Chapter 15: NEUROCOGNITIVE DISORDERS

DSM-5 COGNITIVE DOMAINS

1. Complex attention
2. Executive function
3. Learning & memory
4. Language
5. Perceptual-motor
6. Social cognition
 DSM-IV 1. DELIRIUM
1. Memory impairment A. Disturbance in attention
2. Aphasia = expression & comprehension; attention) and awareness (i.e.,
Wernicke’s Aphasia = difficulty reduced ability to direct, focus,
understanding / comprehension; Broca’s sustain, and shift (reduced
Aphasia = difficulty expressing orientation to the environment).
3. Apraxia = movement B. Develops over a short period of
4. Agnosia = facial / object recognition time (usually hours to a few
5. Executive dysfunction days), represents a change from
6. Probable > Possible baseline attention and
7. Behavioral Disturbance: awareness , and tends to
❖ With: e.g. psychosis, mood, fluctuate in severity during the
agitation course of a day.
❖ Without (not clinically C. Additional disturbance in
significant) cognition visuospatial ability, or
❖ Severity (level of disability): perception). (e.g., memory
➢ Mild = Instrumental deficit, disorientation, language
(Activities of Daily D. Criteria A and C are not another
Living) ADL’s are neurocognitive disorder
preserved E. Disturbance is a direct
➢ Moderate = Basic physiological consequence of
(Activities of Daly AMC, substance intoxication or
Living) ADL’s affected withdrawal or exposure to a
➢ Severe = Fully toxin, or is due to multiple
dependent etiologies.
 SPECIFY WHETHER
● Substance intoxication / withdrawal
delirium = Criteria A and C predominate
in clinical picture
● Medication-induced delirium = Criteria
A and C arise as a side effect of a
medication taken as prescribed.
● Delirium due to another medical
condition = History, physical
examination, or laboratory findings that
the disturbance is attributable to the
physiological consequences of another
medical condition.
● Delirium due to multiple etiologies =
delirium has more than one etiology
A. Course-Specify if:
● Acute = Lasting a few hours or
days.
● Persistent = Lasting weeks.
B. Level of Psychomotor Activity–Specify
if:
● Hyperactive = mood lability,
agitation, and/or refusal to
cooperate with medical care
● Hypoactive = sluggishness and
lethargy that approaches stupor
● Mixed level of activity = Normal
level of psychomotor activity
even though attention and
awareness are disturbed . Also
includes individuals whose
activity level rapidly fluctuates.
DIAGNOSTIC FEATURES
A. Attention/ awareness
● Questions must be repeated
because the individual's
attention wanders, or the
individual may perseverate with
an answer to a previous
question rather than
CRITERIA FOR MILD NEUROCOGNITIVE
appropriately shift attention.
● Easily distracted by irrelevant
stimuli.
● Disturbance in awareness:
manifested by a reduced
orientation to the environment
or at times even to oneself.
B. Short period of time
● Fluctuate during the course of
the day, often with worsening in
the evening and night when
external orienting stimuli
decrease
C. Additional cognition disturbance
● Accompanying change in at
least one other area that may
include memory and learning
(recent memory), disorientation
(particularly to time and place),
alteration in language, or
perceptual distortion or a
perceptual-motor
(misinterpretations, illusions, or
hallucinations; typically visual)
CRITERIA FOR MAJOR
NEUROCOGNITIVE DISORDER
A. Significant cognitive decline in 1 or
more cognitive domains based on:
1. Concerned individual,
knowledgeable informant, or the
clinician
2. Standardized
neuropsychological testing or
clinical assessment.
B. Interfere with independence in everyday
activities
C. Not due to delirium.
D. Not due to another mental disorder
Specify:
● Without behavioral disturbance
● With behavioral disturbance (specify
disturbance)
Specify current severity:
● Mild = Difficulties with instrumental
activities of daily living
● Moderate = Difficulties with basic
activities of daily living
● Severe = Fully dependent.
DISORDER
A. Modest cognitive decline in 1 or more
cognitive domains based on:
1. Concerned individual,
knowledgeable informant, or the
clinician
2. Standardized
neuropsychological testing or
clinical assessment.

B. Do not interfere with independence in
everyday activities
C. Not due to delirium.
D. Not due to another mental disorder
Specify:
● Without behavioral disturbance
● With behavioral disturbance (specify
disturbance)
● Major NCD: 2 or more cognitive
domains impaired
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.
➔ Alzheimer’s: has amyloid plaques and
neurofibrillary tangles in the brain

SPECIFIERS: C. Probable or possible Alzheimer’s

● Psychotic features common in disease:
mild-to-moderate stage of major NCDs ● For MAJOR neurocognitive
due to Alzheimer's disease, Lewy body disorder:
disease, and frontotemporal lobar ❖ Probable AD: either one must be
degeneration. Paranoia, delusions present :
(persecutory) 1. Evidence of AD genetic
mutation (family
Mood disturbances history/ genetic testing)
1. Depression = mild NCD. 2. All three of the following
2. Agitation = moderate to severe NCD. are present:
3. Elation = frontotemporal lobar ➢ Impairment in
degeneration. memory + 1
4. Apathy = NCD due to frontotemporal other domain
lobar degeneration ➢ Progressive,
gradual decline
MAJOR VS MILD NCD IN COGNITIVE ➢ No other
possible
TESTING
etiology
Mild = 1–2 standard deviation (SD) range
➢ Otherwise,
(between the 3rd and 16th percentiles)
Possible AD is
Major = Below 2 SD or 3rd percentile
diagnosed

● For MILD neurocognitive

disorder:
❖ Probable AD = requires
evidence of Alzheimer’s gene.
❖ Possible AD = no evidence of
AD gene, but all 3 of these
factors exist:
➢ Decline in memory &
learning
➢ Progressive, gradual
decline
➢ No evidence of other
2. NCD DUE TO ALZHEIMER’S etiologies.
DISEASE
A. Major or mild neurocognitive disorder. 3. FRONTOTEMPORAL NCD
B. Onset = Insidious and gradual A. Major or mild neurocognitive disorder.
progression B. Onset = Insidious and gradual
● Mild NCD: 1 cognitive domains progression
impaired C. Either (1) or (2);
 1. Behavioral variant ★ Develops Parkinsonian
A. Three or more of the movement after 1 year of
following behavioral cognitive impairment
symptoms: ★ REM sleep problem
❖ Behavioral disinhibition. ★ Neuroleptic sensitivity
❖ Apathy or inertia.
❖ Loss of sympathy or 5. Vascular NCD
empathy. ★ Blockage in veins causes
❖ Perseverative, impairment in memory
stereotyped or ★ Complex attention
compulsive/ritualistic
behavior. 6. NCD due to Traumatic Brain
❖ Hyperorality and dietary
changes.
Injury
B. Decline in social ★ Physical head trauma
cognition and/or ★ Loss of consciousness
executive abilities. ★ Post trauma amnesia
2. Language variant: ★ Dissociative confusion
● Decline in language
ability ( speech 7. NCD due to HIV Infection
production, word A. Major or mild neurocognitive
finding, object naming, disorder.
grammar, B. Documented infection with HIV
comprehension) C. Not better explained by non-HIV
D. Sparing of learning and memory and conditions
perceptual-motor function. D. Not AMC
E. Not better explained by cerebrovascular
disease, another neurodegenerative 8. NCD due to Prion Disease
disease, the effects of a substance, or ★ Protein related
another mental, neurological, or ★ Problems in protein folding in
systemic disorder. the brain
★ Rapid progression
➢ Probable Frontotemporal NCD = either ★ Problems in motor features
of the following: (muscle stiffness)
1. Frontotemporal NCD genetic ★ Contamination in human brain
mutation (family history or ★ Leads to death
genetic testing) ★ No treatment
2. Disproportionate frontal and/or
temporal lobe involvement from 9. NCD due to Parkinson's Disease
neuroimaging. ★ Motor skills problem
➢ Possible frontotemporal NCD = NO ★ Cognitive aspect is affected
genetic mutation and neuroimaging has ★ Tremors
not been performed. ★ Walking difficulties

4. NCD due to Lewy Bodies 10.NCD due to Huntington's Disease

★ Impairment in movement ★ Decline in cognition
★ Vivid visual hallucinations ★ Genetic
(similar to schizophrenia) A. Major mild neurocognitive disorder
★ Insidious onset and gradual B. Onset = insidious and gradual
progression progression
★ Problems in cognition C. Established Huntington’s disease or risk
(family history or genetic testing)
D. Not AMC
 3. attempting to help these
11.SUBSTANCE/MEDICATION-INDU individuals and their caregivers
CED NCD cope with the advancing
A. Major or mild neurocognitive deterioration
disorder
B. Not due to delirium. Persist A. Biological Treatment
beyond the usual duration of ● Research exploration on using
intoxication and acute stem cells or glial cell
withdrawal. regeneration
C. Involved substance or ● Medicine that helps prevent
medication and duration and damage from blood clots due to
extent of use are capable of stroke
producing the neurocognitive ● Developing drugs that will
impairment. enhance the cognitive abilities
D. Timing of neurocognitive of people with neurocognitive
deficits: consistent timing of disorder due to Alzheimer’s
substance or medication use type.
and abstinence B. Psychosocial treatments
E. Not due to AMC ● Memory Wallets (mostly used in
Alzheimer's disease)
● Cognitive stimulation
12. NCD DUE TO ANOTHER MEDICAL ● Exercise
CONDITION ● Caregiver's Assertive Training
A. The criteria are met for major or mild
neurocognitive disorder. PREVENTION
B. There is evidence from the history, ● Control your blood pressure
physical examination, or laboratory ● Do not smoke
findings that the neurocognitive disorder ● Lead an active physical and social life
is the pathophysiological consequence
of another medical condition.
C. Not better explained by another mental
disorder or another specific
neurocognitive disorder (e.g.,
Alzheimer’s disease, HIV infection).

Treatments
1. Challenging unlike other MH disorders =
Nature of the damage
● Researchers are closing in on
how to use the brain’s natural
process of regeneration to
potentially reverse the damage
caused in NCD
● Extensive brain damage, no
known treatment can restore
lost abilities.

❖ Goals of treatment therefore become

1. trying to prevent certain
conditions, such as substance
abuse or strokes
2. trying to delay the onset of
symptoms to provide better
quality of life