Neurocognitive Disorders (Dementia)
Jill C. Cash
Definition
A.Neurocognitive disorders are characterized by deficits in cognitive function, with a significant decline from a previous level of function. Decline may be evident in one or more areas of function, including attention, language, memory, visuospatial skills, or executive function (complex tasks such as organizing, sequencing, judgment, and reasoning).
B.Neurocognitive disorders include Alzheimer’s disease (AD), vascular dementia, Lewy body dementia, and other dementias (frontotemporal dementia, Parkinson’s dementia, HIV dementia, neurosyphilis, and Korsakoff dementia).
C.Clinical features that differentiate these disorders:
1.AD:
a.Gradual onset and a course of progressive decline.
b.Memory, language, and visuospatial deficits.
c.Depressive symptoms, which may precede diagnosis.
d.Delusions, hallucinations, agitation, and apathy.
2.Vascular dementia:
a.Abrupt onset and a stepwise course of progression.
b.Aphasia.
3.Lewy body dementia:
a.Visual hallucinations and delusions.
b.Extrapyramidal symptoms (muscle rigidity, parkinsonism).
c.Fluctuating mental status.
d.Increased sensitivity to antipsychotic medications.
4.Frontotemporal dementia:
a.Change in personality.
b.Hyperorality.
c.Impairment in executive function, with relatively well-retained visuospatial skills.
d.Loss of social awareness.
D.The diagnosis of dementia must be differentiated from delirium, a disturbance in cognition that develops over a short period of time and is characterized by an alteration in attention that fluctuates in severity during the course of the day. Delirium may be the consequence of an acute medical condition, hospitalization, or medication-/substance-induced. Delirium typically may last weeks to months, with gradual improvement in cognition.
Incidence
A.Dementia is present in 1% to 2% of persons aged 65 years, and up to 30% of those 85 years and older have a neurocognitive disorder. AD is the most commonly occurring dementia (60%–70%), with the other cases due to mixed causes (30%), such as multiinfarct or vascular dementia. Alzheimer’s accounts for more than 50% of nursing home admissions and is the condition most feared by aging adults. The Alzheimer’s Association reports more than 5 million Americans have AD. One in three senior adults will die with a diagnosis of AD or another form of dementia. The incidence is higher in women, with almost two thirds of persons with AD being female.
Pathogenesis
The following includes the pathogenesis of each type of dementia:
A.AD:
1.Cortical atrophy is most prominent in the temporal and hippocampal regions of the brain.
2.There is extracellular deposition of beta-amyloid protein.
3.Intracellular neurofibrillary tangles contribute to neuronal loss; tau proteins are a major component.
4.Decreased levels of acetylcholine.
5.The Apo E epsilon 4 allele of chromosome 19 has been associated with familial and late-onset AD.
B.Vascular dementia:
1.Microvascular changes of the brain.
2.Cortical and subcortical infarctions.
C.Lewy body dementia:
1.Extensive cortical neuritic plaques.
2.Presence of Lewy bodies (intraplasmic spherical neuronal inclusion bodies) in the brainstem, cortex, and neocortex.
D.Frontotemporal dementia:
1.Atrophy of the frontal and temporal regions of the brain.
E.A number of diseases alter cerebral metabolism resulting in dementia, such as Huntington’s chorea and Parkinson’s disease (PD). A variety of diseases that can produce or mimic dementia may be arrested or reversed. These are classified as pseudodementia, such as hypothyroidism or depression.
Predisposing Factors
A.Definite risks:
1.Advanced age.
2.Atrial fibrillation (AFib).
3.Depression.
4.Family history.
5.Down syndrome.
B.Possible risks:
1.Delirium.
2.Head trauma.
3.Heavy smoking.
Common Complaints
Interview the patient, family members, and/or friends/caretakers who spend quality time with the patient to assess for social, neurological, and cognitive changes experienced by the patient:
A.Memory impairment.
B.Change in behavior and inability to perform normal activities of self-care.
Other Signs and Symptoms
A.Disoriented to date and/or place.
B.Naming difficulties (anomia).
C.Impaired recent recall.
D.Decreased insight.
E.Impaired judgment.
F.Social withdrawal.
G.Problems managing finances; inability to pay bills and to balance checkbook; spending money in unusual ways.
H.Getting lost in familiar environments.
I.Lack of safety awareness; leaving the stove on, taking medications incorrectly, increased vulnerability to strangers.
Subjective Data
A.Elicit onset and duration of symptoms; commonly, this information comes from family members.
B.Question the family members and/or caregivers regarding personality changes in the patient or any changes in personal hygiene.
C.Review the patient’s history, including history for sexually transmitted infections.
D.Review medications, specifically those medications with anticholinergic side effects, including over-the-counter (OTC) products such as diphenhydramine
E.Is there a loss of interest in things the patient used to find important?
F.Evaluate the patient’s history for any recent major life events such as the death of a spouse, a move to a new living environment, or loss of purpose following retirement.
Examination
A.Evaluate blood pressure (BP), pulse, respirations, and weight.
B.Inspect:
1.Observe general appearance; note grooming, interest in conversation, and apathy.
2.Note the presence of slurred speech and slowed body movements.
3.Inspect the nail beds and mucous membranes for anemia.
C.Auscultate:
1.Auscultate heart, lungs, and abdomen.
D.Palpate: Palpate the thyroid.
E.Neurological exam:
1.Perform a complete neurologic exam, including cranial nerves (CNs), gait, motor function, and cerebellar function.
2.Note facial asymmetry, distal weakness, and any focal neurologic findings.
3.Complete mental status exam with instrument of choice: See section Diagnostic Tests.
4.Assess functional status. May use a functional assessment tool such as the Physical Self-Maintenance Scale, Instrumental Activities of Daily Living (IADL) Scale, or Reisberg Functional Assessment Staging (FAST) Scale. Available at www.pbm.va.gov/PBM/clinicalguidance/drugmonitoring/FunctionalAssessmentStagingFAST73108.doc
5.Complete depression screening with instrument of choice:
a.Geriatric Depression Scale. Available at www.consultgeri.org/try-this/general-assessment/issue-4.pdf.
b.Patient Health Questionnaire (PHQ-9). Available at www.phqscreeners.com.
c.Beck depression scale. Available at www.bmc.org/Documents/Beck-Depression-Inventory-BDI.pdf.
Diagnostic Tests
A.Mini-Mental State Examination (MMSE). Available at www.uml.edu/docs/Mini%20Mental%20State%20Exam_tcm18-169319.pdf.
B.Pfeiffer’s Short, Portable, Mental Status Questionnaire or other mental examination of choice. Pfeiffer’s mental status questionnaire is available at geriatrics.stanford.edu/culturemed/overview/assessment/assessment_toolkit/spmsq.html.
C.The clock-draw test (CDT) may also be administered and used as a screening tool. The clock-draw test (CDT) is available at www.ohsu.edu/xd/outreach/oregon-rural-health/about/rural-health-conference/upload/clock_drawing_test-mini-cog.pdf (see Section II: Procedures).
B.Rule out possible reversible causes of dementia; not all are required, so use discretion:
1.Thyroid function tests, to rule out either hypothyroidism or hyperthyroidism.
2.Complete blood count (CBC).
3.Vitamin B12 level: Anemia or B12 deficiency.
4.Serum chemistry profile: Hyponatremia.
5.Toxicology screen or serum drug screen: Toxicity or intoxication.
6.Venereal disease research laboratory (VDRL), fluorescent treponemal antibody absorption (FTA-ABS), or microhemagglutination assay for antibody to Treponema pallidum (MHA-TP; cerebrospinal fluid [CSF]) to confirm syphilis.
7.HIV-1 antibody titer: AIDS dementia complex.
8.Liver function tests: Liver disease.
9.CT scan or MRI: Vascular dementia, tumor, chronic subdural hematomas (SDHs), normal pressure hydrocephalus (NPH), and AIDS dementia complex.
10.ECG: Creutzfeldt–Jakob disease.
11.Neuropsychological evaluation.
The history is the key to diagnosis of dementia. The physical exam may be normal. Dementia is not a normal part of aging; normal aging intelligence scores decrease by only about 10% by age 80. A thorough search for a potentially reversible cause is required.
Differential Diagnoses
A.Completely reversible dementia, rarely.
B.Depression and adverse reactions to medications are the most common reversible causes of dementia. Use the DEMENTIA pneumonic:
D: Drugs or depression.
E: Emotional upset.
M: Metabolic, for example, vitamin B12 deficiency or hypothyroidism.
E: Ear or eye impairment or sensory impairment.
N: NPH.
T: Tumors or masses, for example, subdural hematomas (SDHs).
I: Infection or sepsis.
A: Anemia.
C.AD.
D.Dementia with Lewy bodies.
E.PD with dementia.
F.Vascular dementia.
G.Frontotemporal dementia.
Plan
A.General interventions:
1.The goal is to treat identifiable abnormalities.
2.Educate family and patient regarding the diagnosis, disease process, and progression.
3.Encourage healthy behaviors including regular exercise, healthy diet, and stress management.
4.Maintain brain function through involvement in stimulating social activities.
5.Consider driving evaluation if the patient is still driving.
6.Recommend the use of a safe-return bracelet.
7.Evaluate the home for safety features.
8.Arrange for supportive care for the family and patient.
9.Information on support groups for the caregiver and family is very helpful.
10.See section Alzheimer’s Disease
for treatment and care for families needing legal and/or financial assistance. Discuss advance directives and planning for future care needs.
B. 
See Section III: Patient Teaching Guide Dementia
:
1.Educate regarding the diagnosis, disease process, and progression.
2.Discuss advance directives and planning for future care needs.
3.Encourage patient and family caregivers to become involved in dementia support groups.
4.Consider driving evaluation, if patient is still driving.
5.Recommend the use of a safe-return bracelet.
6.Evaluate the home for safety features.
7.Avoid medications such as anticholinergic medications, including diphenhydramine, hydroxyzine, tricyclic antidepressants (TCAs), and oxybutynin.
8.Recommended handbooks for the family include the following: