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Week 9: Neurocognitive Disorders - Coggle Diagram
Week 9: Neurocognitive Disorders
Understand diagnostic features of neurocognitive disorder (NCD) and identify 3 major types
Definition of Neurocognitive Disorders
Diagnosed on the basis of deficits in cognitive functioning that represent a marked change from the individual's prior level of functioning
How does it arise
When brain is damaged or impaired in its ability to function due to medical or physical disease, or drug use/withdrawal
Neurocognitive disorders are biologically based but are classified under DSM-V as psychopathological conditions
Symptoms presentation are similarly to other psychiatric disorders
Psychological and environmental factors play key roles in determining the impact and range of disabling symptoms
Even when the aetiological basis is largely brain damage in nature, such damage often causes changes in behaviour, mood and personaility
Persons with neurocognitive disorders often experience depression and/or anxiety, rendering depression and anxiety as common comorbidities
Depression or anxiety often accompany diagnosis
Difference in listing in DSM-IV and DSM-V
Delirium, Dementia, and Amnestic and Other Cognitive Disorders were listed in
DSM-IV
but were replaced with the term Neurocognitive disorders in
DSM-V
What are some DSM-V definitions of neurocognitive disorders?
Delirium
Major Neurocognitive Disorder (dementia)
Mild Neurocognitive Disorder (mild cognitive impairment)
What are some types of major or mild neurocognitive disorder (etiological subtypes)
Alzheimer's Disease
Lewy Body Disease
Vascular Disease
Frontotemporal lobar degeneration
Traumatic Brain Injury
HIV Infection
Prion Diseases
Parkinson's disease
Huntington's Disease
Neurocognitive - Psychopathology interaction
Close link between neurocognitive and psychopathological conditions
Definitions of occupations involved in the working field
Neurologists
Physicians who deal with diseases of the brain and the nervous system
May be the first point of contact in the diagnostic process
Psychiatrists
When the neurocognitive disorder results in behavioral or psychological process, psychiatrists are involved
Physicians who may use medical treatments to manage conditions of client's emotions, behavior and personality
Geriatricians
Common for older adults to have a number of medical conditions
Geriatricians may be roped in to manage an array of issues associated with the neurocognitive disorder vis-à-vis other biopsychological issues affecting older adults
How does occupational therapists come in to work with these individuals
Occupational therapists work closely with neurologists, psychiatrists and geriatricians to address functioning/ occupational participation problems as a result of neurocognitive-psychopathological interactions.
This can be done in an inpatient, outpatient or community rehabilitation setting
The neurocognitive-psychopathology interaction must be considered in our treatment with persons with neurocognitive disorders
Due to this interaction, difference medical specialist may be involved in the treatment plan
Neurocognitive Disorder
Degree of cognitive impairment related to degree of brain damage
However, impairment is dependent on
Nature, location, and extent of neural damage
Premorbid competence and personality of individual
Individual's life situation
Damage or destruction of brain tissue may involve only limited behavioral deficits or a wide range of psychological impairments
Different types of brain damage
Diffuse damage
: Where there is widespread damage such as damage from moderate oxygen deprivation, ingestion of mercury etc, which affects various parts of the brain
Focal damage
: Where impairment depends on the part of the brain that is affected, such as damage in the frontal lobe from head injury or stroke
Describe key features and aetiology of delirium, Alzheimer's Disease, Vascular NCD and Lewy Body NCD
1. Delirium
Definition
: State of extreme mental confusion in which persons have difficulty focusing attention, speaking clearly and coherently, and orienting themselves to the environment
Characteristics
It appears to present itself between normal wakefulness and stupor or coma
Hallucinations and delusions are common
Abnormal psychomotor activity and disturbance of the sleep cycle also seen
Rapid onset (usually hours to few days)
Symptoms fluctuates in severity throughout course of day
Delirium is often caused by medical conditions, substance use, exposure to toxin and infection etc.
Meaning of "Delirium"
De: Straying
lira: Line/norm
Therefore delirium refers to the deviating from the norms in areas such perception, cognition and behaviour
Prevalence
1% to 2% in general community and higher among the older age group
14% more than 85 years of age
10% to 51% post-operation cases and among 70 to 87% of those in intensive care
For those in long term residential settings such as nursing homes, the prevalent rate can be around 60% and around 83% at the end-of-life stage
Assessment
(Structured way to detect delirium)
Confusion Assessment Method
Key features of Delirium
Acute onset
Inattention
Disorganized thinking
Altered level of consciousness
Disorientation
Memory impairment
Psychomotor agitation
Altered sleep wake cycle
Perceptual disturbances
Level of severity of Delirium
Mild
Emotion: Apprehension
Cognition and Perception: Confusing, racing thoughts
Behaviour: Motor problems e.g tremors
Autonomic activity: Abnormally fast heartbeat (tachycardia)
Moderate
Emotion: Fear
Cognition and Perception: Disorientation, Delusions
Behaviour: Muscle spasms
Autonomic Activity: Perspiration
Severe
Emotion: Panic
Cognition and Perception: Meaningless mumbling, vivid hallucinations
Behaviour: Seizures
Autonomic Activity: Fever (Febrile)
Aetiology of Delirium
It is largely due to biological causes
Metabolic disorders: electrolyte imbalances, hypoglycemia/hyperglycemia, hypoxia etc
Infections: dehydration, febrile illness in children can also lead to presentation of delirium
Substance abuse (eg alcohol): effects of medication, exposure to toxins etc
Treatment of Delirium
We need to identify the causal factors of delirium and target treatment on the casual factor
eg if the cause was the infection, treating the infection will address the delirium
Phamacotherapy
Neuroleptics: may address some of the distressing symptoms of deliriums
Benzodiazepines: can be used to treat delirium caused by alcohol and drug withdrawals
Environmental adaptation (Non-phamacological intervention)
Good lighting, clear signages, big calendars and clocks for orientation etc
Strategies to help with reinorientation
Providing prompts and giving clear instructions
2. Dementia
DSM-5: The term "Major Neurocognitive Disorders" is used
Presenting problems
Significant decline in mental functioning indicated bt impairment in more than or equal to one cognitive domains
Onset and progression are usually gradual
Not in the context of delirium
Most frequent type of dementia: Alzheimer's Disease
The risk of dementia increases in later life but is not a consequence of aging
Unlike Delirium, dementia is largely irreversible
Consider: Persons with mild dementia cannot participate in social activities: True or false?
Early stage (Mild) Dementia
Strengths and capabilities
Capable of some verbal and behavioural learning
Able to perform basic activities of daily living (e.g showering, grooming and eating) fairly independently
Able to use familiar strategies and can participate in social activities
Therefore: Should harness these strengths and capabilities to continue to provide opportunities for them to use their intact performance skills and participate in various occupations
Possible difficulties
May experience problems with memory and problem solving and may get frustrated and anxious as they notice increasing memory problems
Encounter difficulties in instrumental activities of daily living (community living activities) such as grocery shopping, using public transportation to new places etc
Gradual difficulties in social and work settings
However despite these difficulties we should facilitate hem in assuming their meaningful life roles and responsibilities as much as poissble
Experience frustration and anxiety with increasing memory problems
Therefore do not challenge them about their forgetfulness or mistakes and seek to understand their anxiety and denial of any difficulties
Differences between Delirium and Dementia
Onset
Delirium: Sudden (hours to days)
Dementia: Slow (months to years)
Duration
Delirium: Brief
Dementia: Long/ Lifetime
Course
Delirium: Fluctuating
Dementia: Stable, downward trajectory over time
Thought disorder
Delirium: Circumstantiality and loose associations
Dementia: generally intact
Insight
Delirium: Lucid intervals
Dementia: Gradual deterioration
Sleep
Delirium: Disruption of sleep-wake cycle
Depending on the severity of the delirium, disruption of sleep wake cycle can be very marked.
Dementia: Nocturnal disruption
In dementia, disturbances in sleep may increase as the disease progresses, starting from nocturnal disruption, to sleep fragmentation and excessive daytime sleepiness
3. Alzheimer's Disease
Definition
Insidious onset and is a progressive, irreversible and fatal neurodegenerative disorder
Family history or genetic testing evidence
First degree relatives of someone with Alzheimer's disease have an increased risk of developing the disease
Evidence: on the involvement of genes in the aetiology of this disease
Presenting symptoms of the different stages of Alzheimer's Disease
Early Stage
Short-term memory problems
Subtle personality changes
Problems with executive functioning
Mid stage
Requires assistance in managing instrumental and gradually basic activities of daily living tasks
Advanced stage
Unable to recall address and names of family members
Talking to self, visual hallucinations, persecutory delusions may also occur
Noted that how for Alzheimer's disease the way it presents itself varies across indivdiuals
What is required for accurate diagnosis
Brain-scanning technology of plaques related to Alzheimer's Disease) has been used for diagnostic purpose, along with neuropsychological testing
Video: Recipe: A Film by Eric Khoo (2013)
Owner of rice stall made a mistake in calculating change, which could be one of the instrumental ADLs affected due to dementia in the early stage
Describe pharmacological and rehabilitative interventions for Person's with Alzheimer's Disease and other forms of NCD
The Well-Being of the Singapore Elderly (WiSE Study) 2015
1 in 10 people aged 60 and above have dementia
Education and employment are factors taht affects rates of dementia
Persons with primary school education are 3.6 times more likely to have dementia than tertiary educated persons
Retirees and housewives with dementia are 25 times more prevalent than workers with dementia
Therefore, it appears that being active and cognitively stimulated may be protective factors for dementia
Difference between Mild Neurocognitive Disorders VS Mild Cognitive Impairment
Mild Neurocognitive disorder (NCD) is new term under
DSM-5
The main difference between Mild NCD VS Key International Symposium Criteria of MCI
Construct of MCI: Primarily involves elderly people
Construct of Mild NCD: Includes acquired cognitive disorders of all age groups
Mild Neurocognitive Disorders
The level of cognitive decline requires compensatory strategies and accommodations to help maintain independence and perform activities of daily living
However, it has not reached the severity of dementia or major neurocognitive disorders
Such changes in cognition can be observed by close ones or detected through objective testing
What assessments is used to detect Mild Cognitive Impairment
Using Montreal Cognitive Assessments (Singapore Version) to detect MCI - MOCA assessment
MCI: Cut-off score of 26/27
Mild Alzheimer's Disease: Cut-off score of 24/25
Fewer than 10 years of education: 1 point has to be added to the total score, to adjust for baseline education