1. Other Cognitive Disorders in Older Adults
The development of this learning module was made possible through a
Gero Innovations Grant from the CSWE Gero-Ed Center’s Master’s
Advanced Curriculum (MAC) Project and the
John A. Hartford Foundation.
Dementia and
Other Cognitive Disorders in Older Adults
Funded by Master’s Advanced Curriculum Project University of Texas at Arlington

2. Selective Glossary/Abbreviations
Etiology - Causes of a condition
Symptoms - Characteristics of a condition
Prognosis - Expected outcome of a condition
Soft signs - Observable indicators of neurological deficits
R/O - Abbreviation for “rule out”
NOS - Abbreviation for “not otherwise specified”
ADL - Abbreviation for “activities of daily living”
DSM-IV – Diagnostic and Statistical Manual - 4th Edition 2

3. Shared Features of the Cognitive Disorders DSM Class
These disorders constitute a “clinically significant deficit in cognition [that is] a significant change from a previous level of functioning” (DSM-IV-TR, p.135).
Etiology is either a general medical condition (GMC), a substance, or combination.

4. Disorder Characteristics
Delirium - A disturbance of consciousness and change in cognition over a short period of time.
Dementia - Multiple cognitive deficits including memory impairment.
Amnestic disorder - Memory impairment in the absence or other significant accompanying cognitive impairments.

5. Cognitive Disorders Delirium due to a GMC 293.0 Delirium NOS 780.09
Dementia - Alzheimer’s Type or due to GMC x
Vascular Dementia x
Dementia NOS
Amnestic Disorder due to a GMC
Amnestic Disorder NOS
Cognitive Disorder NOS
Substance-induced Delirium Subs use code
Substance-induced Persisting Dementia Subs use code
Substance-induced Persisting Amnestic Disorder Subs use code

6. Prevalence and Incidence of Dementia
DSM-IV-TR (2000, p. 156) reports increasing prevalence with increasing age, with a lifetime prevalence of 16-25% for adults >85 years (11% males; 14% females); 40-60% of prevalence rates are moderate-severe.
Clinical Evidence/BMJ (2004) reports lifetime prevalence of some form of dementia at 30% for those who reach age 90, with vascular and Alzheimer’s (AD) each accounting for % of all dementia cases.
According to the Alzheimer's Association the number for AD: million in 2006; may quadruple by They estimate the incidence to double every 5.5 years; incidence of 835 out of 3838 pop. Sample
Estimated lifetime cost of care for a person with AD = $174,000
Retrieved from the Alzheimer’s Association website:
Warner, J., Butler, R., & Arya, P. (2004). Dementia. Clinical
Evidence Mental Health (11),

7. Dementia Subtypes Classification by Age of Onset
with Early Onset (≤65 years old)
with Late Onset (>65 years old)
Classification by
without Behavioral Disturbance
(cognitive impairment only)
with Behavioral Disturbance
(wandering, agitation, foul language, aggression, disrobing/exposure, sexual acting out)
Other prominent features may be coded on Axis I, such as Personality Change due to Alzheimer’s Disease, Aggressive Type 310.1
DSM-IV-TR, p.155
These subtypes can apply to any of the dementia disorders.

8. Dementia of the Alzheimer’s Type
Few RCTs and meta-analyses are conducted for people with types of dementia other than Alzheimer’s disease.
Symptoms include progressive memory impairment, aphasia (language deterioration), apraxia (motor impairment despite intact motor abilities), agnosia (failure to recognize objects), and executive function deficits.
First described as a distinct disorder in the early 1900’s by German psychiatrist and pathologist Alois Alzheimer, who treated and researched an early onset case from onset to death over about a 4 year period.

9. Slowly Progressive Stages of Dementia of the Alzheimer’s Type
No observable impairment, but loss of 3-4 points per year on standardized instrument such as the Mini-Mental State Exam (MMSE).
Very mild decline, with early deficits in recent memory; if bilingual, may gradually revert to language of origin.
Mild decline, with increased irritability/personality change beginning and partial aphasia, apraxia, agnosia after several years, with progression.
Moderate decline (early stage identifiable AD)
Moderately severe decline (mid-stage AD), with more pronounced behavioral/personality changes; may be postponed (average of 7 yrs.) if responsive to medication.
Severe decline (still considered mid-stage)
Very severe decline (late stage AD), with pronounced gait/motor disturbance (risk of falls), eventually mute and bedridden.
Retrieved from Alzheimer’s Association website: http.//

10. Differential Diagnosis
In specifying the clinical condition, first consider and rule out conditions in other categories, such as the psychoses and organic brain syndromes.
Then screen for and distinguish this person’s symptoms from those for other disorders in the same Cognitive Disorder class.

11. Differential Diagnosis for AD
Rule Out (R/O) Mental Retardation
R/O normal Age-Related Cognitive Decline
R/O Factitious Disorder/Malingering
R/O Schizophrenia
R/O Major Depressive Disorder
R/O Other Cognitive Disorders
R/O Substance-Induced Acute or Persistent Dementia
R/O Systemic Conditions Known to Cause Dementia: B12/folic acid/niacin deficiency, hypothyroidism, hypercalcemia, HIV, neurosyphilis.

12. Differential Diagnosis for AD, cont.
No one diagnostic test currently available until autopsy.
CT and FMRI scans show larger cerebral ventricles and wider cortical sulci than in normal aging.
Genetic correlates
MMSE will show 3-4 point decline annually (score > 24 points is “normal”).

13. Differential Diagnosis for Vascular Dementia
Etiology: Multiple strokes at different times, pre-existing vascular disease/hypertension (coded on Axis III).
Onset usually abrupt with fluctuating course of rapid changes in functioning.
Variable pattern of cognitive deficits.

14. Subtypes of Vascular Dementia
With Delirium
With Delusions
With Depressed Mood
Uncomplicated

15. Specifier of Vascular Dementia
Uncoded: With Behavioral Disturbance (wandering, etc., as in AD)

16. Differential Diagnosis for Dementias due to General Medical Condition (GMC)
Establish presence of a GMC by history, physical exam, lab results.
Assess for delirium (MMSE useful) to verify that deficits do not occur exclusively during the course of a delirium.
Common GMCs re: HIV, head trauma, Parkinson’s (Lewy body dementia), Huntington’s/Pick’s (frontotemporal dementia), Creutzfeldt-Jakob Disease
Can occur in children with these GMCs, presenting as significant delay or deviation in development; decreased school performance may be an early sign.

17. Subtypes for Dementia due to GMC
Without Behavioral Disturbance
With Behavioral Disturbance
(as in AD)

18. What Does It Look Like?
Challenges of daily living: Safety, memory enhancement, support for activities of daily living (ADL - hygiene, diet, etc.).
Common issues for caregivers:
As with other chronic mental disorders, caregiving for persons with dementia contributes to psychiatric/physical illness and increased mortality risk.
Higher levels of behavioral disturbance may pose safety risks for caregivers/other family members.
Spouse caregivers are aging as person with dementia’s health status is deteriorating.
Policy applications: Increased need for long-term care insurance, benefits or programs to cover personal care aides in earlier stages of the condition, multi-level housing.
Schulz, R. & Beach, S.R. (1999). Caregiving as a risk factor for mortality: The Caregiver Health Effects Study. Journal of the American Medical Association, 282,

19. Evidence-Based Treatments
Beneficial for cognitive symptoms in adults:
Memory medications:
Donepezil and
Galantamine
Warner, J., Butler, R., & Arya, P. (2004). Dementia. Clinical Evidence Mental Health, (11),

20. Evidence-Based Treatments
Likely to be beneficial for cognitive symptoms:
Ginkgo biloba
Memantine
Reality orientation
Likely to be beneficial for behavioral symptoms. management and health status:
Disease management training and intensive case management for caregivers documented by one Randomized Control Trial (RCT)
Warner, J., Butler, R., & Arya, P. (2004). Dementia. Clinical Evidence Mental Health (11),
Vickrey, B., et al. (2006). The effect of a disease management program on quality and outcomes of dementia care: A randomized controlled trial. Annals of Internal Medicine, 145,
Reality orientation involves presenting info designed to reorient a person in time, place, or person. Range in intensity (e.g., poster/chalkboard giving details of day, date, season, to staff reorienting a patient at each contact. In early stages of AD, patients have been observed to self-administer reality orientation by consuming caffeine followed by careful attention and memorization of the front page of a newspaper.
Disease management intervention consisted of up to 5 training sessions for patient-caregiver dyads on disease management in an outpatient hospital-based clinic setting, with at least 2 in-home sessions and multiple telephone sessions which were conducted by social worker care managers utilizing technology enhanced care plans (specialized computer software-based) to provide support and monitor care according to standardized protocols.

21. Evidence-Based Treatments
Likely to be beneficial for behavioral and psychological symptoms:
Carbamazepine
Reality orientation
Trade off between benefits and harm for behavioral and psychological symptoms:
Haloperidol
Olanzapine
Risperidone
Warner, J., Butler, R., & Arya, P. (2004). Dementia. Clinical Evidence Mental Health, 11, .

22. Evidence-Based Treatments
For caregivers, likely to be beneficial for quality of life:
REACH* II multi-faceted community- based intervention, including enhanced communication technology (1 RCT)
*REACH = Resources for Enhancing Alzheimer’s Caregiver Health
Belle, S. et al. (2006). Enhancing the quality of life of dementia caregivers from different ethnic or racial groups: A randomized controlled trial. Annals of Internal Medicine, 145,
REACH II multi-site study tested a 12-session (9 in-home and 3 telephone intervention) + 5 telephone support group sessions lasting 6 months, which included individualized psychoeducational interventions, health education, CBT interventions, and creation of technology-supported telephone peer support groups. Communications technology included computer-integrated telephones with display screens to facilitate support group conference calls.

23. Evidence-Based Treatments
For caregivers, unknown effectiveness:
Caregiver support group
Educational interventions (how to prevent falls; how to provide safe, supportive environment; how to provide appropriate activities and routine; how to locate peer groups for support and recreation for person with dementia and caregiver)
Respite care (adult day care, home health aide, family care/domiciliary care home, temporary stay in assisted living facility)
Individual and family counseling