Neurocognitive disorders (1)

Chapter 15
Neurocognitive Disorders

Neurocognitive Disorders: An Overview
 Affect learning, memory, and consciousness
 Most develop later in life
 Types of neurocognitive disorders
 Delirium – temporary confusion and
disorientation
 Major or mild neurocognitive disorder – broad
cognitive deterioration affecting multiple
domains
 Amnestic – refers to problems with memory
that may occur in neurocognitive disorders

Neurocognitive Disorders: An Overview
 Shifting DSM perspectives
 From “organic” mental disorders to “cognitive”
disorders
 Broad impairments in cognitive functioning
 Cause profound changes in behavior and
personality
 Thus, although some may consider these to
be general medical conditions, often best
treated by mental health professionals

Delirium: An Overview
 Nature of delirium
 Central features – impaired consciousness and
cognition
 Develops rapidly over several hours or days
 Appear confused, disoriented, and inattentive
 Marked memory and language deficits

Delirium: An Overview (continued)
 Facts and statistics
 Affects up 20% of adults in acute care facilities
(e.g., ER)
 More prevalent in certain populations,
including:
 Older adults
 Those undergoing medical procedures
 AIDS patients and cancer patients
 Full recovery often occurs within several weeks

Medical Conditions Related to Delirium
 Medical conditions
 Dementia (50% of cases involve temporary
delirium)
 Drug intoxication, poisons, withdrawal from
drugs
 Infections
 Head injury and several forms of brain trauma
 Sleep deprivation, immobility, and excessive
stress

Treatment and Prevention of Delirium
 Treatment
 Attention to precipitating medical problems
 Psychosocial interventions
 Reassurance/comfort, coping strategies,
inclusion of patients in treatment decisions
 Prevention
 Address proper medical care for illnesses,
proper use and adherence to therapeutic drugs

Major and Mild Neurocognitive Disorders
 Nature of dementia
 Gradual deterioration of brain functioning
 Deterioration in judgment and memory
 Deterioration in language / advanced cognitive
processes
 Has many causes and may be irreversible

Major and Mild Neurocognitive Disorders
 Major neurocognitive disorder:
 The new DSM-5 term for dementia
 Mild neurocognitive disorder: New DSM-5
classification for early stages of cognitive decline
 Individual is able to function independently
with some accommodations (e.g.,
reminders/lists)

Major Neurocognitive Disorder
 DSM-5 criteria
 One or more cognitive deficits that represent a
decrease from previous functioning
 Substantiated by clinical assessment
 Interfere with daily independent activities

 Prevalence and statistics
 New case identified every 7 seconds
 5% prevalence in adults 65+; 20% prevalence in
adults 85+
 Prevalence of mild neurocognitive disorder is
greater: 10% of adults 70+

 Initial stages
 Memory and visuospatial skills impairments
 Facial agnosia – inability to recognize familiar
faces
 Other symptoms
 Delusions, apathy, depression, agitation,
aggression

 Later stages
 Cognitive functioning continues to deteriorate
 Total support is needed to carry out day-to-day
activities
 Increased risk for early death due to inactivity
and onset of other illnesses

DSM-5 Types of Major and Mild
Neurocognitive Disorder
 Due to Alzheimers Disease
 Frontotemporal
 Vascular
 With Lewy bodies
 Due to traumatic brain
injury
 Substance/medication
induced
 Due to HIV infection
 Due to prion disease
 Due to Parkinson’s Disease
• Due to Huntington’s disease
• Due to another medical
condition
• Due to multiple etiologies
• Unspecified

Neurocognitive Disorder Due to
Alzheimer’s Disease
 Accounts for nearly half of neurocognitive
disorders
 Clinical Features
 Typically develop gradually and steadily
 Memory, orientation, judgment, and reasoning
deficits
 Additional symptoms may include
 Agitation, confusion, or combativeness
 Depression and/or anxiety

[INSERT Table 15.2 HERE, p. 556]

Alzheimer’s Disease : Statistics
 Nature and progression of the disease
 “Nun study” – analysis of nuns’ journal writing
over many years shows patterns of
deterioration
 Early and later stages = slow
 During middle stages = rapid
 Post-diagnosis survival = 8 years
 Onset = 60s or 70s (“early onset” = 40s to 50s)
 50% of the cases of neurocognitive disorder result
from Alzheimer’s disease

Alzheimer’s Disease : Statistics
 Prevalence
 5 million Americans, several million worldwide
 More common in less educated individuals
 More educated individuals decline more
rapidly after onset; this suggests that
education simply provides a buffer period of
better initial coping
 Slightly more common in women
 Possibly because women lose estrogen as
they age; estrogen may be protective

[INSERT Figure 15.1 HERE, p. 548]

Alzheimer’s Disorder: Extent of Deficits
 Range of cognitive deficits
 Aphasia – difficulty with language
 Apraxia – impaired motor functioning
 Agnosia – failure to recognize objects
 Difficulties with
 Planning, Organizing
 Sequencing
 Abstracting information
 Negative impact on social and occupational
functioning

Vascular Neurocognitive Disorder
 Caused by blockage or damage to blood vessels
 Second leading cause of neurocognitive disorder
after Alzheimer’s disease
 Onset is often sudden (e.g., stroke)
 Patterns of impairment are variable
 Most require formal care in later stages

[INSERT Disorder Criteria Summary, Major or Mild
Vascular Neurocognitive Disorder HERE, p. 552]

Vascular Neurocognitive Disorder
 Features
 Cognitive disturbances – identical to dementia
 Obvious neurological signs of brain tissue
damage
 Prevalence 1.5% in people 70-75 and 15% for
people over 80
 Risk slightly higher in men

Frontotemporal Neurocognitive Disorder
 Broadly refers to damage to the frontal or
temporal regions of the brain, affecting
 Personality
 Language
 Behavior
 Two types of impairment
 Declines in appropriate behavior
 Declines in language
 Example: Pick’s disease

Neurocognitive Disorder Due to Pick’s
Disease
 Rare neurological condition which accounts for 5%
of all dementia diagnoses
 Produces a cortical dementia like Alzheimer’s
 Occurs relatively early in life (around 40s or 50s)
 Little is known about what causes this disease

Traumatic Brain injury
 Accidents are leading cause
 Symptoms last for at least one week after head
injury, including problems with executive function,
learning, memory
 Memory loss is the most common symptom
 May be found in athletes who experience
repeated blows to the head (e.g., football players)

Neurocognitive Disorder Due to Lewy
Body Disease
 Lewy bodies = microscopic protein deposits that
damage brain over time
 Symptoms onset gradually
 Symptoms include impaired attention and
alertness, visual hallucinations, motor impairment

Parkinson’s Disase
 Parkinson’s disease
 Degenerative brain disorder
 Dopamine pathway damage
 1 out of 1,000 people are affected worldwide
 Chief difficulty: motor problems
 Tremors, posture, walking, speech
 Not all with PD will develop dementia
 75% survive 10+ years after diagnosis

Neurocognitive Disorder due to HIV
Infection
 HIV-1 can cause neurological impairments and
dementia in some individuals
 Cognitive slowness, impaired attention, and
forgetfulness
 Apathy and social withdrawal
 Typically occurs in later disease stages
 Now occurs in <10% of individuals with HIV;
HAART decreases risk

Huntington’s Disease
 Huntington’s Disease = genetic autosomal
dominant disorder
 Caused by a gene on chromosome 4
 Manifests initially as involuntary limb movements
(chorea), usually later in life
 Somewhere between 20-80% display
neurocognitive disorder
 Dementia follows a subcortical pattern

Neurocognitive Disorder Due to Prion
Disease
 Disorder of proteins in the brain that reproduce
and cause damage
 No known treatment, always fatal
 Can only be acquired through cannibalism or
accidental transmission (e.g., contaminated blood
transfusion)
 Example: Creutzfeldt-Jakob disease
 Affects one out of 1,000,000 persons
 Linked to mad cow disease

Substance/Medication-Induced
Neurocognitive Disorder
 Results from prolonged drug use, especially in
combination with poor diet
 May be caused by alcohol, sedative, hypnotic,
anxiolytic or inhalant drugs
 Brain damage may be permanent
 Symptoms similar to Alzheimer’s
 Deficits may include
 Memory impairment
 Aphasia, apraxia, agnosia
 Disturbed executive functioning

Causes of Neurocognitive Disorder:
The Example of Alzheimer’s Disease
 Features of brains with Alzheimer’s disease
 Neurofibrillary tangles (strandlike filaments)
 Amyloid plaques (gummy deposits between
neurons)
 Brains of Alzheimer’s patients tend to atrophy

 Multiple genes are involved in Alzheimer’s disease
 Include genes on chromosomes 21, 19, 14, 12
 Chromosome 14
 Associated with early onset Alzheimer’s
 Chromosome 19
 Associated with late onset Alzheimer’s

 Deterministic genes
 Rare genes that inevitably lead to Alzheimer’s
 Beta-amyloid precursor gene
 Presenilin-1 and Presenilin-2 genes
 Susceptibility genes
 Make it more likely but not certain to develop
Alzheimer’s

 Example of susceptibility gene: ApoE4 gene
 Located on chromosome 19
 Associated with late onset Alzheimer’s
 Among Alzheimer’s patients, more prevalent in
those who also have a family history of the
disease
 More likely to produce cognitive decline in the
context of a stressful environment (gene-
environment interaction)

The Contributions of Psychosocial
Factors in Neurocognitive Disorders
 Psychosocial factors do not cause dementia
directly
 May influence onset and course
 Lifestyle factors – drug use, diet, exercise, stress
 Cultural factors
 Risk for certain conditions vary by ethnicity and
class
 Psychosocial factors
 Educational attainment, coping skills, social
support

Medical Treatment of Neurocognitive
Disorders
 Few primary treatments exist
 Most treatments attempt to slow progression of
deterioration, but cannot stop it
 Future directions
 Glial cell-derived neurotrophic factor, stem
cells: may slow deterioration
 Some drugs target cognitive deficits
 Cholinesterase-inhibitors: Aricept, Exelon,
Reminyl
 Long-term effects not well demonstrated

Medical Treatment of Neurocognitive
Disorders
 Exploratory treatments
 Ginkgo biloba to improve memory – findings
are mixed
 Drugs to treat associated symptoms
 SSRIs for depression and anxiety
 Antipsychotics for agitation
 All are only modestly effective for short periods
 Currently testing vaccines on genetically altered
mice

Psychosocial Treatment of
 Aims of psychosocial treatments
 Enhance lives of patients and their families
 Teach compensatory skills
 Use memory enhancement devices, if needed
 Example: “Memory wallets” containing
statements about one’s life
 Cognitive stimulation can delay onset of more
severe symptoms

Psychosocial Treatment of
 Caregivers get instructions on how to handle
problematic behavior, including
 Wandering
 Socially inappropriate behavior
 Aggressive or rebellious behavior
 Caregivers also under great deal of stress, may
need their mental health treatment

Prevention of Neurocognitive Disorders
 Reducing risk in older adults
 Use of anti-inflammatory medications
 Control blood pressure, don’t smoke and lead
active social life
 Other targets of prevention efforts
 Increasing safety behaviors to reduce head
trauma
 Reducing exposure to neurotoxins and use of
drugs

Summary of Neurocognitive Disorders
 Cognitive disorders span a range of deficits
 Affect attention, memory, language, and motor
behavior
 Causes include
 Aging
 Medical conditions
 Abnormal brain structures
 Drug use
 Environmental factors

Summary of Neurocognitive Disorders
 Most result in progressive deterioration of
functioning
 Few treatments exist to reverse damage and
deficits, but progression may be slowed

Neurocognitive disorders (1)

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