Updated: 8/21/2020

Major Neurocognitive Disorder

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Snapshot
  • A 67-year-old man is brought to the clinic by his daughter, who is concerned by his inability to take care of himself in the past few years. The daughter reports that about 2-3 years ago, she and her siblings noticed that he was having trouble recalling events from their family trips and frequently forgot names of relatives and friends. In the past year, the patient has been struggling to manage his finances, cook, or maintain his house. The daughter recently moved her father into her own house to ensure that he would have supervision and help with his daily activities. Upon questioning, the patient is able to state his first and last name, but appears confused when asked where he is.
Introduction
  • Overview
    • major neurocognitive disorder (formerly called dementia under the DSM-IV) is characterized by impairments in memory, speech, comprehension and reasoning, and spatial-temporal awareness
  • Epidemiology
    • prevalence
      • 12-20% of individuals ≥ 65 years of age in the US
    • demographics
      • most common in individuals ≥ 60 years of age
      • more common in African-Americans than Caucasians
  • Pathophysiology
    • causative etiologies include:
      • neurodegenerative brain diseases
        • Alzheimer disease
          • > 50% of cases of major neurocognitive disorder
        • Parkinson disease
        • frontotemporal dementia
        • dementia with Lewy bodies
        • Huntington disease
      • cerebrovascular disease
        • ~20% of cases of major neurocognitive disorder
      • hypoxic brain damage
      • Wilson disease
      • syphilis
      • progressive multifocal leukoencephalopathy
      • HIV
      • Creutzfeldt-Jakob disease
  • Prognosis
    • memory impairment progressively worsens
    • patients may require assistance with activities of daily living (ADLs), such as dressing, bathing, and using the bathroom
    • feeding difficulties may require placement of a permanent gastrointestinal tube
    • time from diagnosis to death may vary from 3-10+ years
Presentation
  • Symptoms
    • memory loss
    • gradual, progressive cognitive impairment
      • aphasia
      • apraxia
      • agnosia
      • loss of abstract thought
      • impaired judgment
    • behavioral/personality changes
    • no change in level of consciousness
  • Physical exam
    • Mini-Mental State Examination (MMSE)
      • 20–24 points
        • mild level of major neurocognitive disorder
      • 13–20 points
        • moderate level of major neurocognitive disorder
      • < 13 points 
        • advanced level ofmajor neurocognitive disorder
    • Montreal Cognitive Assessment (MoCA)
      • 18–25 points 
        • mild cognitive impairment
      • 10–17 points
        • moderate cognitive impairment
      • < 10 points
        • severe cognitive impairment
Imaging
  • Noncontrast head CT or MRI
    • detect reversible causes of dementia (e.g., tumor and hematoma)
Studies
  • Laboratory studies
    • vitamin B12
    • thyroid hormone levels
Differential
  • Normal aging
    • key distinguishing factor
      • independence in daily activities is preserved
  • Major depressive disorder
    • key distinguishing factor
      • cognitive deficits manifest after mood symptoms
      • cognition improves after effective antidepressant therapy
Treatment
  • Lifestyle
    • cognitive stimulation techniques
      • image recognition practice
      • arithmetic practice
  • Medical
    • cholinesterase inhibitors (e.g., donepezil, rivastigmine, and galantamine)
      • first-line treatment for Alzheimer disease and vascular dementia
    • memantine
      • moderate to advanced cases of Alzheimer disease and vascular dementia

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