Cognitive disorder

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Cognitive disorders (CDs), also known as neurocognitive disorders (NCDs), are a category of mental health disorders that primarily affect cognitive abilities including learning, memory, perception, and problem-solving. Neurocognitive disorders include delirium, mild neurocognitive disorders, and major neurocognitive disorder (previously known as dementia). They are defined by deficits in cognitive ability that are acquired (as opposed to developmental), typically represent decline, and may have an underlying brain pathology. [1] The DSM-5 defines six key domains of cognitive function: executive function, learning and memory, perceptual-motor function, language, complex attention, and social cognition. [2]

Contents

Although Alzheimer's disease accounts for the majority of cases of neurocognitive disorders, there are various medical conditions that affect mental functions such as memory, thinking, and the ability to reason, including frontotemporal degeneration, Huntington's disease, dementia with Lewy bodies, traumatic brain injury (TBI), Parkinson's disease, prion disease, and dementia/neurocognitive issues due to HIV infection. [3] Neurocognitive disorders are diagnosed as mild and major based on the severity of their symptoms. While anxiety disorders, mood disorders, and psychotic disorders can also have an effect on cognitive and memory functions, they are not classified under neurocognitive disorders because loss of cognitive function is not the primary (causal) symptom. [4] [5] Additionally, developmental disorders such as autism typically have a genetic basis and become apparent at birth or early in life as opposed to the acquired nature of neurocognitive disorders.

Causes vary between the different types of disorders but most include damage to the memory portions of the brain. [6] [7] [8] Treatments depend on how the disorder is caused. Medication and therapies are the most common treatments; however, for some types of disorders such as certain types of amnesia, treatments can suppress the symptoms but there is currently no cure. [7] [8]

Classifications

The previous edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) included a section entitled "Delirium, Dementia and Amnestic and Other Cognitive Disorders," which was revised in DSM-5 to the broader "Neurocognitive Disorders." Neurocognitive disorders are described as those with "a significant impairment of cognition or memory that represents a marked deterioration from a previous level of function". [4] The main principle distinguishing neurocognitive disorders from mood disorders and other psychiatric conditions that involve a cognitive component (i.e. increased lapses in memory noted by patients with depression) is that cognitive decline is the "defining characteristic" of the disorder. [2] [5] Additionally, the term "neurocognitive" was added because these disorders most often have alterations/disfunction in neural physiology (i.e. amyloid plaque build-up in Alzheimer disease). [5] The subsections include delirium, mild neurocognitive disorder, and major neurocognitive disorder.

Delirium

Delirium is a type of neurocognitive disorder that develops rapidly over a short period of time. Delirium may be described using many other terms, including: encephalopathy, altered mental status, altered level of consciousness, acute mental status change, and brain failure. It is described in the DSM-5 as a fluctuating acute change in mental status with associated changes in cognition, attention, and level of consciousness. [9] The onset of delirium can vary from minutes to hours and sometimes days. However, the course of the delirium typically lasts from a few hours to weeks, depending on the underlying cause. [4] Delirium can also be accompanied by a shift in attention, mood swings, violent or unordinary behaviors, and hallucinations. Additionally, changes in cognition can makes situational awareness and processing new information very difficult for patients. Delirium is most common in hospitalized patients, appearing in 18-35% of patients requiring hospital admission. [9] It is also a diagnosis which can be acquired during hospital stays, typically by elderly patients or those with risk factors of delirium. While it is a common diagnosis, delirium can increase the risk of a longer hospital stay and the risk of complications throughout the hospital stay. [9] [10]

Mild Neurocognitive Disorder

Mild neurocognitive disorders, also referred to as mild cognitive impairment (MCI), can be thought of as a middle ground between normal aging and major neurocognitive disorder. [11] Unlike delirium, mild neurocognitive disorders tend to develop slowly and are characterized by a progressive memory loss which may or may not progress to major neurocognitive disorder. [11] Studies have shown that between 5-17% of patients with mild cognitive disorder will progress to major neurocognitive disorder each year. [11] [12] The likelihood of developing mild neurocognitive disorder increases with age, affecting 10-20% of adults ages 65 and older. Men also seem to be at a higher risk of developing mild neurocognitive disorder. [13] In addition to memory loss and cognitive impairment, other symptoms include aphasia, apraxia, agnosia, loss of abstract thought, behavioral/personality changes, and impaired judgment.

Major Neurocognitive Disorder

Mild and major neurocognitive disorders are differentiated based on the severity of their symptoms. Also still known as dementia, major neurocognitive disorder is characterized by significant cognitive decline and interference with independence, while mild neurocognitive disorder is characterized by moderate cognitive decline and does not interfere with independence. To be diagnosed, it must not be due to delirium or other mental disorder. They are also usually accompanied by another cognitive dysfunction. [4] For non-reversible causes of dementia such as age, the slow decline of memory and cognition is lifelong. [4]

Diagnostic Methods

There are multiple testing methods used to assess a patient's cognition and level of consciousness, including the Mini Mental Status Exam (MMSE), Montreal Cognitive Assessment (MoCA), Mini-Cog, and Cognitive Assessment Method (CAM), Glasgow Coma Score (GCS), Richmond Agitation and Sedation Scale (RASS), etc. The CAM has been shown to be the most commonly used tool to assess for delirium. [9] [14] [15] Additionally, a meta-analysis looking at the accuracy and usefulness of the various testing methods reported that the MMSE was the most commonly used tool to evaluate major neurocognitive disorder, while the MoCA appeared to be the most useful when screening for minor neurocognitive disorder. [15] More recent systematic reviews have demonstrated the need for further, well designed research on the Mini-Cog and MoCA for evaluating cognitive decline and the development of clinical guidelines on their use in various settings. [16] [17]

Causes

Delirium

There are many causes of delirium, and many times there are multiple factors that can be contributing to delirium, particularly in the hospital setting. Common potential causes of delirium include new or worsening infections (i.e. urinary tract infections, pneumonia, and sepsis), neurological injury/infections (i.e. stroke and meningitis), environmental factors (i.e. immobilization and sleep deprivation), and medication/drug use (i.e. side effects of new medications, drug interactions, and use/withdrawal from recreational drugs). [6] [14] [18] [19]

Mild and major neurocognitive disorder

Neurocognitive disorders can have numerous causes: genetics, brain trauma, stroke, and heart issues. The main causes are neurodegenerative diseases such as Alzheimer's disease, Parkinson's disease, and Huntington's disease because they affect or deteriorate brain functions. [7] Other diseases and conditions that cause NCDs include vascular dementia, frontotemporal degeneration, Lewy body disease, prion disease, normal pressure hydrocephalus, and dementia/neurocognitive issues due to HIV infection. They may also include dementia due to substance abuse or exposure to toxins.

Neurocognitive disorders may also be caused by brain trauma, including concussions and traumatic brain injuries, as well as post-traumatic stress and alcoholism. This is referred to as amnesia, and is characterized by damage to major memory encoding parts of the brain such as the hippocampus. [8] Difficulty creating recent term memories is called anterograde amnesia and is caused by damage to the hippocampus part of the brain, which is a major part of the memory process. [8] Retrograde amnesia is also caused by damage to the hippocampus, but the memories that were encoded or in the process of being encoded in long-term memory are erased [8]

Treatment

Delirium

The overarching principle of delirium treatment is finding and treating the underlying cause. If the patient is truly experiencing delirium, their symptoms should begin improving/resolving with proper treatment of their illness, intoxication, etc. [9] Medication such as antipsychotics or benzodiazepines can help reduce the symptoms for some cases. For alcohol or malnourished cases, vitamin B supplements are recommended and for extreme cases, life-support can be used. [6]

Mild and Major Neurocognitive Disorder

There is no cure for neurocognitive disorder or the diseases that cause it. Antidepressants, antipsychotics, and other medications that help slow the progression of memory loss/behavioral symptoms are available and may help to treat the diseases.[ citation needed ] Ongoing psychotherapy and psychosocial support for patients and families are usually necessary for clear understanding and proper management of the disorder and to maintain a better quality of life for everyone involved; although older patients with major neurocognitive disorders usually require assistance with their daily activities leading to placement in long-term care homes. [20] [21] [22] Speech therapy has been shown to help with language impairment, therefore improving long-term development and academic outcome. [23]

Studies suggest that diets with high Omega 3 content, low in saturated fats and sugars, along with regular exercise can increase the level of brain plasticity. [24] Other studies have shown that mental exercise such a newly developed "computerized brain training programs" can also help build and maintain targeted specific areas of the brain. These studies have been very successful for those diagnosed with schizophrenia and can improve fluid intelligence, the ability to adapt and deal with new problems or challenges the first time encountered, and in young people, it can still be effective in later life. [8]

See also

Related Research Articles

<span class="mw-page-title-main">Dementia</span> Long-term brain disorders causing impaired memory, thinking and behavior

Dementia is the general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities. This typically involves problems with memory, thinking, and behavior. Aside from memory impairment and a disruption in thought patterns, the most common symptoms include emotional problems, difficulties with language, and decreased motivation. The symptoms may be described as occurring in a continuum over several stages. Dementia ultimately has a significant effect on the individual, caregivers, and on social relationships in general. A diagnosis of dementia requires the observation of a change from a person's usual mental functioning and a greater cognitive decline than what is caused by normal aging.

Delirium is a specific state of acute confusion attributable to the direct physiological consequence of a medical condition, effects of a psychoactive substance, or multiple causes, which usually develops over the course of hours to days. As a syndrome, delirium presents with disturbances in attention, awareness, and higher-order cognition. People with delirium may experience other neuropsychiatric disturbances, including changes in psychomotor activity, disrupted sleep-wake cycle, emotional disturbances, disturbances of consciousness, or, altered state of consciousness, as well as perceptual disturbances, although these features are not required for diagnosis.

<span class="mw-page-title-main">Dementia with Lewy bodies</span> Type of progressive dementia

Dementia with Lewy bodies (DLB) is a type of dementia characterized by changes in sleep, behavior, cognition, movement, and regulation of automatic bodily functions. Memory loss is not always an early symptom. The disease worsens over time and is usually diagnosed when cognitive impairment interferes with normal daily functioning. Together with Parkinson's disease dementia, DLB is one of the two Lewy body dementias. It is a common form of dementia, but the prevalence is not known accurately and many diagnoses are missed. The disease was first described by Kenji Kosaka in 1976.

Vascular dementia (VaD) is dementia caused by problems in the blood supply to the brain, resulting from a cerebrovascular disease. Restricted blood supply (ischemia) leads to cell and tissue death in the affected region, known as an infarct. The three types of vascular dementia are subcortical vascular dementia, multi-infarct dementia, and stroke related dementia. Subcortical vascular dementia is brought about by damage to the small blood vessels in the brain. Multi-infarct dementia is brought about by a series of mini-strokes where many regions have been affected. The third type is stroke related where more serious damage may result. Such damage leads to varying levels of cognitive decline. When caused by mini-strokes, the decline in cognition is gradual. When due to a stroke, the cognitive decline can be traced back to the event.

<span class="mw-page-title-main">Neurocognition</span> Cognitive functions related to a brain region

Neurocognitive functions are cognitive functions closely linked to the function of particular areas, neural pathways, or cortical networks in the brain, ultimately served by the substrate of the brain's neurological matrix. Therefore, their understanding is closely linked to the practice of neuropsychology and cognitive neuroscience – two disciplines that broadly seek to understand how the structure and function of the brain relate to cognition and behaviour.

<span class="mw-page-title-main">Donepezil</span> Medication used for dementia

Donepezil, sold under the brand name Aricept among others, is a medication used to treat dementia of the Alzheimer's type. It appears to result in a small benefit in mental function and ability to function. Use, however, has not been shown to change the progression of the disease. Treatment should be stopped if no benefit is seen. It is taken by mouth or via a transdermal patch.

The mini–mental state examination (MMSE) or Folstein test is a 30-point questionnaire that is used extensively in clinical and research settings to measure cognitive impairment. It is commonly used in medicine and allied health to screen for dementia. It is also used to estimate the severity and progression of cognitive impairment and to follow the course of cognitive changes in an individual over time; thus making it an effective way to document an individual's response to treatment. The MMSE's purpose has been not, on its own, to provide a diagnosis for any particular nosological entity.

HIV-associated neurocognitive disorders (HAND) are neurological disorders associated with HIV infection and AIDS. It is a syndrome of progressive deterioration of memory, cognition, behavior, and motor function in HIV-infected individuals during the late stages of the disease, when immunodeficiency is severe. HAND may include neurological disorders of various severity. HIV-associated neurocognitive disorders are associated with a metabolic encephalopathy induced by HIV infection and fueled by immune activation of macrophages and microglia. These cells are actively infected with HIV and secrete neurotoxins of both host and viral origin. The essential features of HIV-associated dementia (HAD) are disabling cognitive impairment accompanied by motor dysfunction, speech problems and behavioral change. Cognitive impairment is characterised by mental slowness, trouble with memory and poor concentration. Motor symptoms include a loss of fine motor control leading to clumsiness, poor balance and tremors. Behavioral changes may include apathy, lethargy and diminished emotional responses and spontaneity. Histopathologically, it is identified by the infiltration of monocytes and macrophages into the central nervous system (CNS), gliosis, pallor of myelin sheaths, abnormalities of dendritic processes and neuronal loss.

Memory disorders are the result of damage to neuroanatomical structures that hinders the storage, retention and recollection of memories. Memory disorders can be progressive, including Alzheimer's disease, or they can be immediate including disorders resulting from head injury.

<span class="mw-page-title-main">Organic brain syndrome</span> Disorder of mental function whose cause is alleged to be known as physiological

Organic brain syndrome, also known as organic brain disease, organic brain damage, organic brain disorder, organic mental syndrome, or organic mental disorder, refers to any syndrome or disorder of mental function whose cause is alleged to be known as organic (physiologic) rather than purely of the mind. These names are older and nearly obsolete general terms from psychiatry, referring to many physical disorders that cause impaired mental function. They are meant to exclude psychiatric disorders. Originally, the term was created to distinguish physical causes of mental impairment from psychiatric disorders, but during the era when this distinction was drawn, not enough was known about brain science for this cause-based classification to be more than educated guesswork labeled with misplaced certainty, which is why it has been deemphasized in current medicine. While mental or behavioural abnormalities related to the dysfunction can be permanent, treating the disease early may prevent permanent damage in addition to fully restoring mental functions. An organic cause to brain dysfunction is suspected when there is no indication of a clearly defined psychiatric or "inorganic" cause, such as a mood disorder.

Clouding of consciousness, also called brain fog or mental fog, occurs when a person is slightly less wakeful or aware than normal. They are not as aware of time or their surroundings and find it difficult to pay attention. People describe this subjective sensation as their mind being "foggy".

Brain training is a program of regular activities purported to maintain or improve one's cognitive abilities. The phrase “cognitive ability” usually refers to components of fluid intelligence such as executive function and working memory. Cognitive training reflects a hypothesis that cognitive abilities can be maintained or improved by exercising the brain, analogous to the way physical fitness is improved by exercising the body. Cognitive training activities can take place in numerous modalities such as cardiovascular fitness training, playing online games or completing cognitive tasks in alignment with a training regimen, playing video games that require visuospatial reasoning, and engaging in novel activities such as dance, art, and music.

Cognitive impairment is an inclusive term to describe any characteristic that acts as a barrier to the cognition process or different areas of cognition. Cognition, also known as cognitive function, refers to the mental processes of how a person gains knowledge, uses existing knowledge, and understands things that are happening around them using their thoughts and senses. A cognitive impairment can be in different domains or aspects of a person's cognitive function including memory, attention span, planning, reasoning, decision-making, language, executive functioning, and visuospatial functioning. The term cognitive impairment covers many different diseases and conditions and may also be symptom or manifestation of a different underlying condition. Examples include impairments in overall intelligence ,specific and restricted impairments in cognitive abilities, neuropsychological impairments, or it may describe drug-induced impairment in cognition and memory. Cognitive impairments may be short-term, progressive or permanent.

Alcohol-related dementia (ARD) is a form of dementia caused by long-term, excessive consumption of alcoholic beverages, resulting in neurological damage and impaired cognitive function.

Mild cognitive impairment (MCI) is a neurocognitive disorder which involves cognitive impairments beyond those expected based on an individual's age and education but which are not significant enough to interfere with instrumental activities of daily living. MCI may occur as a transitional stage between normal aging and dementia, especially Alzheimer's disease. It includes both memory and non-memory impairments. The cause of the disorder remains unclear, as well as both its prevention and treatment, with some 50 percent of people diagnosed with it going on to develop Alzheimer's disease within five years. The diagnosis can also serve as an early indicator for other types of dementia, although MCI may remain stable or even remit.

<span class="mw-page-title-main">Alzheimer's disease</span> Progressive neurodegenerative disease

Alzheimer's disease (AD) is a neurodegenerative disease that usually starts slowly and progressively worsens, and is the cause of 60–70% of cases of dementia. The most common early symptom is difficulty in remembering recent events. As the disease advances, symptoms can include problems with language, disorientation, mood swings, loss of motivation, self-neglect, and behavioral issues. As a person's condition declines, they often withdraw from family and society. Gradually, bodily functions are lost, ultimately leading to death. Although the speed of progression can vary, the typical life expectancy following diagnosis is three to nine years.

Subcortical dementias includes those diseases which predominantly affects the basal ganglia along with features of cognitive decline.

<span class="mw-page-title-main">Type 3 diabetes</span> Medical condition

Type 3 diabetes is a proposed pathological linkage between Alzheimer's disease and certain features of type 1 and type 2 diabetes. Specifically, the term refers to a set of common biochemical and metabolic features seen in the brain in Alzheimer's disease, and in other tissues in diabetes; it may thus be considered a "brain-specific type of diabetes." It was recognized at least as early as 2005 that some features of brain function in Alzheimer's disease mimic those that underlie diabetes. However, the concept of type 3 diabetes is controversial, and as of 2021 it was not an officially recognized diagnosis.

The Addenbrooke's Cognitive Examination (ACE) and its subsequent versions are neuropsychological tests used to identify cognitive impairment in conditions such as dementia.

Geriatric psychology is a subfield of psychology that specializes in the mental and physical health of individuals in the later stages of life. These specialized psychologists study a variety of psychological abilities that deplete as aging occurs such as memory, learning capabilities, and coordination. Geriatric psychologists work with elderly clients to conduct the diagnosis, study, and treatment of certain mental illnesses in a variety of workplace settings. Common areas of practice include loneliness in old age, depression, dementia, Alzheimer's disease, vascular dementia, and Parkinson's disease.

References

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