NEUROCOGNITIVE DISORDERS Chapter 13 Copyright © 2014 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education

Characteristics of Neurocognitive Disorders These disorders involve cognitive decline acquired in life in one or more domains of cognition. Based upon concerns of the client or someone who knows the client well, and performance on objective assessment measures. The DSM-5 provides descriptions to help clinicians provide a diagnosis that indicates both the fact that the individual has a neurocognitive disorder and, where known, the possible cause. Brain’s functioning affects our abilities to think, remember, and pay attention. In DSM-IV-TR, this set of disorders is titled delirium, dementia, amnestic, and other cognitive disorders. Symptoms: Mood disorders Personality disorders Injuries to the brain including brain trauma, disease, or exposure to toxic substances including drugs. Copyright © 2014 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education

neurocognitive disorders In DSM-5, the term neurocognitive disorder replaces dementia Refers to a form of cognitive impairment in which individuals undergo progressive loss of cognitive functions severe enough to interfere with their normal daily activities and social relationships. Clinicians still use the term “dementia,” and the DSM-5 work group considered dementia to be useful in settings where medical personnel are familiar with the term. Copyright © 2014 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education

Delirium A neurocognitive disorder that is temporary in nature involving disturbances in attention or awareness. A temporary state in which individuals experience a clouding of consciousness Unaware of what is happening around them Unable to focus or pay attention The symptoms tend to appear abruptly and fluctuate over the course of the time that they have the disorder Core of the disorder involves an acute state of confusion, impairment in cognitive processing that affects memory, orientation, executive functioning, ability to use language, visual perception, and learning. Copyright © 2014 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education

Delirium Develops for a variety of reasons Substance intoxication Substance withdrawal Head injury High fever Vitamin deficiency People of any age can experience delirium, common among medically or psychiatrically hospitalized older adult patients. Copyright © 2014 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education

Delirium Causes Tests and treatment Infection Central nervous system disorder Metabolic disorders Tests and treatment Delirium Rating Scale-Revised Pharmacological approach Haloperidol and respiridone Apart from the cognitive symptoms of inattention and memory loss, individuals experiencing delirium have hallucinations, delusions, abnormalities in sleep-wake cycles, changes in mood, and movement abnormalities. The advantage of using Delirium Rating Scale-Revised is that although designed for psychiatrists, other professionals and researchers can also use it. Pharmacological approach administers antipsychotics. Standard approach uses haloperidol, but clinicians may use “off-label” antipsychotics such as respiridone. This combination appears to help resolve symptoms in as many as 84 percent of cases over a period of 4 to 7 days Copyright © 2014 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education

Neurocognitive Disorder due to Alzheimer’s Disease This is a neurocognitive disorder associated with progressive, gradual declines in memory, learning, and at least one other cognitive domain. Progressive and gradual cognitive deficits due to severe cerebral atrophy Copyright © 2014 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education

Diagnostic Criteria for Neurocognitive Disorder due to Alzheimer’s Disease Copyright © 2014 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education

FIGURE 13.1 - Changes in the Brain Associated with Alzheimer’s Disease Mild cognitive impairment (MCI): A condition in which an individual suffers some memory problems but does not show symptoms of dementia. Copyright © 2014 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education

Stages of Alzheimer’s Disease Not Alzheimer Early-stage Middle-stage Late-stage Copyright © 2014 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education

Stages of Alzheimer’s Disease Copyright © 2014 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education

Diagnosis of Alzheimer’s Disease Brain imaging techniques Neuropsychological testing NINCDS/ADRDA guidelines Mini-Mental State Examination The diagnosis of Alzheimer’s disease based on the NINCDS/ADRDA criteria involves thorough medical and neuropsychological screenings. Continued improvement of MRI has resulted in a virtual explosion of studies on the diagnosis of Alzheimer’s disease through brain imaging. Clinicians convened to revise the 1984 NINCDS/ADRDA Guidelines. Goal was to develop diagnostic criteria not dependent on the expensive and potentially invasive brain scans used in research. The clinical tool that clinicians most commonly use for diagnosing Alzheimer’s disease is a specialized form of the mental status examination, which we call the Mini-Mental State Examination. Copyright © 2014 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education

Pseudodementia False dementia, symptoms caused by depression that mimic those apparent in early stages of Alzheimer's People with depression are anxious, have difficulty sleeping, show disturbed appetite patterns, and experience suicidal thoughts, low self-esteem, guilt, and lack of motivation. People with pseudodementia are likely to have a history of prior depressive episodes that may have been undiagnosed. Copyright © 2014 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education

Theories and Treatment of Alzheimer’s Disease All theories regarding the cause of Alzheimer’s disease focus on biological abnormalities involving the nervous system. Neurofibrillary tangles Tau Amyloid plaques Secretases Neurofibrillary tangles- A characteristic of Alzheimer’s disease in which the material within the cell bodies of neurons becomes filled with densely packed, twisted protein microfibrils, or tiny strands. Amyloid plaques- A characteristic of Alzheimer’s disease in which clusters of dead or dying neurons become mixed together with fragments of protein molecules. Secretases trim the part of APP remaining outside the neuron so that it is flush with the neuron’s outer membrane Copyright © 2014 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education

Figure 13.3 - Neurofibrillary Tangle Copyright © 2014 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education

figure 13.4 - Development of Amyloid Plaques Secretases: Enzymes that trim part of the APP remaining outside the neuron so that it is flush with the neuron’s outer membrane. Copyright © 2014 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education

Risk factors for Alzheimer's disease Cigarette smoking Obesity Lack of physical exercise Neurofibrillary tangles: Material within the cell bodies of neurons becomes filled with densely packed, twisted protein microfibrils, or tiny strands. Tau: A protein that normally helps maintain the internal support structure of the axons. Amyloid plaques: Clusters of dead or dying neurons become mixed together with fragments of protein molecules. Two main implications of research documenting the behavioral risk factors for Alzheimer’s disease: People can reduce their risk of Alzheimer’s disease by taking advantage of behaviors that contribute to its development. Risk factors increase the likelihood of an individual developing cerebrovascular disease, depression, and other causes of dementia. Copyright © 2014 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education

Mechanism of Action and Side Effects of Alzheimer’s Medications Copyright © 2014 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education

Behavioral strategies Behavioral psychologists are developing strategies to maximize the daily functioning of people with Alzheimer’s disease. Target both patient and caregiver to: Increase patient independence Eliminate wandering and aggression Provide social support for caregivers Caregivers are often targeted since they suffer adverse effects from the constant demands of caregiving. Strategies that can promote the patient’s independence and reduce his or her distressing behaviors. Support groups Copyright © 2014 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education

Neurocognitive Disorders due to Neurological Disorders Other than Alzheimer’s Disease causes that include degenerative neurological conditions other than Alzheimer’s disease Copyright © 2014 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education

Neurocognitive Disorders due to Neurological Disorders Other than Alzheimer’s Disease Fronto-temporal neurocognitive disorder- Neurocognitive disorder that involves the fronto-temporal area of the brain. Symptoms are reflected in personality changes: Apathy, lack of inhibition, obsessiveness, and loss of judgment. Neglect of personal habits and loss of the ability to communicate eventually occurs. The onset of the disorder is slow and insidious. Copyright © 2014 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education

Neurocognitive disorder with Lewy bodies A form of neurocognitive disorder with progressive loss of: Memory Language Calculation Reasoning and higher mental functions Results from the accumulation of abnormalities called Lewy bodies throughout the brain. Copyright © 2014 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education

Vascular neurocognitive disorder A form of neurocognitive disorder resulting from a vascular disease that causes deprivation of the blood supply to the brain. multi-infarct dementia (MID), caused by transient attacks in which blood flow to the brain is interrupted by a clogged or burst artery. Although each infarct is too small to be noticed at first, over time the progressive damage caused by the infarcts leads the individual to lose cognitive abilities Copyright © 2014 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education

Pick’s disease A relatively rare progressive degenerative disease that affects the cerebral cortex’s frontal and temporal lobes. It is caused by the accumulation in neurons of unusual protein deposits In addition to memory problems, people with this disorder become socially disinhibited, acting either inappropriately and impulsively or appearing apathetic and unmotivated. Unlike Alzheimer’s Disease, personality alterations occur before memory problems. Pick’s disease is a relatively rare progressive degenerative disease that affects the cerebral cortex’s frontal and temporal lobes. It is caused by the accumulation in neurons of unusual protein deposits called Pick bodies. In addition to having memory problems, people with this disorder become socially disinhibited, acting either inappropriately and impulsively or appearing apathetic and unmotivated. In contrast to the sequence of changes that people with Alzheimer’s disease show, people with Pick’s disease undergo personality alterations before they begin to have memory problems. Copyright © 2014 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education

neurocognitive disorder due to Parkinson’s disease A neurocognitive disorder that involves degeneration of neurons in the subcortical structures that control motor movements. At rest, hands, ankles, or head may shake involuntarily Akinesia: Muscular rigidity, difficulty initiating movement Copyright © 2014 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education

Parkinson’s Disease Symptoms Bradykinesia: General slowing of motor activity Loss of fine motor coordination Slowed, shuffling gait Difficulty starting or stopping movement like walking Signs of cognitive deterioration Expressionless and speech becomes stilted Many cognitive functions, such as attention, concentration, and immediate memory, remain intact. Copyright © 2014 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education

additional Neurocognitive disorders Huntington’s disease Creutzfeldt-Jakob disease Lewy body dementia: Similar to Alzheimer's disease with progressive loss of memory, language, calculation, and reasoning, as well as other higher mental functions. Diagnosed when Lewy bodies are found more diffusely throughout the brain. Frontotemporal dementias: Involve the frontotemporal area of the brain. Reflected in personality changes such as apathy, lack of inhibition, obsessiveness, or loss of judgment. Motivation and communication are lost. Huntington's disease: Hereditary condition causing dementia that involves a widespread deterioration of the subcortical brain structures and parts of the frontal cortex that control motor movements. Creutzfeldt-Jakob disease: A neurological disease transmitted from animals to humans that leads to dementia and death resulting from abnormal protein accumulations in the brain. Vascular dementia: Resulting from a vascular disease that causes deprivation of the blood supply to the brain. Multi-infarct dementia: Caused by transient attacks in which blood flow to the brain is interrupted by a clogged or burst artery. Copyright © 2014 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education

Figure 13.6 - Other Diseases That Can Cause Deterioration in Cognitive Function Copyright © 2014 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education

Neurocognitive Disorder Due to Traumatic Brain Injury Traumatic Brain Injury (TBI)- Damage to the brain caused by exposure to trauma. Post-concussion syndrome: Constellation of physical, emotional, and cognitive symptoms persists from weeks to years Trauma to the head that results in an alteration or loss of consciousness, or post- traumatic amnesia is called traumatic brain injury, or TBI. Th e diagnostic criteria for neurocognitive disorder due to traumatic brain injury require evidence of impact to the head along with loss of consciousness, amnesia following the trauma, disorientation and confusion, and neurological abnormalities such as seizures. Th e symptoms must occur imm ediately aft er the trauma or aft er recovering consciousness, and past the acute postinjury period. According to the Centers for In older adults, falls are the most common cause of TBIs. People undergoing mild TBI may experience a related condition known as post-concussion syndrome (PCS). Copyright © 2014 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education

Neurocognitive Disorders due to Another General Medical Condition Previously referred to as amnesia Amnesia is the inability to recall information that was previously learned or to register new memories. Can result from a wide variety of medical problems, including: Head trauma Loss of oxygen herpes simplex Copyright © 2014 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education

Substance-Induced neurocognitive disorder Medications Illicit drugs Lead Mercury Insecticides Industrial solvents The most common cause: Chronic alcohol use Memory loss must persist over time for the clinician to assign the diagnosis of amnestic disorder. Copyright © 2014 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education

Biopsychosocial Perspective No viable treatment for Alzheimer’s disease Computer networks - Innovative, high-technology methods for reducing the stress placed on caregivers Traditional approach – Emotional support Cognitive-behavioral Copyright © 2014 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education

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