PSY 6670 Diagnosis & Treatment Planning Lecture 2: Neurocognitive Disorders Treatment Planning Joel Fairbanks, Ph.D.

Epidemiology 35 million Americans over 65 with dementia. Prevalence rate 15% after age 65. Incident rate rises between 70 – 80 years. Prevalence rate 25 % for those 65 – 74 years. Prevalence rate 45 % for those over 80. Over half of all hospitalized elderly mental patients have dementia.

2016 Study of Prevalence Rate for Dementia Rate for Dementia fell from 12 % of the elder population in 2000 to 9% in 2014. That equates to a reduction of 1 Million cases reported per year in 2014.

DSM – IV Diagnoses for Dementia Dementia, Uncomplicated Dementia, with Depression Dementia, with Delusions Dementia, with Delirium

DSM-5 Diagnosis Criteria for Dementia Neurocognitive Disorders (Dementia) is a syndrome due to disease of the brain in which there is a disturbance of multiple higher cortical functions, including Memory, Thinking, Orientation, Comprehension, Calculation, Learning Capacity, Language, and Judgment.

Diagnosis Criteria for Dementia The decline of higher cortical functions interferes with personal activities of Daily Living; such as washing, dressing, eating, personal hygiene, excretory and toilet activities. How such a decline manifests itself will depend largely on the social and cultural setting in which the patient lives.

Types of Dementia Symptoms and presentation Alzheimer’s Type Lewy Bodies Vascular Disease (CVA) Neurological Disorders (e.g. Parkinson’s Dx.) Drug/Alcohol Abuse (Korsakoff’s Dx.) Traumatic Brain Injury (TBI)

Mild vs. Major Neurocognitive Disorder According to the DSM-5, Mild Neurological Disorders differ from Major N.D. in that the cognitive decline and deficits in one or more cognitive domains are modest and Do Not sufficiently interfere with personal activities so as to lose the capacity for independence.

Additional Treatment Concerns Most of these patients will also have significant other medical problems, conditions, or physical disabilities that will challenge their independence and treatment. Substance Use (especially alcohol or prescription medications) is a common comorbid condition that will also need to be addressed.

Differential Diagnosis Delirium (infections or poisons/heavy metals) Autoimmune Diseases Metabolic Disorders Vitamin B1, B12, Niacin, Folic Acid Deficiencies Neoplasms (tumors) Mechanical Disorders (hydrocephalus or hematoma) Psychosis Pseudo-Dementia Normal Aging

Psychosocial Interventions Patient Care: The primary goal is to make the patient as comfortable as possible. The environment should be kept simple and helpful. Clocks, calendars, labels, lists, familiar routines, short-term tasks, brief walks and simple exercise. Family Counseling: Supportive and help to develop Behavioral Interventions for the patient in the home.

Safety Awareness and Planning Removable of risk conditions such as: alcohol use, poor nutrition, exposure to toxins (cleaners), falls, wandering, stoves/ovens, self medication/over medication, and “noncompliance” with medications.

Cognitive Medications Donepezil (Aricept 5 and10 mg) Galantamine (Razadyne 8 – 24 mg) Memantine (Namenda XR 5 – 28 mg) Rivastigmine (Exelon patch 6 – 12 mg)

Pseudobulbar Affect Disorder (PBA) Symptoms include frequent and often inappropriate, excessive, and uncontrollable, crying or laughing outbursts. Nuedexta 20/10 (dextromethorphan 20 mg/ quinidine 10 mg)

Case Study Video : Vivian

Impairments in functioning Treatment Needs Vivian Case Study What are Vivian’s Symptoms Impairments in functioning Treatment Needs Possible Goals for Treatment

What are Vivian’s “Strengths” and available Resources ?

Who else would you consult regarding the care and treatment of Vivian ? Primary Care Physician In-Home medical/nursing services Social Worker or Case Manager Council on Aging State Senior Services Department Meals on Wheels Community Transportation Family or neighbors

If the goal is to maintain Vivian living “independently” in her own home, what would be 3 Objectives (or short-term goals) for at this time ? 1. 2. 3.

Goal 1: Create a safe environment to maintain the patient in the home, living “independently” with her spouse for the next 6 months. 1. Conduct a Home Safety Check (2 weeks) 2. Patient will be complaint with the taking of her daily medications as prescribed by her PHC (6 months) 3. Refer the patient to neurologist to assess her ability to safely operate a motor vehicle (1 month).

What Interventions would you employ?

What Safety Concerns need to be included into her Treatment Plan ?

How would monitor and assess the effectiveness of this Treatment Plan?