1. Neurocognitive Disorders of the DSM-5

3. Neurocognitive Disorders
Neurocognitive disorders are a category of mental health disorders that primarily affect learning, memory, perception, and problem solving
Primarily COGNITIVE disorders
Acquired and represent decline
(i.e. not developmental)
Underlying brain pathology

4. Neurocognitive Disorders(NCD)
Delirium
Major Neurocognitive Disorder
Mild Neurocognitive Disorder

5. Delirium

6. Delirium It can last from few days to weeks, and may become chronic.
It is a waxing and waning change in a patient’s level of consciousness.
Many different presentations  Under-Recognized/Diagnosed.
It can be caused by virtually any medical disorder.
If untreated, it has a high morbidity and mortality:
23-33% mortality rate within 3 months
50% mortality rate within 1yr
20-75% mortality rate in elderly during hospitalization
It can last from few days to weeks, and may become chronic.

7. Prevalence of Delirium
0.4% of adults years old
1.1% of 55 years and older
5-15% of patients in general medical or surgical wards
20% burn pts
20-30% in surgical intensive care units
30-40% of hospital pts older than 65
30-40% AIDS pts
80% of pts with terminal illness
90 % of cardiotomy pts

8. Epidimiology 10 – 30% of medically admitted patients exhibit delirium.
Common in:
Elderly patients.
ICU patients.
Post-OP surgery patients.
Cancer patients

9. Risk factors
Advanced age Pre-existing brain damage (Dementia, CVA and tumors) Prior history of delirium Alcohol dependence DM Cancer Sensory impairment or blindness. Malnutrition Male gender

10. Etiology Almost any medical condition can cause delirium.
Most commonly due to:
Infections
Medications
Substance intoxication and withdrawal.
Electrolyte imbalances.

11. AEIOU TIPS
Alcohol / Drug toxicity or withdrawal Electrolyte abnormality Iatrogenic (Anticholinergics, BDZs, Antiepileptic, Anti-hypertensives, Hypoglycemics, narcotics, steroids, H2 receptor blockers, NSAIDS, antibiotics, antiparkinsonians) Oxygen hypoxia Uremic / Hepatic encephalopathy. Trauma Infection Poisons Seizures (Postictal), Stroke.

12. Clinical manifestations
Impairment in recent memory. Disorientation: usually to time and place, rarely to person. Language disturbances: Dysarthria, Dysnomia, Dysgraphia and aphasia. Changes in speech: Slow, pressured, rambling or disorganized. Perceptual disturbances: visual hallucinations. Sleep disturbances: Sun-downing with daytime drowsiness and night-time insomnia and confusion.

14. Disturbed psychomotor behavior: Hyperactivity or Hypoactivity, may shift from one extreme to other over the course of the day. Emotional disturbances. Perseveration: Inability to shift attention appropriately, making conversations difficult.

15. Specify if 1-Substance Intoxication Delirium
2-Substance Withdrawal Delirium
3-Medication-induced delirium(side effect, eg dexamethasone )
4-Delirium due to Multiple Etiologies
5-Delirium due to another medical condition
Specify if:
Acute: Lasting a few hours or days.
Persistent: Lasting weeks or months. Specify if:
Hyperactive , hypo , mixed

16. Treatment Rule out life threatening causes.
Definitive treatment requires the identification and treatment of the underlying conditions.
Supportive care: Hydration and nutrition.
Patient safety:
One-on-one nursing observation.
Frequently orient patient.
Avoid napping and keep lights on or shades open to correct sleep cycle.

17. Psychotropic medications (Symptomatic treatment of delirium):
Haloperidol PO/IM/IV.
BDZs are usually avoided unless delirium is secondary to alcohol or BDZ withdrawal.

18. Delirium Differs from other NCD
Rapid Onset in hours to days
Linked to Medical Condition, Substance Intoxication/Withdrawal, Medications, other causes
May resolve completely
Symptom length:
Acute- hours to days
Persistent-weeks to months

19. Major and Mild Neurocognitive Disorders (NCD)

20. Cognitive domains specified
DSM-5:
Complex attention
Executive function
Learning & memory
Language
Perceptual-motor
Social cognition
DSM-IV:
Memory impairment
Aphasia
Apraxia
Agnosia
Executive dysfunction

27. Major NCD Significant Cognitive Decline Interfere with independence
Not due to delirium
Not due to other mental disorder

28. Mild NCD Moderate Cognitive Decline NOT Interfere with independence
Not due to delirium
Not due to other mental disorder

29. Mild vs Major NCD Cognitive Testing
Mild: 1–2 standard deviation (SD) range (between the 3rd and 16th percentiles)
Major: Below 2 SD or 3rd percentile
These should not be rigidly used! Consider premorbid level, sensitivity of tests etc.

30. Test Scores

31. Test Scores
MILD
MAJOR

32. Other Descriptors Possible vs Probable Behavioral Disturbance:
With: e.g. psychosis, mood, agitation
Without (not clinically significant)
Severity (level of disability)
Mild: Instrumental ADL’s are preserved
Moderate: Basic ADL’s affected
Severe: Fully dependent

33. Neurocognitive Disorders (NCD) vs. Dementia
Dementia typically refers to degenerative d/o in elderly
DSM expands category to d/o of younger
– E.g. HIV, traumatic brain injury

35. Alzheimer disease Epidemiology:
Most common type of dementia (50-70%) and affects 4.5 million in the states.
W:M is 3:1.
Four-fold increased risk if one first degree relative.
Alzheimer disease is common in persons with Down syndrome surviving to middle age.

36. Dr.Alois Alzheimer
Alzheimer is credited with identifying the first published case of "presenile dementia“.

37. Alzheimer disease Epidemiology:
Most common type of dementia (50-70%) and affects 4.5 million in the states.
W:M is 3:1.
Four-fold increased risk if one first degree relative.
Alzheimer disease is common in persons with Down syndrome surviving to middle age.

38. Neurophysiology
These patients have a decrease in Ach due to loss of noradrenergic neurons in the basal ceruleus and decreased Choline acetyltransferase (Required for Ach synthesis).

39. Amyloid cascade hypothesis:
Excess of the Amyloid-beta peptides by overproduction or diminished clearance.
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Most cases especially with onset after 65 years are sporadic.
Genes are accounting for 5% of the cases with usually early onset.

40. Pathogenesis linked to genes
Alzheimer genes:
Presenilin I (Chr.14)
Presenilin II (Chr.1)
APP (Chr.21)
APOe4 (Chr.19)
Homozygous (2%)  50-90% chance after 85.
Heterozygous (15%)  45% chance after 85.
20 % chance in the general population.

41. Clinical manifestations
Gradual and progressive decline in cognitive functions especially language and memory. Personality changes, mood swings and paranoia are very common. Motor and sensory functions are intact until late in the illness. Gradual and progressive course, typically 10 years from Dx to death.

43. Diagnosis
Remains a clinical diagnosis. Neuropsychological testing is helpful. Definitive diagnosis is possible only postmortem.

47. Senile (Neuritic) plaque Directly proportional!

48. Neurofibrillary tangles

49. Treatment
No cure or truly effective treatment. Physical and emotional support, proper nutrition, exercise, and supervision. NMDA receptor antagonists: memantine Cholinesterase inhibitors to help slow progression: Tacrine (Cognex) Donepezil (Aricept) Rivastigmine (Exelon)

50. Thank you