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Toronto Notes 2019 Neurocognitive Disorders
Major Neurocognitive Disorder (Dementia)
• seeNeurology,N21
DSM-5 Diagnostic Criteria for Major Neurocognitive Disorder
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, 5th ed. 2013. American Psychiatric Association
A. evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition) based on both:
1. concern of the individual, a knowledgeable informant, or the clinician that there has been a significant decline in cognitive function;
and
2. substantial impairment in cognitive performance, preferably documented by standardized neuropsychological testing or, in its absence, another quantified clinical assessment
B. cognitive deficits interfere with independence in everyday activities (i.e. at a minimum, requiring assistance with complex instrumental activities of daily living such as paying bills or managing medications)
■ Note:ifdeficitsdonotinterfereasinBandimpairmentsaremild-moderateasinA,thisis considered “mild neurocognitive disorder”; see Neurology, N21
C. cognitive deficits do not occur exclusively in the context of a delirium
D. cognitive deficits are not better explained by another mental disorder (e.g. major depressive disorder,
schizophrenia)
E. in the case of neurodegenerative dementias such as Alzheimer’s Disease, disturbances should be of
Psychiatry PS21
insidious onset and progressive Specify whether due to:
Alzheimer’s disease Frontotemporal lobar degeneration Lewy body disease
Vascular disease
Traumatic brain injury
Epidemiology
Normal pressure hydrocephalus Substance/medication use
HIV infection
Prion disease
Parkinson’s disease
Huntington’s disease Another medical condition Multiple etiologies Unspecified
The 4 As of Dementia Amnesia
Aphasia
Apraxia
Agnosia
The “Mini Cog” Rapid Assessment
• 3 word immediate recall
• Clock drawn to “10 past 11” • 3 word delayed recall
Flags for Differentiating Most Common Causes of Dementia
Alzheimer’s disease: predominantly memory and learning issues
Frontotemporal degeneration: language type (early preservation), behavioural type (apathy/ disinhibition/self-neglect)
Lewy body disease: recurrent, soft visual hallucinations (e.g. rabbits), autonomic impairment (falls, hypotension), EPS, does not respond well to pharmacotherapy, fluctuating degree of cognitive impairment
Vascular disease: vascular risk factors, focal neurological signs, abrupt onset, stepwise progression
Normal pressure hydrocephalus: abnormal gait, early incontinence, rapidly progressive
• prevalenceincreaseswithage:5%inpatients>65yrofage;35-50%inpatients>85yrofage • probabilityofdementiainanolderpersonwithreportedmemorylossisestimatedtobe60% • prevalenceisincreasedinpeoplewithDown’ssyndromeandheadtrauma
• Alzheimer’sdiseasecomprises>50%ofcases;vascularcausescompriseapproximately15%
of cases (other causes of dementia neurocognitive disorder – see Neurology, N21) • averagedurationofillnessfromonsetofsymptomstodeathis8-10yr
Subtypes
• withorwithoutbehaviouraldisturbance(e.g.wandering,agitation) • early-onset: <65 yr
• late-onset: >65 yr
Investigations (rule out reversible causes)
• standard“neurocognitivework-up”:seeDelirium,PS19
• asindicated:VDRL,HIV,LP,CXR,EEG,SPECT,headCTorMRI
• indicationsforheadimaging:sameasfordelirium,plus:age<60,rapidonset(unexplaineddeclinein
cognition or function over 1-2 mo), dementia of relatively short duration (<2 yr), recent significant head trauma, unexplained neurological symptoms (new onset of severe headache/seizures)
Management
• seeNeurology,N21forfurthermanagement
• treatunderlyingmedicalproblemsandpreventnewones
• provideorientationcuesforpatient(e.g.clock,calendar)
• provideeducationandsupportforpatientandfamily(e.g.dayprograms,respitecare,supportgroups,
home care)
• considerpowerofattorney/livingwillandlong-termcareplan(nursinghome) • informMinistryofTransportationaboutpatient’sinabilitytodrivesafely
• considerpharmacologicaltherapy
■ cholinesterase inhibitors (donepezil [Aricept®], rivastigmine, galantamine) for mild to severe disease ■ NMDA receptor antagonist (memantine) for moderate to severe disease
■ low-dose antipsychotics (e.g. risperidone, quetiapine), SSRIs or trazodone if behavioural or
emotional symptoms prominent – start low and go slow ■ reassess pharmacological therapy every 3 mo