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Neurocognitive Disorders

Neurocognitive Disorders. Nazar M Mohammad Amin Professor of Psychiatry M B Ch B, D P M, M R C Psych., F R C Psych., F A C P. Neurocognitive Disorders. Neurocognitive disorders in DSM 5 include

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Neurocognitive Disorders

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  1. Neurocognitive Disorders Nazar M Mohammad Amin Professor of Psychiatry M B Ch B, D P M, M R C Psych., F R C Psych., F A C P

  2. Neurocognitive Disorders Neurocognitive disorders in DSM 5 include Delirium and followed by syndromes of Major Neurocognitive Disorder (NCD) and Mild Neurocognitive disorder.

  3. Neurocognitive Disorders Both types of NCD have subtypes NCD due to Alzheimer’s disease, Vasculsar NCD NCD with Lewy bodies NCD due to parkinson’s disease Frontotemporal NCD NCD due to traumatic brain injury NCD due to HIV infection Substance/medication induced NCD

  4. Neurocognitive Disorders NCD due to Huntington’s Disease NCD due to Prion’s disease NCD due to another medical condition NCD due to multiple etiologies Unspecified NCD

  5. Neurocognitive Disorders • Cognitive deficits are present in many mental disorders but only disorders whose core features are cognitive are included in the NCD category. • The cognitive decline was not present from birth or very early in life therefore represent a decline from a previously attained level of functioning.

  6. Neurocognitive DisordersDelirium • Is a disturbance in attention and awareness of the environment, develops over a short period of time( hours to a few days), tends to fluctuate in severity during the course of a day, with additional cognitive disturbance as memory,orientation,language, perception and others, is not due to another neurocognitive disorder or in the context of severely reduced level of arousal such as coma, and there is evidence that disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal or exposure to toxin or is due to multiple etiologies. DSM 5

  7. Neurocognitive DisordersDelirium Clinical features • The cardinal feature is disturbed consciousness as drowsiness, decreased awareness of the surroundings, disorientation and distractibility • There is mental slowness, perceptual abnormalities, and disorganization of sleep wake cycle. • It is worse at night • There is restlessness and hyperactivity or hypoactive with retardation and perseveration.

  8. Neurocognitive DisordersDelirium Clinical features cont • Thinking is slow and muddled . • Ideas of reference, persecutory delusions which are transient and poorly elaborated. • Misinterpretation and illusions, visual hallucinations, tactile and auditory hallucinations. • Anxiety, depression and emotional lability • Depersonalization and derealization • Impaired attention and registration leads to amnesia for the period of the delirium.

  9. Neurocognitive DisordersDelirium Causes of delirium: • Drugs & alcohol intoxication, withdrawal and delirium tremens, opiates, prescribed drugs, Antiochinergics, sedatives, digoxin, diuretics, lithium, and steroids. • Medical conditions, febrile illnesses, septicemia, organ failure( cardiac, renal, hepatic), hyper or hypoglycemia, postoperative hypoxia, Thiamine deficiency

  10. Neurocognitive DisordersDelirium Causes of delirium: cont • Neurological conditions, epileptic seizures or post ictal, head injury, space occupying lesions, encephalitis,cerebralhemorrhage • Constipation, dehydration, pain and sensory deprivation.

  11. Neurocognitive DisordersDelirium Management of delirium It is a medical emergency • The underlying cause must be treated drugs must suspected as a common cause Urgent investigations are necessary General measures to relieve distress, control agitation and prevent exhaustion Frequent explanation, reorientation, and reassurance. • Avoid unnecessary staff changes and encourage relatives to be with the patient, nursing in a quiet single room with adequate lighting

  12. Neurocognitive DisordersDelirium Management of deliriumcont Drug treatment Used to treat the underlying cause, control agitation and distress and allow adequate sleep. • Haloperidol is used and some cases are treated with atypical antipsychotics. Atypical antipsychotics should be avoided in dementia especially with Lewy bodies, and in epilepsy and withdrawal from alcohol (DT). Chlordiazepoxide is used in DTs.

  13. Neurocognitive DisordersDelirium Outcome • Many cases recover rapidly • The outcome is worse in the elderly, preexisting dementia or physical illness. • Delirium in the elderly increases the risk of death in the next two years, institutionalization and risk of dementia.

  14. Neurocognitive Disordersamnesia and amnesic syndromes • Amnesia Is Loss Of Memory For Episodic Memory As Anterograde Amnesia And Retrograde Amnesia. • It Is Associated With Social And Occupational Dysfunction And Evidence Of A General Medical Condition. • Amnesia Occurs In The Absence Of Evidence For Generalized Intellectual Dysfunction.

  15. Neurocognitive Disordersamnesia and amnesic syndromes Causes of amnesia: Transient • Transient global amnesia • Transient epileptic amnesia • Head injury • Alcoholic blackouts • Post ECT • PTSD • Psychogenic fugue • Amnesia for criminal offence

  16. Neurocognitive Disordersamnesia and amnesic syndromes Causes of amnesia: persistent • Korsakov syndrome • Herpes encephalitis • Posterior cerebral artery and thalamic strokes • Head injury

  17. Neurocognitive Disordersamnesia and amnesic syndromes Clinical features • Profound deficit in episodic memory • Disorientation for time • Loss of autobiographical information • Anterograde amnesia for verbal and visual material • Lack of insight • New learning is impaired but retrograde amnesia is partially preserved

  18. Neurocognitive Disordersamnesia and amnesic syndromes Korsakov syndrome also called Wernicke Korsakov Syndrome A syndrome that follows Wernicke’s encephalopathy Delirium, ataxia, pupillary abnormalities, ophthalmoplegia, nystagmus, and peripheral neuropathy

  19. Neurocognitive Disordersamnesia and amnesic syndromes Korsakov syndrome also called Wernicke Korsakov Syndrome • It is due to thiamine deficiency caused by alcohol abuse, hyperemesis gravidarum, severe malnutrition, or due to infarction, tumors or infection There is neuronal loss, gliosis and microhemorrhages in the periaqueductal and periventricular gray matter

  20. Neurocognitive Disordersamnesia and amnesic syndromes Korsakov syndrome also called Wernicke Korsakov Syndrome It is regarded as a medical emergency And diagnosed by decreased red cell transketolase level and increased MRI signal in midline structures Treatment is by replacing the thiamine before administering glucose

  21. Neurocognitive Disordersamnesia and amnesic syndromes Transient global Amnesia • Occurs in middle or late life • There is sudden onset of isolated ,often profound, anterograde amnesia in a clear consciousness ,

  22. Dementia Is an acquired global impairment of intellect, memory, and personality without impairment of consciousness. The main complaint is poor memory. Disturbance of behavior, language, personality, mood or perception.

  23. Dementia • It is often precipitated by intercurrent illness or change in social circumstances. • Amnesia, impaired attention and concentration with difficulty in new learning, the amnesia is for recent events to start with and then involve more remote material.

  24. Dementia • Loss of flexibility and adaptability and if you press the patient who lost this flexibility, there will be sudden explosions of anger or grief(catastrophic reaction). • Self neglect and avoids social engagements. • Disorientation for time and then for place and person.

  25. Dementia • Aimless behavior • Slow thinking with perseveration • False ideas, mostly persecutory • Speech becomes incoherent or mute.

  26. Dementia • Behavioral, affective, and psychotic features accompany the cognitive deficits. • Insight is retained at first but gradually lost. • Depression, anxiety, distress, irritability and aggression occurs. • Later affect becomes blunted. • Hallucinations and delusions could appear too.

  27. Dementia • there are special tools to screen for cognitive impairment such as MMSE (Mini-Mental State Examination). • Diagnosis and finding the cause requires the following investigations: Full blood count and ESR, urea and electrolytes, liver function tests, calcium and phosphate, thyroid function tests, Vitamin B12 and Folate, MRI and CT brain scan, urinalysis, syphilis serology, HIV status, CXR, Neuropsychological assessment, Genetic testing and EEG.

  28. Dementia Risk assessment include: • Self neglect, poor judgment, wandering, abuse, disinhibition, aggression, exploitation by relatives, fitness to drive and aggression toward others.

  29. Dementia Alzheimer’s disease • 60% of dementia is due to Alzheimer disease • 2-7% of the population aged over 65years. • The prevalence increases with increasing age.

  30. DementiaAlzheimer’s disease clinical features Amnesia, gradual and progressive Aphasia Apraxia Agnosia Disturbance in executive functioning e.g. planning and reasoning Depression Psychosis (delusions and hallucinations) behavioural symptoms e.g. agitation and wandering Personality change (reduction in drive, aggression, sexual disinhibition) Median survival from diagnosis is 5-7 years.

  31. DementiaAlzheimer’s disease • Neuropathology • The brain is shrunken, widened sulci, enlarged ventricles, brain weight is reduced. • Neurofibrillary tangles, and senile plaques(amyloid plaques) • There is selective loss of neurons in the hippocampus and entorhinal cortex, gliosis, and loss of synapses. • The protein at the heart of the senile plaques is β amyloid.

  32. DementiaAlzheimer’s disease Aetiology Genes. Most of the cases are not genetically inherited but in rare cases it is familial and causative mutations were identified in three genes, APP(amyloid precursor protein, presenilin1 and presenilin 2. Environmental factors include past history of depression, diabetes mellitus, obesity, aluminum exposure and head injury.

  33. DementiaAlzheimer’s disease NSAIDs, hormone replacement, and statins are protective. Other theories include cholinergic hypothesis based on the loss of acetylcholine in the cerebral cortex. The role of oxidative stress, inflammation, and apoptosis(programmed cell death).

  34. Dementiavascular dementia Is the second commonest cause of dementia. More in men than women, more in Japan, China and Russia. Clinical features: It appears in the late sixties or seventies. Emotional and personality changes appear first followed by impairment of memory and intellect.

  35. Dementiavascular dementia Depression, emotional liability and confusion Behavioral retardation and anxiety Transient Ischemic attacks or mild strokes are common. The course is stepwise with periods of deterioration and partial recovery. They have shorter survival than Alzheimer patients.

  36. Dementiavascular dementia • They have signs of hypertension, arteriosclerosis in the peripheral and retinal vessels and signs of focal neurological deficits. • The etiological factors include the same for cerebrovascular diseases including diabetes, hypertension, hyperhomocysteinaemia. • It is possible to have both Alzheimer's dementia and vascular dementia in the same patient at the same time.

  37. DementiaDementia with Lewy Bodies • Is the second or third most frequent cause of dementia • The cardinal feature is Lewy bodies in the cerebral cortex. • Main clinical features include fluctuating level of dementia, recurrent delirium like phases, parkinsonism and visual hallucinations

  38. DementiaDementia with Lewy Bodies Neuropathology • Presence of Lewy bodies in the cerebral cortex • They are seen in the substantial nigra • Presence of α-synuclein and ubiquitin proteins.

  39. DementiaFrontotemporal Dementias • Is the second most common form of presenile dementia. • Presentation is usually between 45&70 years of age. • Prominence of behavioral rather than cognitive features.

  40. DementiaFrontotemporal Dementias • The frontal form present with behavioral and personality change and the temporal form with language disorder. • There are familial and sporadic cases. • 10%of the cases are autosomal dominant.

  41. DementiaFrontotemporal Dementias • Subtypes include : • Pick’s disease. • Semantic dementia

  42. DementiaFrontotemporal Dementias • On neuroimaging there is focal and asymmetrical atrophy of the temporal and frontal poles. • EEG is usually normal unlike the diffuse slowing in Alzheimer's disease. • Acetylcholine and dopamine are not affected but serotonin markers are reduced.

  43. Thank you

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