Neurocognitive disorders

By:
Ivan Wudexi
Reza Syahputra
Smitha Dhiya
Siti Syamsu Lausiri
 History
Organic mental disorder (DSM-IIII-TR)
Cognitive disorders (DSM-IV-TR)
Neurocognitive disorders (DSM-V-TR)
Functional vs organic is there any diagnosis
without organic contributions?
Structural vs functional
Delirium, dementia and amnestic disorder
combined as they share similar manifestations
in a decline of cognitive function
 Definition
Cognitive disorders are acquired which leads to
impaired cognition has not been present since birth or
very early life, and thus represents a decline from a
previously attained level of functioning
They result from primary or secondary abnormalities of
the CNS.
Three main categories of cognitive disorders are:
Dementia
Delirium
Amnestic Disorders

First aid for the psychiatry clerkship

 Complex
attention

Executive
Language
functioning

Cognitive
domains

Learning
Perceptual-
and
motor
memory

Social
cognition
Dementia
 Dementia
An impairment of memory and other cognitive
functions without alteration in the level of
consciousness.
Most forms of dementia are progressive and
irreversible
Major cause of disability in the elderly
Affects memory, cognition, language skills,
behavior and personality
First aid for the psychiatry clerkship
 Epidemiology of dementia
Incidence increases with age
20% of people >age 80 have a severe form of
dementia
Associations:
delusions and hallucinations occur in 30% of
demented patients
Affective symptoms, including depression and
anxiety in 40-50% of patients
Personality changes are also common
First aid for the psychiatry clerkship
 Etiology of dementia
Most common causes of dementia:
1. Alzheimers disease (50-60%)
2. Vascular dementia (10-20%)
3. Major depression (pseudodementia)

First aid for the psychiatry clerkship

 Psychiatric
Depression (pseudodementia)
Delirium
Schizophrenia
Malingering
 Clinical features of dementia
Memory impairment
History of personality change, forgetfulness, social withdrawal,
lability of affect, disinhibition,silliness, diminished self-care, apathy,
fatigue, deteriorating executive functioning.
Hallucinations and delusions often paranoid (20-40%) and poorly
systematized.
Anxiety and/or depression in 50%.
Neurological features (e.g. seizures, focal deficits, primitive reflexes,
pseudobulbar palsy, long-tract signs).
Catastrophic reaction
Pathological emotion spontaneous lability.
Sundowner syndrome as evening approaches confusion increases
and falls become common.

Oxford handbook of psychiatry 1st edition

 Investigations
Investigations Include:
Blood chemistry profiles (glucose, sodium, potassium,
chlorine, bicarbonate, BUN, creatinine)
Fasting blood glucose
CBC with differential
TSH
Cobalamin level
Folate level
ESR, CRP
Urinalysis, urine microscopy and culture
CXR
 Principles of management
Assessment: diagnostic; functional; and social.
Cognitive enhancement: acetylcholinesterase inhibitors (Tacrine;
Donepezil; Rivastigmine); antioxidants (Selegiline, vit E); ? hormonal
(oestrogen; HRT).
Treat psychosis/agitation: antipsychotics (novel agents preferable).
Treat depression/ insomnia: SSRIs; hypnotics.
Treat medical illness.
Psychological support: to both patient and care-givers.
Functional management: maximise mobility; encourage
independence with self-care, toilet, and feeding; assist with
communication.
Social management: accommodation; activities; financial matters;
legal matters (power of attorney, wills, and curatorship).
Delirium
 Delirium
An acute disorder of cognition related to
impairment of cerebral metabolism.
The hallmark of delirium is waxing/waning of
consciousness.
Needs quick and accurate diagnosis as there
is a high mortality rate if untreated.
It can last from hours to days (Acute), or
weeks to months (Persistent)
 Delirium - pathophysiology
The neurotransmitter hypothesis decrease in acetylcholine
activity primarily in the formatio reticularis
Medications anticholinergic
Pars ascendens: thalamus, hypothalamus, cortex
Pars descendens: cerebellum, sensory nerves
 Clinical manifestations
Prodromal: fatigue, anxiety, irritable, sleep disturbance
Consciousness
Attention
Orientation: mild (time) -> severe (place and people)
Language and cognitive
Perception: visual and auditoric hallucinations
Mood: fluctuation
Sleep-wake cycle: agitation, sundowning, reversal
Neurologic deficit: tremor, disfasia, asteriksis, urine
incontinence
 DSM-V TREATMENT CRITERIA
for delirium
A. A disturbance in attention and awareness
B. The disturbance develops over a short period of
time (usually hours to a few days), represents a
change from baseline attention and awareness,
and tends to fluctuate in severity during the day
C. Additional disturbance in cognition
D. Evidence from history, physical exam, laboratory
showing direct physiological consequence of
another medical condition
 Etiology of delirium
Substance intoxication: cannabis,
amphetamine, opioids
Substance withdrawal: Alcohol, opioid
Medication induced delirium: sedatives,
hypnotic, or anxiolytic
Delirium due to another medical condition:
dehydration, malnutrition
Delirium due to multiple etiologies: medical
condition + substance intoxication
 Differential diagnosis
Dementia
Acute stress disorder severely traumatic event
Fluent aphasia (wernickes)
Acute amnestic syndrome
Psychotic disorders/bipolar with psychosis/
depressive disorder with psychosis
Depression hypoactive patients
Malingering: atypical presentation + absence of
medical condition/substance
 Treatment
First and foremost: treat the underlying cause, rule out life-threatening
causes
If cause is by anticholinergic medications phyostigmine 1-2mg IV/IM
and repeat 15-30minutes if needed
Treat symptoms of psychosis and insomnia.
Haloperidol 2-10mg IM repeated one hour later if stiill agitated
Benzodiazepines (short and intermediate acting) for insomnia:
lorazepam 1-2mg or diazepam 10mg before sleep
Avoid fenotiazines have anticholinergic effects
Positive/negative use of benzodiazepines; can cause paradoxical
disinhibition, respiratory depression, increased risk for falls
Frequently reorient patient.
Avoid napping.
Keep lights on, shades open during the day.
Treat drug withdrawal
Amnestic disorders
 Amnestic disorders
Amnestic disorders cause impairment of
memory without other cognitive problems or
altered conciousness.
Always occur secondary to an underlying
medical condition
 Etiology
Hypoglycemia
Systemic illness (such as thiamine deficiency)
Hypoxia
Head trauma
Brain tumor
CVA
Seizures
Multiple sclerosis
Herpes simplex encephalitis
Substance use (alcohol, benzodiazepines, medications)
 treatment
Treatment of underlying cause
Supportive psychotherapy if needed (to help
patients accept their limits
and understand their course of recovery)
 Course and prognosis
Variable depending on underlying medical
cause:
Usually transient with full recovery: Seizures,
medication-induced
Possibly permanent: Hypoxia, head trauma,
herpes simplex encephalitis,
CVA
maturnuwun