2. Chapter outline
• Introduction
• The classification of Neurocognitive
disorders
• History of Neurocognitive disorders
• Delirium
• Neurocognitive Disorders (Dementia)
• Amnestic disorders (ICD-10)
• Assessment of neurocognitive disorders
• Contextual and cross-cultural perspectives
3. Introduction
• Cognition refers to tasks that include:
• memory
• language
• orientation
• judgment
• problem-solving
• planning
• ability to have interpersonal relationships
• praxis (perform actions)
• Cognitive disorder is when regular trouble in
these areas disrupts daily functioning.
• Causes of cognitive disorders include head
injury, medical conditions, substance abuse, and
aging.
7. Classification of Neurocognitive
disorders
• Three groups:
• Delirium,
• Major or Minor Neurocognitive Disorders
(Dementia)
• Amnestic disorders.
• Within Major or Minor Neurocognitive Disorders:
e.g. Alzheimer’s disease, Vascular dementia, Multi-
infarct dementia, Frontotemporal, Creutzfeldt-Jacob
disease (mad cow disease), Huntington’s disease,
Parkinson’s disease, Human Immunodeficiency
Virus (HIV) disease, etc.
8. History of Neurocognitive
disorders
• No longer referred to as organic because name
implies that non-organic disorders or functional
mental disorders (e.g. depression) have no
biological basis.
• ICD-10 still uses the term ‘organic’.
9. Delirium
Clinical picture
• Temporary state of mental confusion, with
fluctuating consciousness.
• Occurs suddenly and is reversible.
• Abnormal mental state, not a disease, often
accompanied by anxiety, disorientation and
incoherent speech.
• Main feature - impairment in consciousness.
• Consciousness ranges from fully alert to comatose.
10. Delirium, cont.
Epidemiology
• General population:
• 18-55 yrs: 0.4%
• 55 yrs +: 1.1%
• Medical inpatients:
• 10%-13% (increasing in the elderly)
• Delirium incidence for new admissions: 3%-29%
• Occurrence rate per admission: 11%-42%
12. Delirium, cont.
Classified according to aetiology
• Delirium due to general medical condition
• Delirium due to misuse/abuse of substances -
Intoxication Delirium/Substance Withdrawal
Delirium
• Delirium due to several causes - Delirium Due to
Multiple Aetiologies
• When aetiology is unknown - diagnosed as Delirium
Not Otherwise Specified
13. Delirium, cont.
Treatment and management
• If associated with underlying physical cause:
• recovery can be expected
• provided physical cause treated correctly
• Recovery can occur in a few hours to days.
• Co-occurring dementia and old age contribute to
longer recovery time.
• Better recovery if:
• underlying aetiology addressed
• premorbid functioning good
• no previous diagnosis of delirium
14. Delirium, cont.
• Most individuals make full recovery.
• Delirium may progress to stupor, coma, seizures, or
death, especially if underlying aetiology not
addressed.
• Environmental interventions:
• limit environmental factors that exacerbate
delirium
• give cognitive and emotional support to re-
orient and reassure patients
• Doctors may also prescribe drugs to control
agitation.
15. Major or Minor Neurocognitive
Disorders (NCD)
• The DSM-IV-TR referred to these disorders as Dementia, and ICD-
10 still uses this description.
• Although the DSM-5 now refers to these disorders as Neurocognitive
Disorders (NCD), the term dementia is still retained to certain extent
(APA, 2013).
• The APA (2013) states that the term dementia is a customary
description of degenerative disorders for older adults, however, the
term neurocognitive disorders is more inclusive as it includes
neurocognitive disorders that affect younger people as well (APA,
2013).
• The APA (2013) views these disorders as unique when compared to
the other DSM-5 categories as the underlying pathology and
aetiology can be easily determined.
• The primary diagnosis would be Major or Mild NCD, followed by an
aetiological subtypes (e.g. Alzheimer’s disease, Parkinson’s disease,
HIV infection, etc.)
16. Major or Minor Neurocognitive
Disorders
To understand the clinical picture of these disorders, it is necessary
to note which neurocognitive domains are affected. The DSM-5
describes these as follows (APA, 2013):
• Complex attention: Sustained, divided and selective attention as
well as processing speed.
• Executive functioning: Planning, decision making, working
memory error detection and correction, inhibition and mental
flexibility.
• Learning and memory: All memory registers (e.g. short-term,
semantic, autobiographical) and implicit learning.
• Language: Expressive and receptive language.
• Perceptual-motor: This includes visual perception, visuo-
constructional abilities, perceptual-motor, praxis and gnosis.
• Social cognition: Recognition of emotions and theory of mind.
17. NCD
Clinical picture
• Gradual loss of mental abilities resulting in an
inability to complete simple, everyday activities.
• May also lose ability to solve problems, control
emotions and undergo personality change.
• Other symptoms: Hallucinations, agitation, and
memory loss.
• Dementia can be caused by various diseases.
• Common in the elderly - not to be confused with
normal decline in cognitive functioning occurring with
age.
• Memory impairment a core symptom.
• Person unable to learn new things and forgets
things.
18. NCD, cont.
• Deterioration of language function: Aphasia and
echolalia.
• Deterioration of ability to recognise familiar objects
and people.
• Problems with executive functioning associated
with the frontal lobe.
• Spatially disorientated; poor judgement and insight.
• May not be aware of memory loss and cognitive
deterioration and may do irrational things.
• Demonstrate inappropriate behaviour or become
violent towards others.
• Depression and suicide common.
• Physical injuries resulting from motor disturbances.
19. NCD, cont.
Epidemiology, cont.
• Prevalence of dementia in Africa lower than rest of
the world.
• Possible reasons for lower rates include:
• differential survival rates
• relatives hiding symptoms due to stigma
• reluctance to seek medical assistance
• poor access to medical care
• feeling old person come to end of useful life
• defective case finding techniques
• Incomplete statistics of prevalence in developing
societies, but estimate is 6.8%.
• Prevalence of different causes of dementia varies
across cultural groups.
20. NCD, cont.
Aetiology
• Dementias are sub-categorised according to
presumed aetiology, and include:
• Dementia of the Alzheimer’s Type
• Vascular Dementia
• Dementia Due to Other General Medical
Conditions
• Substance-Induced Persisting Dementia
• Dementia Due to Multiple Aetiologies
• Dementia Not Otherwise Specified
21. NCD, cont.
Alzheimer’s Type
• Most common - 50% of all cases.
• Major risk factors are:
• family history
• genetic factors
• head injury
• Onset of Alzheimer’s is subtle - initial memory
impairment and gradual deterioration of
cognitive abilities.
• Pathology is associated with parietal and
temporal regions of the brain.
22. NCD, cont.
Vascular
• Cerebrovascular disease is second most common
cause of dementia.
• Injury or brain disease infarctions (death/damage of
vessels) due to obstruction in blood supply lesions
and changes to brain structures.
• Abrupt onset and fluctuating course.
• Risk factors: Hypertension, diabetes, advanced age,
stroke, alcoholism, cardiovascular risk factors (smoking,
obesity).
• Disorder more common in men.
• Compared to Alzheimer’s Type, more likely to have
depression, affective changes, disturbance of gait, and
confusion.
24. NCD, cont.
Huntington’s disease
• Genetically influenced
degeneration of brain cells.
• Chance of inheritance is
50-50, with inheritance
predicting certain onset.
• Dementia associated with
the disease characterised by
more motor than language
abnormalities. Figure 7.2: MRI image – demonstrates bilateral
atrophy of the head of the caudate nuclei and
compensatory ventricular dilatation of the frontal
horns bilaterally suggestive of Huntington’s
disease
25. NCD, cont.
Picks Disease
Frontotemporal
• Shrinking of the frontal
and temporal regions.
• Most common in men
with first-degree
relatives.
• Leads to prominent
personality and
behavioural changes.
Figure 7.3: CT scan of Pick’s disease
26. NCD, cont.
Lewy body disease
• Round deposits in the cerebral cortex which
contain damaged nerve cells.
• Similar to Alzheimer’s but more rapid.
27. NCD, cont.
Creutzfeldt-Jakob disease
• More commonly known as ‘mad cow disease’.
• Rare disease affecting muscle control, personality
and memory.
• As the illness worsens blindness, involuntary
movements, weakness and, eventually, coma.
✪ See slide show at:
http://reference.medscape.com/features/slideshow/cjd#
28. NCD, cont.
Human Immunodeficiency
Virus (HIV) disease
• Characterised by:
• forgetfulness
• slowness
• poor concentration
• difficulties with problem
solving
• apathy
• social withdrawal
Figure 7.5: HIV particles adhering
to a CD4 lymphocyte
29. NCD, cont.
Head trauma
• Extremely high prevalence in South Africa due to
high incidence of motor vehicle accidents and
violence (see Table 7.5).
• Head injury-related dementia is characterised by
emotional lability, dysarthria (speech impairment)
and impulsivity.
32. NCD, cont.
Treatment and management of NCD
• Condition is often not reversible.
• But, important to know the underlying cause in
order to try to reverse or arrest the process.
• Preventative measures, especially in vascular
dementia, can be implemented.
• Those suffering from changes in cognitive function
can benefit from supportive and educational
psychotherapy.
33. Amnestic disorders (ICD-10)
Clinical picture
• Memory impairment in the absence of other
cognitive impairments.
• Characterised by:
• inability to learn new information (anterograde
amnesia) or
• inability to recall knowledge stored from before
onset of disorder (retrograde amnesia)
• Short-term and recent memory are affected.
• Onset can be sudden or gradual.
34. Amnestic disorders, cont.
Classified according to aetiology
• Amnestic Disorder Due to a General Medical
Condition
• Substance-Induced Persisting Amnestic Disorder
• Amnestic Disorder Not Otherwise Specified
Epidemiology
• No adequate studies on incidence and prevalence
of amnestic disorders.
• Probably quite high in SA due to high incidence of
motor vehicle accidents and violence.
35. Amnestic disorders, cont.
Aetiology
• Main brain areas implicated in amnestic disorders:
• temporal lobes
• midline nuclei of the thalamus
• Hippocampus
• mamillary bodies
• amygdala (left more implicated than right).
• Frontal lobe symptoms include confabulation and
apathy.
36. Amnestic disorders, cont.
Aetiology, cont.
• Possible causes of amnestic disorders:
• systemic conditions (such as thiamine or Vitamin B1
deficiency) (e.g. Korsakoff’s syndrome)
• hypoglycaemia (low blood sugar)
• brain-related conditions like hypoxia (low oxygen)
• seizures and epilepsies
• surgical procedures to the brain/head injury
• infections (e.g. herpes simplex encephalitis)
• tumours
• cerebro-vascular diseases
• substance-related conditions (e.g. alcohol,
neurotoxins, sedatives, and over-the-counter-drugs)
• multiple sclerosis
37. Amnestic disorders, cont.
Treatment and management
• Primary approach = treat underlying cause:
• If underlying cause is primary, systemic or cerebral,
can use thiamine, antiretroviral medication, or aspirin.
• Despite variety of pharmaco-therapeutic trials, no
drug treatments have proved effective in amnestic
disorders.
• Rehabilitation for mild cases of amnesia involves
memory techniques and tools.
• Emotional and social support for difficulties in
occupational and social functioning.
• Many people gradually recover; psychotherapy,
counselling help individual adjust to illness and
recovery.
38. Assessment of Neurocognitive
disorders
• Review of clinical notes
• Interview
• Observation
• Screening tests:
• Mini Mental Status Examination (MMSE) to evaluate
cognitive function
• Glasgow Coma Scale (GCS) to quantify the level of
consciousness
• Clock Drawing Test (CDT) to assess cognitive
functioning in psychiatric and neurological settings
• Dementia scales include:
• HIV Dementia Scale (HDS)
• Deterioration Cognitive Observee (DECO)
• Clinical Dementia Scale (CDS)
39. Assessment of Neurocognitive
disorders, cont.
• Scales are filled out by a health practitioner or
caregiver.
• Both the HDS and DECO scales correlate
positively with the MMSE.
• More sophisticated neuropsychological tests may
be administered after screening.
• Other assessments include:
• X-rays
• MRI (Magnetic Resonance Imaging)
• fMRI (Functional Magnetic Resonance Imaging)
• PET (Positron Emission Tomography)
40. Contextual & cross-cultural
perspectives
• Individual or group beliefs influence health
behaviour.
• Beliefs also influence how health-care facilities
are used.
• Important to be aware of cultural and language
differences - can influence diagnosis of cognitive
disorders.
• In SA, evaluation and understanding influenced by:
• past inequalities in education
• lack of facilities and resources
41. Contextual & cross-cultural
perspectives, cont.
• Some cognitive symptoms accounted for by different
indigenous world views:
• Ukuthwasa = calling to be a traditional healer (role =
to help in caring/healing process of the whole person)
• Ukufa kwabantu = ‘illnesses of the people’; not
recognised by the patient as an illness/disease but
as disturbance caused by breaking a taboo or
displeasing an ancestor or due to a spell that has
been cast on the patient:
• Indiki, ufufunyane or izizwe (spirit possession)
• Umnyama (pollution or contamination)
• Ubuthakathi (bewitchment or sorcery)
• Ukuphonsa (curses or spells)
• Umkhondo; umeqo; idliso (some form of poisoning)
42. Contextual & cross-cultural
perspectives, cont.
• All cultures and religions have traditional
explanations for abnormal behaviour.
• Western society relies on technological medicine;
80%-90% from developing societies rely on
traditional healing.
• Being unaware of patient’s cultural background
misdiagnoses and distress for the patient.
• Most neuropsychological and psychological
assessments developed in Western context
may be invalid when used in developing countries.
• Also, individuals from other cultures may not be
familiar with general knowledge used in tests.
43. Conclusion
• Prevalence of cognitive disorders increasing due
to greater longevity (better health, improved diet
and living conditions, etc.).
• Three categories: Delirium; dementia; amnestic
disorders.
• For each, aetiology influences onset, course,
treatment, and outcome of disorder.
• Diagnosis is complex and difficult because of:
• symptom overlap with medical conditions
• beliefs
• cultural and contextual factors
