et al., 2007). someone cope longer with the cognitive deterioration that marks Cognitive deterioration with Alzheimer’s disease is slow dur- the beginning of neurocognitive deficits. Some people may adapt ing the early and later stages but more rapid during the middle more successfully than others and thus escape detection longer. stages (Richards & Sweet, 2009). The average survival time is Brain deterioration may thus be comparable for both groups, but estimated to be about 8 years, although many individuals live better-educated individuals may be able to function successfully dependently for more than 10 years. In some forms, the dis- on a day-to-day basis for a longer period. This tentative hypoth- ease can occur relatively early, during the 40s or 50s (sometimes esis may prove useful in designing treatment strategies, especially referred to as early onset), but it usually appears during the 60s during the early stages of the disorder. 550 C ha p ter 15 Neuro c o g n itive D isorde rs Copyright 201 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  A biological version of this theory— the cognitive reserve hypothesis— suggests that the more synapses a per- © Tim Beddow/Science Source/Photo © Tim Beddow/Science Source/Photo son develops throughout life, the more neuronal death must take place before the signs of dementia are obvious (Farias et al., 2012). Mental activity Researchers, Inc. Researchers, Inc. that occurs with education presumably builds up this reserve of synapses and serves as an initial protective factor in the development of the disorder. It is likely that both skill development and The PET scan of a brain afflicted with Alzheimer’s disease (left) shows significant tissue deteriora- the changes in the brain with educa- tion in comparison with a normal brain (right). tion may contribute to how quickly the disorder progresses. and important study—the Women’s Health Initiative Memory Research suggests that Alzheimer’s disease may be more Study—looked at hormone use among women and its effect on prevalent among women (Craig & Murphy, 2009), even when Alzheimer’s disease (Shumaker et al., 2004). In its initial findings, women’s higher survival rate is factored into the statistics. In the study followed women over age 65 using a type of combined other words, because women live longer than men on average, estrogen plus progestin known as Prempro and, contrary to the they are more likely to experience Alzheimer’s and other diseases, belief that giving women estrogen would decrease their chance of but longevity alone does not account for the higher prevalence developing neurocognitive disorder, they observed an increased of the disorder among women. A tentative explanation involves risk for Alzheimer’s disease (Coker et al., 2010). More research the hormone estrogen. Women lose estrogen as they grow older, is ongoing into the individual effects of these two types of so perhaps estrogen is protective against the disease. A large hormones on dementia. DSM 5 TABLE 15.4 Diagnostic Criteria for Major or Mild Neurocognitive Disorder due to Alzheimer’s Disease A. The criteria are met for major or mild neurocognitive disorder. B. There is insidious onset and gradual progression of impairment in one or more cognitive domains (for major neurocognitive disorder, two domains must be impaired). C. Criteria are met for either probable or possible Alzheimer’s disease as follows: For major neurocognitive disorder: Probable Alzheimer’s disease is diagnosed if either of the following is present; otherwise, possible Alzheimer’s disease should be diagnosed. 1. Evidence of a causative Alzheimer’s disease genetic mutation from family history or genetic testing 2. All three of the following are present: a. Clear evidence of decline in memory and learning and at least one other cognitive domain (based on detailed history or serial neuropsychological testing). b. Steadily progressive, gradual decline in cognition, without extended plateaus. c. No evidence of mixed etiology (i.e., absence of other neurodegenerative or cerebrovascular disease, or another neuro- logical, mental, or systemic disease or condition likely contributing to cognitive decline). For mild neurocognitive disorder: Probable Alzheimer’s disease is diagnosed if there is evidence of a causative Alzheimer’s disease genetic mutation from either genetic testing or family history. Possible Alzheimer’s disease is diagnosed if there is no evidence of a causative Alzheimer’s disease genetic mutation from either genetic testing or family history, and all three of the following are present: 1. Clear evidence of decline in memory and learning. 2. Steadily progressive, gradual decline in cognition, without extended plateaus. 3