Neurocognitive Disorders: A Review

Course Content

Course Title: Neurocognitive Disorders: A Review
Author: Mallory Antico
Activity Type: Knowledge
CE: 4 contact hours


Learning Objectives

  • Describe the pathophysiology and etiology of mild and major neurocognitive disorders.
  • Understand key elements in person-centered care.
  • Describe cultural considerations in caring for patients with neurocognitive disorders.
  • Explain how social determinants of health impact those with or at risk for neurocognitive disorders.
  • Compare and contrast the differences between mild and major neurocognitive disorders.
  • Describe nursing interventions that can be used to effectively care for patients who have neurocognitive disorders.
  • Describe the treatment of neurocognitive disorders.

Course Overview

Neurocognitive disorders, previously known as dementia, are a group of conditions characterized by significant cognitive decline that interferes with daily functioning (Larson, 2023). This course provides a comprehensive overview of mild and major neurocognitive disorders, including their definitions, diagnostic criteria, etiology, clinical presentation, and management strategies. It explores the impact of these disorders on individuals, families, and society with an emphasis on the role nurses can play in early detection, accurate diagnosis, and appropriate interventions. Delirium is another neurocognitive disorder that shares some clinical features of mild and major neurocognitive disorders, however, it is outside of the scope of this article.


Overview and Key Terms

Mild and Major Cognitive Impairment

Mild cognitive impairment (MCI) and major cognitive impairment, often referred to as dementia, represent different stages of cognitive decline. What differentiates the two is mainly the severity of symptoms and how much those manifestations impact the patient’s everyday life. MCI refers to a noticeable decline in cognitive abilities that is greater than expected for an individual's age and educational background but does not significantly interfere with daily functioning. It is the state in between normal cognition and major cognitive impairment. Not all individuals with MCI will progress to major neurocognitive disorders, but they have a higher risk compared to those without MCI (Peterson, 2023).

Individuals with MCI may experience mild memory loss, particularly in recent events. They may also exhibit difficulties with other cognitive functions such as attention, language, problem-solving, or decision-making. Generally, they can still manage their day-to-day activities independently, although they may take longer or require more effort for complex tasks. They are often aware of their cognitive difficulties and may feel concerned or frustrated about their deficits (Peterson, 2023).

Major cognitive impairment refers to a more severe and progressive decline in cognitive functioning that significantly impacts daily life and independence, across one or more cognitive domains. It affects an individual's ability to perform routine activities independently, such as self-care, managing finances, driving, or maintaining household tasks. Assistance or supervision may be required. They often have reduced insight into their cognitive deficits and may be less aware of their functional limitations. Major cognitive impairment is typically progressive, with decline worsening gradually over months or years. The rate of progression varies depending on the underlying cause and individual factors (Peterson, 2023).


Table 1. Cognitive Domains (Weinberg & Holiman, 2023).

Category Definition Clinical Manifestations
Learning and memory The acquisition, retention, and retrieval of new information. It includes both immediate and delayed recall, recognition memory, and learning new skills or procedures.
  • Difficulty in remembering recent events
  • Problems with recalling past memories
  • Challenges in learning and retaining new information
Language The comprehension and production of spoken or written language. It includes tasks such as understanding and expressing ideas, following verbal instructions, reading, and writing.
  • Word-finding difficulties
  • Problems with understanding and comprehending language (receptive and expressive deficits)/li>
Executive function Higher-order cognitive processes responsible for planning, problem-solving, decision-making, and goal-directed behavior.
  • Difficulty organizing and implementing tasks
  • Making inappropriate judgments
  • Limited self-control
Complex attention The ability to focus, sustain attention, and shift attention appropriately in complex or demanding situations. It includes tasks such as divided attention, working memory, and selective attention.
  • Trouble staying focused
  • Easily distracted
  • Difficulty multitasking
Perceptual-motor The ability to perceive and interpret information and use that to navigate and interact with the surrounding environment.
  • Impaired spatial orientation
  • Problems with depth perception
  • Difficulty recognizing objects or faces
  • Unable to accurately judge distances
Social cognition The ability to understand and interpret social cues, emotions, and intentions of others.
  • Difficulty recognizing emotions
  • Unable to understand social norms
  • Trouble maintaining appropriate social behavior


Historical Perspective

The diagnosis and understanding of neurocognitive disorders have evolved significantly over time. Descriptions of cognitive decline resembling neurocognitive disorders can be found in ancient civilizations; however, the concept of neurocognitive disorders as a distinct medical condition was not well-defined during this period. It wasn’t until the early 19th century, that the term "senile dementia" was coined by French physician Jean Étienne Dominique Esquirol. He recognized that older individuals could experience progressive cognitive decline without an apparent cause. This marked the first attempt to classify dementia as a distinct disorder (Vatanabe, Manzine, & Cominetti, 2020).

In the early 1900s, German psychiatrist Alois Alzheimer observed a patient named Auguste Deter with severe memory loss, language difficulties, and behavioral changes. After Deter's death, Alzheimer examined her brain and discovered neurofibrillary tangles and plaques, which are characteristic pathological features of what became known as Alzheimer's disease. Over the course of the 20th century, researchers began to distinguish different subtypes of dementia. They recognized that Alzheimer's disease was the most common cause, but other forms like vascular dementia were also identified (Vatanabe, Manzine, & Cominetti, 2020).

The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, has described neurocognitive-type disorders which have evolved over time as more was understood about the conditions. The first edition of the DSM did not include specific diagnostic criteria for dementia. It classified cognitive disorders under the broad category of "Organic Brain Syndromes" without detailed subcategories. The second edition of the DSM introduced the term "Senile Dementia" and included a separate category for it however, the diagnostic criteria were relatively vague and did not provide a comprehensive framework for diagnosing or classifying different types of dementia (Vatanabe, Manzine, & Cominetti, 2020).

The third edition of the DSM brought significant changes to the classification of dementia. It introduced more specific diagnostic criteria and listed dementia as a distinct disorder under the category of "Organic Mental Disorders." This edition emphasized the importance of cognitive impairment and functional decline in the diagnosis of dementia. These criteria provided a standardized framework for diagnosing dementia and distinguishing it from other mental disorders. The revised third edition of the DSM made some refinements to the diagnostic criteria for dementia. It introduced the term "Dementia of the Alzheimer's Type" as a specific subtype and included additional subtypes such as vascular dementia and dementia due to other medical conditions (Vatanabe, Manzine, & Cominetti, 2020).

The fourth edition of the DSM further expanded the classification of dementia. It introduced a more detailed and comprehensive framework for diagnosing different types of dementia. This edition included specific criteria for Alzheimer's disease, vascular dementia, dementia due to other medical conditions, substance-induced dementia, and dementia not otherwise specified (Vatanabe, Manzine, & Cominetti, 2020).

The fifth edition of the DSM brought further revisions to the diagnostic criteria for neurocognitive disorders, replacing the term "dementia." It introduced the category of "Neurocognitive Disorders.” This edition emphasized a continuum of cognitive impairment, ranging from mild to major, and incorporated changes in criteria for specific disorders like Alzheimer's disease and frontotemporal neurocognitive disorder. The DSM is periodically updated to reflect advances in research and understanding. The changes in the diagnostic criteria have aimed to improve accuracy, reliability, and consistency in the diagnosis of dementia and related neurocognitive disorders (Vatanabe, Manzine, & Cominetti, 2020).

A factor in the evolution of diagnostic criteria in the DSM was the development of neuroimaging techniques. Magnetic resonance imaging (MRI) and positron emission tomography (PET) allowed researchers to visualize brain changes associated with neurocognitive disorders. These imaging technologies have contributed to the understanding of different subtypes and improved diagnostic accuracy. In 2011, the National Institute on Aging and the Alzheimer's Association published new diagnostic guidelines, emphasizing the importance of biomarkers and the preclinical stage of Alzheimer's disease (Vatanabe, Manzine, & Cominetti, 2020).

Presently, there is a growing emphasis on early detection and prevention of dementia. Efforts are underway to identify biomarkers and develop interventions to delay the onset or slow the progression of cognitive decline. Understanding and diagnosis of neurocognitive disorders are still evolving, and ongoing research continues to refine our knowledge (Vatanabe, Manzine, & Cominetti, 2020).


Stigma

Neurocognitive disorders have unfortunately been associated with various forms of stigma for centuries. Stigma refers to negative attitudes, beliefs, stereotypes, and discriminatory behaviors that are directed toward individuals or groups based on certain characteristics or conditions. Many people lack knowledge and understanding about neurocognitive disorders, leading to misconceptions and stereotypes. This lack of awareness can contribute to fear, anxiety, and negative attitudes towards individuals with these conditions (Rewerska-Ju?ko & Rejdak, 2020).

Neurocognitive disorders can significantly impact a person's cognitive abilities, memory, and personality. The changes in behavior and functioning can sometimes lead to a loss of identity and dignity, which may be perceived negatively by others. They often experience social isolation and exclusion due to the symptoms they exhibit. Friends, family members, and even society at large may distance themselves due to discomfort, lack of understanding, or fear of the unknown (Rewerska-Ju?ko & Rejdak, 2020).

The stigma associated with neurocognitive disorders has evolved over time, but unfortunately, it still persists in many societies. In the past, symptoms of neurocognitive disorders were often misattributed to supernatural or moral causes. This led to fear, discrimination, and social isolation, with individuals being marginalized or hidden away from society. As scientific understanding advanced, dementia began to be recognized as a medical condition, however in the early 20th century, mental illness still carried a significant stigma, and individuals with dementia were often institutionalized in psychiatric hospitals or asylums, further isolating them from society (Rewerska-Ju?ko & Rejdak, 2020).

From the mid-20th century onward, deinstitutionalization movements aimed to shift care from large psychiatric institutions to community-based settings. While this led to greater autonomy and improved quality of life for some, it also exposed individuals with dementia to the potential stigma. With the recognition of Alzheimer's disease as the most common cause of dementia, advocacy groups, such as the Alzheimer's Association, have played a significant role in raising awareness, reducing stigma, and promoting research and support services. These efforts have helped increase public knowledge about dementia and combat some of the associated stigma (Rewerska-Ju?ko & Rejdak, 2020).

Stigma can also affect the caregivers of individuals with neurocognitive disorders. Caregivers may experience social judgment, criticism, and isolation, adding to the overall burden and stress of caring for their loved ones (Rewerska-Ju?ko & Rejdak, 2020). It is important for nurses to challenge these stigmas and promote understanding, empathy, and support for individuals with neurocognitive disorders. Raising awareness, educating the public, and fostering inclusive communities can help combat stigma and create a more supportive environment for individuals and their families affected by these conditions.

Despite these positive developments, stigma still exists, and people with neurocognitive disorders continue to face various forms of discrimination, isolation, and misunderstanding. Public education, awareness campaigns, and ongoing advocacy are crucial in challenging stigmatizing attitudes and creating a more inclusive and supportive society for individuals living with these disorders and their families (Rewerska-Ju?ko & Rejdak, 2020).


Pathophysiology and Etiology of Neurocognitive Disorders

Etiology

There are many different causes of neurocognitive disorders and each has its own unique pathophysiologies.

Neurodegenerative Causes

There are four common neurodegenerative causes of neurocognitive disorders: Alzheimer’s disease (AD), Dementia with Lewy bodies (DLB), Frontotemporal dementia (FTD), and Parkinson's disease dementia (PDD). Less common neurodegenerative causes include progressive supranuclear palsy, corticobasal degeneration, multisystem atrophy, chronic traumatic encephalopathy, and Huntington's disease, but this article will focus on the four most common (Larson, 2023).


Alzheimer’s Disease (AD)

AD is a complex neurodegenerative disorder characterized by progressive cognitive decline, memory loss, and changes in behavior and personality. While the exact cause of AD is not fully understood, researchers have identified several key pathological features and processes involved in its pathophysiology. The accumulation of abnormal protein deposits called amyloid-beta plaques is a hallmark of AD. Amyloid-beta is derived from the amyloid precursor protein through abnormal processing. The excessive production and aggregation of amyloid-beta peptides lead to the formation of insoluble plaques, which disrupt the communication between neurons and contribute to neuronal damage (Keene & Montine, 2023).

Another characteristic feature of AD is the presence of neurofibrillary tangles within neurons. These tangles are composed of an abnormal form of a protein called tau. In AD, tau proteins become hyperphosphorylated, leading to their misfolding and clumping together, which disrupts the normal structure and function of neurons. The accumulation of amyloid-beta plaques and neurofibrillary tangles triggers a cascade of events that ultimately result in neuronal cell death and neurodegeneration. The loss of neurons, particularly in brain regions crucial for memory and cognitive function such as the hippocampus and cerebral cortex, leads to the characteristic cognitive decline observed in AD (Keene & Montine, 2023).

Inflammation also plays a significant role in the pathophysiology of AD. Activated immune cells, such as microglia, respond to the presence of amyloid-beta plaques and release inflammatory molecules. While inflammation initially aims to clear the plaques, chronic and excessive inflammation can damage neurons and exacerbate the disease progression. Oxidative stress, an imbalance between the production of harmful reactive oxygen species and the body's ability to neutralize them, is observed in AD. The accumulation of amyloid-beta, inflammation, and impaired mitochondrial function can all lead to increased oxidative stress, causing damage to cells and further exacerbating neurodegeneration (Keene & Montine, 2023). The pathophysiology of AD is complex and multifactorial, involving a combination of genetic, environmental, and lifestyle factors. Ongoing research aims to deepen our understanding of the disease's mechanisms to develop effective treatments and interventions (Keene & Montine, 2023).


Dementia with Lewy bodies (DLB)

DLB is a neurodegenerative disorder characterized by the presence of abnormal protein deposits called Lewy bodies in the brain. The exact cause of DLB is not fully understood, but there are several known pathological features and processes that contribute to its pathophysiology. The hallmark pathological feature of DLB is the presence of Lewy bodies, which are abnormal aggregates of alpha-synuclein protein. Alpha-synuclein normally plays a role in regulating neurotransmitter release, but in DLB, it forms insoluble clumps within neurons. These Lewy bodies predominantly accumulate in specific brain regions, including the cortex, limbic system, and brainstem. Alongside Lewy bodies, DLB is characterized by the presence of abnormal structures called Lewy neurites. These are thread-like extensions that develop from neurons and contain alpha-synuclein aggregates. Lewy neurites can disrupt neuronal functioning and contribute to the progressive deterioration seen in DLB (McFarland, 2023).

DLB is associated with disruptions in various neurotransmitter systems. There is a loss of dopamine-producing cells in the substantia nigra, leading to a decrease in dopamine levels. Additionally, there may be impairments in other neurotransmitters such as acetylcholine, norepinephrine, and serotonin. These imbalances contribute to the cognitive, motor, and psychiatric symptoms observed in DLB. Progressive neurodegeneration, resulting in the loss of neurons and their connections, affects regions responsible for cognitive functions, including memory, attention, executive function, and visual-spatial abilities. The degeneration of dopamine-producing cells in the substantia nigra also contributes to motor symptoms (McFarland, 2023).

Much like in AD, inflammation and immune system activation are observed in the brains of individuals with DLB. Some individuals with DLB may also exhibit vascular changes, including small vessel disease and cerebral microinfarcts. These changes can contribute to cognitive impairment and further exacerbate the neurodegenerative processes in DLB. The interaction between Lewy bodies, neurotransmitter imbalances, neurodegeneration, inflammation, and vascular changes are complex and collectively contribute to the clinical manifestations and progression of DLB (McFarland, 2023).


Frontotemporal Dementia (FTD)

FTD refers to a group of neurodegenerative disorders characterized by the progressive degeneration of the frontal and/or temporal lobes of the brain. More research is needed to understand the exact pathophysiology of FTD, but several features contribute to its development. FTD is associated with the abnormal accumulation of specific proteins in the brain, including tau, TAR DNA-binding protein 43 (TDP-43), and occasionally fused in sarcoma (FUS) protein. Different subtypes of FTD can be characterized by the predominant protein involved. Tau pathology is observed in some cases of FTD, while TDP-43 pathology is more common in others (Lee, 2023).

Progressive neurodegeneration occurs in the frontal and/or temporal lobes, leading to the loss of neurons and their connections. This degeneration affects specific brain regions involved in personality, behavior, language, and executive functions. The exact mechanisms underlying neurodegeneration in FTD are not completely understood but likely involve a combination of protein aggregation, disruption of cellular processes, and excitotoxicity. Inflammation and immune system activation have also been implicated in FTD. Chronic inflammation can further contribute to neuronal damage and disease progression (Lee, 2023).In some cases, FTD has a genetic component. Mutations in specific genes are associated with familial forms of FTD. These genetic mutations disrupt normal protein production and processing, leading to the accumulation of abnormal proteins and subsequent neurodegeneration (Lee, 2023).

These processes lead to significant functional impairments in FTD. These brain regions are critical for executive functions, social behavior, language production and comprehension, emotional processing, and decision-making. The specific symptoms and clinical manifestations of FTD depend on the areas of the brain predominantly affected. Ongoing research aims to better understand the underlying mechanisms to develop targeted therapies for this challenging condition (Lee, 2023).


Parkinson's Disease Dementia (PDD)

PDD refers to the development of dementia in individuals with Parkinson's disease (PD). PD is a chronic and progressive neurodegenerative disorder that primarily affects the movement and motor control of individuals. It is characterized by the gradual loss of dopamine-producing cells in a specific region of the brain called the substantia nigra. Dopamine is a neurotransmitter involved in movement, reward, and cognitive functions. When most people think of PD, motor symptoms such as tremors, bradykinesia, and rigidity come to mind, but the disease also has non-motor features including cognitive decline that can progress to PDD (Rodnitzky, 2023).

The pathophysiology of PDD involves complex interactions between several factors. PDD is characterized by the presence of Lewy bodies, abnormal protein aggregates, primarily composed of alpha-synuclein. These Lewy bodies are found in the brain regions involved in movement control and cognitive function, including the substantia nigra and cerebral cortex. The accumulation of alpha-synuclein disrupts normal cellular processes and impairs neuronal function and it leads to a loss of dopamine-producing cells. Additionally, there is degeneration and loss of neurons in areas such as the cortex, limbic system, and hippocampus, which are associated with cognitive functions. In PD and PDD, there is a significant reduction in dopamine levels due to the loss of dopaminergic neurons in the substantia nigra. This dopamine depletion contributes to motor symptoms in PD and may also affect cognitive functions in PDD (Rodnitzky, 2023).

Acetylcholine is another important neurotransmitter involved in cognitive functions. In PDD, there is an imbalance between dopamine and acetylcholine systems, with a relative decrease in cholinergic activity. This imbalance contributes to cognitive impairment, particularly in attention, memory, and executive functions. Similar to other neurodegenerative causes of neurocognitive disorders, neuroinflammation can further exacerbate damage. Other factors, such as oxidative stress, mitochondrial dysfunction, and excitotoxicity, have also been implicated in the pathophysiology of PDD. These processes can contribute to cellular damage, neuronal death, and the progressive cognitive decline observed in PDD (Rodnitzky, 2023).


Vascular Causes

Vascular neurocognitive disorders refer to a group of conditions characterized by cognitive impairment resulting from cerebrovascular disease or vascular-related brain injury. These disorders are caused by disruptions in blood flow to the brain, leading to damage to brain tissue. Several vascular causes can contribute to the development of neurocognitive disorders including ischemic or hemorrhagic strokes, small vessel disease, hypoperfusion, vasculitis, and cerebral amyloid angiopathy (CAA) (Smith & Wright, 2023).

A stroke occurs when the blood supply to a part of the brain is suddenly interrupted or reduced, resulting in brain cell damage or death. Strokes can be ischemic, caused by a blockage in a blood vessel, or hemorrhagic, caused by bleeding in the brain. Both types of stroke can lead to cognitive impairments depending on the location and extent of the brain damage. Small vessel disease refers to the narrowing, blockage, or damage to the small blood vessels in the brain. It can result from conditions such as hypertension, diabetes, atherosclerosis, or chronic inflammation. Small vessel disease can lead to the development of white matter lesions, lacunar infarcts, or microbleeds, all of which can contribute to cognitive decline (Smith & Wright, 2023).

Reduced blood flow to the brain, known as cerebral hypoperfusion, can occur due to various reasons, including carotid artery stenosis, cardiac dysfunction, or low blood pressure. Prolonged or severe cerebral hypoperfusion can result in brain tissue damage and cognitive impairment. CAA is characterized by the deposition of amyloid plaques in the walls of small blood vessels in the brain. This can lead to the weakening and rupture of blood vessels, causing small hemorrhages and microinfarctions. CAA is commonly associated with Alzheimer's disease but can also contribute to vascular cognitive impairment. Cerebral vasculitis is an inflammatory condition that affects the blood vessels in the brain, leading to their inflammation and potential damage. This can result in reduced blood flow and oxygen supply to the brain, causing cognitive impairments (Smith & Wright, 2023).

The vascular causes of neurocognitive disorders often present with a heterogeneous pattern of cognitive deficits, including executive dysfunction, difficulties with attention and concentration, and impaired memory. The severity and specific symptoms depend on the location, extent, and chronicity of the vascular lesions. Preventing or managing vascular risk factors such as hypertension, diabetes, and high cholesterol, and maintaining a healthy lifestyle can help reduce the risk of developing vascular neurocognitive disorders. Treatment strategies may include lifestyle modifications, medication management to control underlying conditions, and rehabilitation therapies to optimize cognitive function and daily functioning (Smith & Wright, 2023).


Traumatic, Infectious, and Metabolic Causes

Trauma

Traumatic brain injury (TBI) is a significant cause of neurocognitive disorders. TBIs occur when there is a sudden impact or jolt to the head, leading to damage and dysfunction of brain tissue. The severity and long-term effects of TBIs can vary depending on the extent and location of the injury. Concussions are mild TBIs that result from a direct blow to the head or a sudden acceleration or deceleration of the head. They are commonly associated with sports-related injuries, falls, or motor vehicle accidents. While concussions are considered mild, repeated concussions or inadequate recovery can lead to long-term neurocognitive deficits. Moderate to severe TBIs involve more significant brain damage. These injuries can cause structural damage to the brain, including bruising, bleeding, and tearing of brain tissue. Neurocognitive deficits resulting from moderate to severe TBIs can be more pronounced and may have a lasting impact on cognitive function (Larson, 2023).

Diffuse axonal injury occurs when there is widespread damage to the brain's white matter, often caused by severe acceleration or deceleration forces. This injury leads to the disruption of axons, the nerve fibers responsible for transmitting signals between brain cells. Diffuse axonal injury can result in a wide range of cognitive impairments, including memory problems, attention deficits, and executive dysfunction (Larson, 2023).

The neurocognitive deficits resulting from traumatic causes can vary depending on the specific area of the brain affected and the severity of the injury. Common cognitive impairments associated with traumatic neurocognitive disorders include difficulties with memory, attention, concentration, information processing speed, executive functions, and problem-solving abilities. Other associated symptoms may include mood changes, behavioral problems, and sensory impairments (Larson, 2023).

Rehabilitation and treatment for traumatic neurocognitive disorders typically involve a multidisciplinary approach, including physical therapy, occupational therapy, speech therapy, cognitive rehabilitation, and psychological support. The goal is to improve cognitive function, manage symptoms, promote functional independence, and enhance the individual's quality of life following a traumatic brain injury (Larson, 2023).

Infections

Infectious causes can contribute to the development of neurocognitive disorders. Several infections can directly affect the central nervous system and lead to cognitive impairments, the most common being Human Immunodeficiency Virus (HIV) infection, neurosyphilis, Lyme disease, and viral encephalitis (Larson, 2023).

HIV can directly invade and damage the CNS, leading to a condition known as HIV-associated neurocognitive disorders (HAND). HAND encompasses a spectrum of cognitive impairments, ranging from mild neurocognitive impairment to HIV-associated dementia. The virus can affect multiple areas of the brain, leading to cognitive deficits, motor abnormalities, and behavioral changes (Larson, 2023).

Syphilis is a sexually transmitted infection caused by the bacterium Treponema pallidum. When left untreated, syphilis can progress to neurosyphilis, where the bacteria invade the CNS. Neurosyphilis can manifest as various neurological and psychiatric symptoms, including cognitive impairments, personality changes, memory deficits, and gait disturbances (Larson, 2023).

Lyme disease is caused by the bacterium Borrelia burgdorferi, transmitted through the bite of infected ticks. In some cases, Lyme disease can lead to neurological complications, including neurocognitive impairments. Cognitive deficits observed in Lyme disease may include difficulties with memory, attention, processing speed, and executive functions (Larson, 2023).

Viral encephalitis refers to inflammation of the brain caused by viral infections. Certain viruses, such as herpes simplex virus (HSV), varicella-zoster virus (VZV), and West Nile virus (WNV), can directly infect the brain and cause neurocognitive impairments. The severity and specific cognitive deficits can vary depending on the virus and the regions of the brain affected. Infectious causes of neurocognitive disorders can often be prevented or managed with appropriate medical interventions. Prompt diagnosis and treatment of the underlying infection, along with supportive care and antiviral or antibiotic therapies, are crucial in minimizing neurological complications and cognitive decline. Proper infection control measures and preventive strategies, such as safe sex practices, vaccination, and tick bite prevention, can also help reduce the risk of developing infectious-related neurocognitive disorders (Larson, 2023).

Metabolic

Metabolic causes can contribute to the development of neurocognitive disorders. These disorders arise from disturbances in the body's metabolic processes, which can affect the function and structure of the brain. Common examples of metabolic causes include hypothyroidism, hepatic encephalopathy, and vitamin B deficiencies (Larson, 2023).

Hypothyroidism refers to an underactive thyroid gland, which leads to insufficient production of thyroid hormones. Thyroid hormones play a crucial role in brain development and function. When thyroid hormone levels are low, cognitive impairments can occur, including difficulties with memory, attention, and processing speed. Liver disease can lead to the accumulation of toxins in the blood, including ammonia. When these toxins reach the brain, they can cause cognitive impairments collectively known as hepatic encephalopathy. Symptoms may include confusion, personality changes, impaired attention, and memory deficits (Larson, 2023).

Vitamin B12 is essential for the normal functioning of the nervous system. A deficiency in vitamin B12 can lead to neurological complications, including neurocognitive impairments. Cognitive symptoms may include memory loss, confusion, and difficulties with abstract thinking. Thiamine (vitamin B1) is important for energy production and normal brain function. Severe thiamine deficiency can lead to a condition called Wernicke-Korsakoff syndrome. It is commonly associated with chronic alcoholism and can cause neurocognitive impairments, including confusion, memory deficits, and problems with coordination (Larson, 2023).

Treating metabolic causes of neurocognitive disorders typically involves addressing the underlying metabolic abnormality. This may involve medication, dietary modifications, vitamin or hormone supplementation, and management of the underlying condition. Early detection and intervention are essential to prevent or minimize neurological complications and optimize cognitive function (Larson, 2023).


Genetic Factors and Familial Patterns

Some neurocognitive disorders can have a genetic component. Certain genetic mutations have been identified as rare causes of early-onset familial AD. These mutations directly influence the production and accumulation of amyloid plaques and tau tangles in the brain, the characteristic features of AD (Keene & Montine, 2023; Sherva & Kowall, 2023). FTD can also have a genetic basis, with several genes identified as associated with the development of familial forms of the disorder. These mutations affect proteins involved in brain cell function, leading to abnormal protein accumulation and neurodegeneration (Lee, 2023).

In addition to rare genetic mutations, there may be genetic risk factors that increase the susceptibility to neurocognitive disorders without causing them directly. For example, certain gene variants are associated with an increased risk of developing late-onset Alzheimer's disease (Keene & Montine, 2023). Genetic testing and counseling can help individuals and families understand their risk and make informed decisions regarding management and potential interventions (Lee, 2023).


Less Common Causes

There are several less common causes of neurocognitive disorders as well. Alcohol-related dementia occurs in individuals who have a history of heavy and chronic alcohol use over a prolonged period. Normal Pressure Hydrocephalus (NPH) is a neurological disorder characterized by an abnormal accumulation of cerebrospinal fluid (CSF) in the brain's ventricles, leading to an enlarged brain ventricle size. The exact cause of NPH is often unknown, although it can be secondary to other conditions such as trauma, infection, brain hemorrhage, or tumor. In some cases, NPH can develop as a result of the aging process, without a specific identifiable cause (Larson, 2023).

Another less common cause is a chronic subdural hematoma, which is a type of brain injury characterized by the accumulation of blood between the brain's surface and its outermost protective layer, the dura mater. Unlike an acute subdural hematoma, which develops rapidly after a severe head injury, a chronic subdural hematoma typically develops over a period of weeks or months and may not have an obvious history of trauma. The accumulation of blood creates pressure on the brain, which can cause a range of neurocognitive symptoms (Larson, 2023).


Multiple Causes

ate neurocognitive disorders (Larson, 2023).

Risk factors

There are several risk factors that are associated with developing neurocognitive disorders. Advanced age is the most significant risk factor. The prevalence of both minor and major neurocognitive disorders increases with age, particularly in individuals over 65 years old. Having a family history of cognitive impairment can also increase risk for these conditions. Certain genetic factors, such as the presence of specific gene variants have been linked to a higher risk of neurocognitive disorders. Conditions that affect cardiovascular health, including hypertension, high cholesterol levels, diabetes mellitus, obesity, and smoking, have also been associated with an increased risk. In addition, other conditions that affect blood vessels and circulation, such as cerebrovascular disease, can contribute to the development of neurocognitive disorders (Peterson, 2023).

Certain lifestyle behaviors can influence the risk of neurocognitive disorders. These include a sedentary lifestyle, lack of physical exercise, unhealthy diet, excessive alcohol consumption, and smoking (Press & Alexander, 2023). Depression and other mental health conditions have been linked to an increased risk and it is thought that chronic stress and social isolation may also play a role. Lower levels of education have been associated with a higher risk of developing neurocognitive disorders.

Social determinants of health play a significant role in the development, progression, and outcomes of neurocognitive disorders. These are the social, economic, and environmental conditions in which people live and work, and they can greatly influence an individual's health and well-being. Lower socioeconomic status is associated with an increased risk of neurocognitive disorders. Limited access to quality healthcare, education, and resources may result in delayed diagnosis, inadequate treatment, and poorer management of neurocognitive disorders. Socioeconomic factors can also impact lifestyle behaviors, such as diet, exercise, and exposure to environmental toxins, which can further contribute to the development or progression of these disorders (Press & Alexander, 2023).

Education level is strongly associated with cognitive health. Higher levels of education provide individuals with better cognitive reserve, which can delay the onset and progression of neurocognitive disorders. Additionally, access to lifelong learning opportunities and cognitive stimulation throughout life can help maintain cognitive function and reduce the risk of cognitive decline (Press & Alexander, 2023).

Social connections and support networks play a crucial role in maintaining mental health and cognitive function. Isolation, loneliness, and lack of social engagement have been linked to an increased risk of cognitive decline and neurocognitive disorders. Social support can provide emotional well-being, cognitive stimulation, and opportunities for physical activity and social interaction, all of which are beneficial for brain health (Press & Alexander, 2023).

Disparities in healthcare access can impact the diagnosis and management of neurocognitive disorders. Limited access to healthcare services, including specialized diagnostic evaluations, timely treatment, and ongoing care, can result in delayed interventions and suboptimal outcomes for individuals with neurocognitive disorders. Health literacy, which refers to an individual's ability to understand and navigate health information, plays a role in neurocognitive health. Limited health literacy can result in challenges in understanding and following treatment plans, medication regimens, and lifestyle recommendations for managing neurocognitive disorders (Press & Alexander, 2023).

The physical and social environment in which individuals live can impact cognitive health. Exposure to environmental toxins, such as air pollution or lead, can contribute to cognitive impairment. Additionally, living in disadvantaged neighborhoods with limited resources, inadequate housing, and higher levels of stress can adversely affect cognitive health (Press & Alexander, 2023).

Addressing social determinants of health is crucial in promoting better neurocognitive outcomes. Strategies to reduce health disparities, improve access to quality healthcare, enhance education opportunities, promote social engagement, and create supportive environments can help mitigate the impact of social determinants on neurocognitive disorders. Additionally, public health initiatives aimed at raising awareness, improving health literacy, and providing targeted interventions can play a vital role in reducing the burden of neurocognitive disorders in vulnerable populations (Press & Alexander, 2023).

Engaging in a healthy lifestyle, maintaining cardiovascular health, staying mentally and socially active, and managing chronic conditions effectively may help reduce the risk of neurocognitive disorders and promote brain health (Press & Alexander, 2023). Regular check-ups and discussions with healthcare providers can provide personalized guidance on risk-reduction strategies (Peterson, 2023).


Assessment of Neurocognitive Disorders

Most evaluations for neurocognitive disorders begin in office visits with an interview of the patient. Most major medical associations do not recommend for or against routine screening in adults due to insufficient evidence, so most screening is done when the patient experiences symptoms (Larson, 2023). Since many patients do not always recognize the severity of their deficits, a close loved one should accompany the patient to the visit to share their perspective. Neurocognitive disorders are characterized by a range of clinical manifestations that reflect the progressive decline in cognitive abilities. The specific symptoms and their severity can vary depending on the underlying cause of the disorder (see Table 2) (Weinberg, & Holiman, 2023).


Table 2. Specific features associated with underlying causes of neurodegenerative disorders (Weinberg, & Holiman, 2023).

Alzheimer’s disease
  • Gradual onset and slow progression
  • Symptoms may have brief plateaus
  • Memory impairment, learning, and executive function
  • Language deficits
  • Problematic behaviors, including agitation, combativeness, and psychosis, may arise
  • Psychosis may take the form of delusions
Frontotemporal neurocognitive disorder
  • Personality and behavioral changes
  • Language impairment
  • Insight impairment, socially inappropriate, apathetic, impulsive
  • Learning and memory dysfunction in later stages
Dementia with Lewy Bodies
  • Cognitive decline occurs within one year of appearance of motor symptoms
  • Visual hallucinations and fluctuating cognition that presents similarly to delirium
  • Mood disturbances, autonomic dysfunction, and altered sleep patterns
Parkinson disease dementia
  • PD symptoms precedes the onset of major neurocognitive decline by at least a year
  • Apathy, depression, hallucinations, and REM sleep
  • Atypical presentation may include early postural instability and cognitive impairment with depression, apathy, and anxiety
Parkinson disease dementia
  • PD symptoms precedes the onset of major neurocognitive decline by at least a year
  • Apathy, depression, hallucinations, and REM sleep
  • Atypical presentation may include early postural instability and cognitive impairment with depression, apathy, and anxiety
Vascular neurocognitive disorder
  • Cognitive decline related to cerebrovascular event(s)
  • Decline in processing speed, complex attention, and executive dysfunction
  • Depression and personality changes
Traumatic etiologies
  • Symptoms can be attributed to a traumatic injury
  • Presentation may be variable and depend on location and severity of injury
  • May include inattention, executive dysfunction, or problems with learning and memory
  • Associated findings include disturbances in emotional function and personality change
  • Chronic traumatic encephalopathy can include parkinson-like symptoms
Infectious etiologies
  • Symptoms can be attributed to an infectious disease
Genetic etiologies
  • Symptoms can be attributed to a genetic factors


Memory deficits are a hallmark feature of neurocognitive disorders. Individuals may experience difficulty remembering recent events, new information, or conversations. They may also have trouble recalling previously learned information and may rely heavily on memory aids or assistance from others. They can affect a person's ability to make sound judgments and decisions. Patients may exhibit poor judgment in financial matters, have difficulty weighing risks and benefits, and struggle with problem-solving tasks (Weinberg, & Holiman, 2023).

Language and communication skills may also be affected in neurocognitive disorders. Individuals may have trouble finding the right words to express themselves, experience difficulty following conversations, and have trouble understanding written or spoken language. Executive functions involve higher-level cognitive processes, including planning, organizing, initiating and completing tasks, and self-monitoring. Neurocognitive disorders can disrupt these functions, leading to difficulties with organizing daily activities, managing time, and multitasking. Individuals may become disoriented in familiar surroundings or struggle with spatial awareness. They may have difficulty finding their way in familiar environments or become lost even in well-known places (Weinberg, & Holiman, 2023).

Neurocognitive disorders can manifest with various behavioral and psychological symptoms, including changes in personality, mood swings, agitation, aggression, apathy, anxiety, depression, and social withdrawal. Some neurocognitive disorders, such as Parkinson's disease dementia, may include motor symptoms like tremors, rigidity, bradykinesia, and autonomic instability. As the neurocognitive disorder progresses, individuals may struggle with activities of daily living, such as dressing, bathing, feeding themselves, and managing personal hygiene (Weinberg, & Holiman, 2023).


Screening Tools and Assessment Methods

There are several screening tools and formal assessment methods that may be used in diagnosing neurocognitive disorders. The most common are outlined in this section.


Diagnostic and Statistical Manual of Mental Disorders Criteria

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), provides diagnostic criteria for neurocognitive disorders. In order to meet the criteria for a major neurodegenerative disorder diagnosis the patient must exhibit significant cognitive decline from a previous level of performance in one or more cognitive domains (see table 1). Evidence of this criteria would come from concerns of the individual, a knowledgeable informant, or the clinician and a substantial impairment in cognitive performance, preferably documented by standardized neuropsychological testing or, in its absence, another quantified clinical assessment. Additional criteria are that the cognitive deficits interfere with independence in everyday activities, they do not occur exclusively in the context of delirium, and they are not better explained by another mental disorder (Larson, 2023).

The DSM-5 also provides criteria for mild neurocognitive disorder, which represents a less severe form of cognitive impairment. The criteria for mild neurocognitive disorder are similar to major neurocognitive disorder but with some differences in the severity and impact of cognitive decline. Specific criteria for each type of neurocognitive disorder (such as Alzheimer's disease, vascular dementia, frontotemporal dementia, etc.) are not included in the DSM-5. Instead, these specific criteria and diagnostic guidelines are typically outlined by professional medical organizations, such as the National Institute on Aging-Alzheimer's Association (NIA-AA) criteria for Alzheimer's disease, or the Lund and Manchester Groups' criteria for frontotemporal dementia. These guidelines provide more detailed information about the specific clinical and diagnostic features of each type of neurocognitive disorder (Larson, 2023).


Mini-Mental State Examination (MMSE)

The MMSE is a widely used screening tool for assessing cognitive function and detecting cognitive impairment. It is a brief questionnaire that evaluates various cognitive domains, including orientation, registration, and recall of information, attention and calculation, language, and visual-spatial abilities. The MMSE consists of a series of questions and tasks, and the individual's performance is scored based on their responses (see summary of tasks in Table 3). Each component of the MMSE is scored, and the total score ranges from 0 to 30, with higher scores indicating better cognitive function. The interpretation of the MMSE score depends on factors such as the person's age, education level, and cultural background (Larson, 2023).


Table 3. Components of the MMSE (Larson, 2023).

Orientation The person is asked to state the current date, month, year, day of the week, and their location (e.g., city, state, country).
Registration The examiner provides three unrelated words and asks the person to repeat them. This assesses immediate recall.
Attention and Calculation The person is asked to perform simple calculations or serial subtraction tasks, such as subtracting 7 from 100 and repeating the result (in practice this is referred to as “serial 7’s”)
Recall After a short delay (usually 5 minutes), the person is asked to recall the three words they were asked to remember earlier.
Language This section includes tasks such as naming objects, following verbal instructions, and repeating sentences.
Visual-Spatial Abilities The person may be asked to copy a simple drawing or solve a visual puzzle.


While the MMSE is a widely used screening tool, it is important to note that it has some limitations. It primarily assesses cognitive domains affected by Alzheimer's disease and may not capture impairments in other types of neurocognitive disorders. Additionally, the MMSE is not a diagnostic tool but rather a screening measure, and a comprehensive evaluation by a healthcare professional is necessary to make a formal diagnosis.


Montreal Cognitive Assessment (MoCA)

The MoCA is a widely used screening tool for assessing cognitive function, similar to the Mini-Mental State Examination (MMSE). The MoCA assesses multiple cognitive domains and provides a more detailed evaluation compared to the MMSE (see Table 4 for more details). The MoCA has gained popularity due to its ability to detect mild cognitive changes that may be missed by other screening tools. It provides a more comprehensive assessment of cognitive function and is particularly useful in identifying cognitive deficits associated with MCI or early stages of neurocognitive disorders such as Alzheimer's disease.

The MoCA is scored out of 30 points, with a higher score indicating better cognitive function. The interpretation of the MoCA score may vary based on factors such as age, education level, and cultural background. A score of 26 or above is generally considered normal, while scores below 26 may indicate cognitive impairment. Like the MMSE, the MoCA is a screening tool and a thorough evaluation by a healthcare professional is necessary for a definitive diagnosis (Larson, 2023).

Table 3. Components of the MoCA (Larson, 2023).

Visuospatial and Executive Functioning This includes tasks such as drawing a clock, copying a 3D cube, and performing a trail-making task.
Naming The person is asked to name pictures of objects or animals.
Attention This section includes tasks like serial subtraction or sustained attention tests. or sustained attention tests.
Language The person may be asked to repeat sentences, name words that start with a specific letter, or generate words that fit certain categories.
Abstraction The person is asked to explain the similarities between certain words or concepts.
Delayed Recall After a short delay, the person is asked to recall specific words or information that was presented earlier.
Orientation This section assesses the person's knowledge of time, date, and place.


Clock Drawing Test (CDT)

The CDT is a commonly used cognitive screening tool that assesses visuospatial abilities, executive function, and cognitive impairment. It involves asking an individual to draw a clock face, including the numbers and hands, to evaluate their cognitive and visual-motor skills. The person is typically given a blank sheet of paper and asked to draw a clock indicating a specific time, such as "10 minutes past 10" or "quarter to 4". The test administrator may provide additional instructions or ask the person to complete specific tasks, such as placing the hands at a particular position (Larson, 2023).

The drawings are typically scored based on specific criteria, assessing elements. Different scoring systems exist, and the interpretation of the results may vary depending on the specific guidelines used. The examiner looks for different inaccuracies with the clock. They look to see how the patient draws the circle, evenly spaces the numbers, and places the hands correctly. Individuals with cognitive impairment may struggle with various aspects of the test, such as omitting numbers or difficulty following instructions. The CDT serves as a part of a comprehensive cognitive assessment and can help in identifying potential cognitive impairments (Larson, 2023).


Mini-Cog

The Mini-Cog is a brief cognitive screening tool used to assess cognitive impairment and detect potential neurocognitive disorders. It consists of two components: a three-item recall task and the CDT.. The Mini-Cog is designed to be easy to administer and requires minimal time. The person is presented with three unrelated words (for example, orange, bed, dollar) and asked to remember them. After a short delay of approximately one to three minutes, the person is asked to recall the three words. One point is given for each correctly recalled word (Larson, 2023).

The CDT is completed as described above and is scored for the presence of all necessary elements (numbers, hands) and the accuracy of the hands indicating the correct time. The scoring of the Mini-Cog involves combining the results of the recall task and the CDT. The maximum total score is 5 points: 2 points for correct recall of all three words and 3 points for a correctly drawn clock with the hands indicating the specified time. The interpretation of the Mini-Cog score can help determine whether further cognitive evaluation is warranted. Generally, a score of 3 or lower suggests the possibility of cognitive impairment or dementia, while a score of 4 or 5 is often considered normal (Larson, 2023).


Addenbrooke's Cognitive Examination (ACE-III)

The ACE-III is a comprehensive neuropsychological assessment tool used to evaluate cognitive function. It was developed as an update to the earlier version, ACE-R (Addenbrooke's Cognitive Examination-Revised), with additional items and improved sensitivity to detect cognitive impairments. The ACE-III assesses several cognitive domains, including attention, memory, language, visuospatial skills, and executive function (table 4).


Table 2. Components of the ACE-III (Larson, 2023).

Attention and Orientation This section assesses attention, concentration, and orientation to time and place through tasks such as serial subtraction, digit span, and orientation questions.
Memory Various memory tasks evaluate both immediate and delayed recall of verbal and visual information. These tasks include word recall, story recall, and a visual recognition task.
Verbal Fluency This section examines language and executive function by asking individuals to generate words belonging to specific categories (semantic fluency) or starting with a given letter (phonemic fluency).
Language Language abilities are assessed through tasks such as naming objects, following complex commands, and comprehension of written sentences.
Visuospatial Abilities This section evaluates visuospatial skills and constructional abilities, including copying a complex figure and drawing a clock.


Each section of the ACE-III is scored, and the total score ranges from 0 to 100, with higher scores indicating better cognitive function. The interpretation of the ACE-III score considers factors such as age, education level, and cultural background. Significant deviations from expected scores may suggest cognitive impairment. The ACE-III has been used extensively in research and clinical settings, but its availability and usage may vary across different healthcare settings and regions (Larson, 2023).


Diagnostics

Laboratory Testing

It is recommended that limited laboratory testing is completed for suspected neurocognitive disorders. The exception is when a patient presents with acute symptoms that mimic neurocognitive disorders or when a more detailed and specific workup is completed. Blood testing might include a vitamin B12 level, complete blood count, and thyroid-stimulating hormone. Other laboratory testing is generally done if there is a suspicion of a certain cause. For example, screenings for neurosyphilis or HIV are not recommended unless there is a high clinical suspicion. Genetic testing is rarely done and is only performed when there is a strong family history (Larson, 2023).


Imaging

The published literature has varying recommendations for routine neuroimaging for neurocognitive disorders. Some recommend neuroimaging while others emphasize the clinical exam without imaging. These practices may vary based on symptoms and practice settings. A computed tomography (CT) or Magnetic Resonance Imaging (MRI) scan of the brain generally is indicated in patients with acute onset of cognitive impairment or neurological symptoms or when clinical findings suggest a structural cause. While the CT is less expensive and is often used to rule acute problems, MRI is preferred for its ability to recognize many different types of pathological processes. MRI findings for each type of neurocognitive disorder varies, but some common findings include cerebral atrophy, ventriculomegaly, cerebrovascular disease, and microhemorrhages (Larson, 2023).


Specialized testing

Some more specialized testing might be important in some select patients. Neuropsychological testing is a lengthy and comprehensive evaluation of the cognitive domains that can be useful when bedside cognitive testing is inconclusive and in differentiating symptoms from other mental illnesses. Cerebrospinal fluid studies might be indicated in patients who are suspected to have symptoms caused by lyme disease. Positron Emission Tomography (PET) scans are very expensive and are not routinely used for the diagnosis of neurocognitive disorders (Larson, 2023).


Challenges in Diagnosing Neurocognitive Disorders

Making a diagnosis of neurocognitive disorders can be challenging due to various factors. The symptoms of different types can overlap, making it difficult to differentiate between them. Memory loss, cognitive decline, and changes in behavior can be seen in multiple forms of neurocognitive disorders and in other conditions. Many individuals with neurocognitive disorders have other medical conditions or comorbidities that can contribute to cognitive impairment. Conditions such as depression, delirium, thyroid disorders, vitamin deficiencies, or medication side effects can mimic or exacerbate cognitive symptoms (Larson, 2023).

While biomarkers, such as amyloid and tau protein levels in cerebrospinal fluid or imaging techniques like PET scans, can aid in the diagnosis of some neurocognitive disorders, they are not widely available or affordable for routine clinical use. The absence of easily accessible and highly specific biomarkers often requires a comprehensive evaluation that includes clinical history, physical examination, neuropsychological testing, and imaging studies to arrive at a diagnosis (Larson, 2023).

Furthermore, neurocognitive disorders can manifest in various ways, and the symptoms may differ among individuals. Some people may primarily exhibit memory loss, while others may present with behavioral changes, language difficulties, or visuospatial impairments. The varied symptomatology adds complexity to the diagnostic process and necessitates a comprehensive evaluation of cognitive function across multiple domains (Larson, 2023).

Another challenge is that patients may delay seeking medical attention for cognitive symptoms due to a lack of awareness or stigma associated with the condition. Patients, families, or even healthcare professionals may attribute cognitive changes to normal aging or hesitate to discuss potential symptoms. Early detection and intervention can be crucial in managing neurocognitive disorders and it is important to raise awareness and reduce the stigma surrounding cognitive decline (Larson, 2023).

Some individuals with early stages of neurocognitive disorders may compensate for their deficits, making it challenging to detect the impairment during routine clinical visits. Symptoms can be subtle and progress slowly, making it difficult to differentiate between normal aging and the early stages of disease. Regular follow-up evaluations are essential to monitor cognitive changes over time and detect potential progression (Larson, 2023).

Given these challenges, a comprehensive evaluation by a healthcare professional, often including a multidisciplinary team, is crucial for an accurate diagnosis. The assessment should consider medical history, physical examination, neuropsychological testing, imaging studies, and, when available and appropriate, the use of biomarkers. Collaboration with specialists such as neurologists, neuropsychologists, and geriatricians can enhance diagnostic accuracy and help tailor appropriate management and support (Larson, 2023).


Treatment of Neurocognitive Disorders

The treatment of neurocognitive disorders focuses on managing symptoms, slowing down disease progression when possible, and improving the individual's quality of life. The specific treatment approach depends on the underlying cause of the neurocognitive disorder. Regular monitoring and adjustments to the treatment approach are necessary as the disease progresses and symptoms change. Caregiver support, education, and access to community resources play a vital role in managing neurocognitive disorders. Medications may be prescribed to address the symptoms of neurocognitive disorders, such as changes in behavior, mood, or movement, or to treat underlying causes (Weinberg & Holiman, 2023).

Treatment Specific to the Underlying Disease

Alzheimer’s Disease

Pharmacological treatment of AD slows the progression of the disease. These medications may temporarily improve cognitive symptoms, behavior, and functional abilities in some individuals. Cholinesterase inhibitors (such as donepezil, rivastigmine, and galantamine) and an N-methyl-D-aspartate (NMDA) receptor antagonist (memantine) are used to treat AD. Cholinesterase inhibitors help to increase the levels of acetylcholine, a neurotransmitter involved in memory and learning. Memantine works by regulating glutamate, a neurotransmitter that is excessively active in AD (Weinberg & Holiman, 2023).


Dementia with Lewy Bodies

There is no cure for DLB, treatment focuses on managing symptoms, improving quality of life, and providing supportive care. Cholinesterase inhibitors are commonly used to improve cognitive function and manage symptoms related to memory and thinking, however, these medications may also exacerbate Parkinson-type symptoms in some individuals, so careful monitoring is necessary. In some cases, medications used for Parkinson's disease, such as levodopa, may be prescribed to manage motor symptoms (Weinberg & Holiman, 2023; Larson, 2023).

Frontotemporal Dementia

There are no medications specifically approved for the treatment of FTD. All pharmacological treatment of FTD is aimed at managing symptoms that are associated with the disorder and improving quality of life (Weinberg & Holiman, 2023; Larson, 2023).

Parkinson’s Disease Dementia

Medications may be prescribed to address both the motor symptoms of PD and the cognitive symptoms of PDD. Levodopa, which is the mainstay of treatment for PD, can help manage motor symptoms and may also provide some benefit for cognitive symptoms. Cholinesterase inhibitors may also be prescribed to address cognitive symptoms. As PDD is associated with both cognitive decline and motor symptoms of PD, optimizing the treatment of motor symptoms is important. This may involve adjusting medication dosages, adding or modifying anti-parkinsonian medications, or considering deep brain stimulation (DBS) surgery in select cases (Weinberg & Holiman, 2023).

Vascular Causes

The treatment of vascular dementia aims to manage symptoms, slow down disease progression, and reduce the risk of future vascular events. Medications may be prescribed to manage underlying vascular risk factors and reduce the risk of further vascular damage such as medications to control high blood pressure, manage diabetes, lower cholesterol levels, prevent blood clot formation, and improve blood circulation. Additionally, in some cases, medications used for Alzheimer's disease, such as cholinesterase inhibitors or memantine, may be prescribed to manage cognitive symptoms (Weinberg & Holiman, 2023).

Treating and managing acute vascular events, such as stroke, is crucial to minimize further damage to the brain. Prompt medical attention and appropriate interventions, such as medications to dissolve blood clots or surgical procedures, may be required in case of a stroke. Controlling vascular risk factors is essential in managing vascular dementias. This includes regular monitoring and management of blood pressure, blood sugar levels, cholesterol levels, and overall cardiovascular health. Lifestyle modifications, as mentioned later, play a significant role in reducing vascular risk (Weinberg & Holiman, 2023).

Traumatic Causes

Medical management focuses on addressing the immediate and long-term consequences of the traumatic event. This may involve stabilization, surgical interventions if necessary, and management of any associated medical conditions. Rehabilitation services play a crucial role in maximizing functional abilities and improving overall quality of life. These therapies aim to restore or compensate for cognitive, physical, and communication impairments resulting from the traumatic event (Weinberg & Holiman, 2023).

Non-pharmacological interventions and medications may be used to manage specific symptoms associated with trauma-related neurocognitive disorders. For example, medications may be prescribed to address cognitive symptoms, such as memory loss or attention deficits. Behavioral and psychological symptoms, such as aggression or mood changes, may be managed through behavioral interventions, psychotherapy, or medications as required (Weinberg & Holiman, 2023).

Infectious Causes

Neurocognitive disorders caused by infections, such as HIV-associated neurocognitive disorders or neurosyphilis, require a multifaceted approach to treatment. The specific treatment approach depends on the underlying infection and the associated neurocognitive symptoms. The primary goal is to address the underlying infection that is causing or contributing to the neurocognitive symptoms. This may involve administering appropriate antimicrobial medications specific to the infectious organism. Treatment protocols are determined based on the specific infection diagnosed through laboratory tests and clinical evaluation. Combination therapy or long-term treatment may be necessary. In some cases, preventing recurrent or additional infections is crucial to minimize the risk of further cognitive decline. This may involve implementing infection control measures such as safe sexual practices, preventing tick bites, and addressing any underlying factors that increase susceptibility to infections. The involvement of infectious disease specialists to develop an individualized treatment plan based on the specific infection may also be necessary (Weinberg & Holiman, 2023).

Metabolic Causes

Neurocognitive disorders caused by metabolic factors, such as metabolic encephalopathy, hypothyroidism, or vitamin deficiencies, require targeted treatment to address the underlying metabolic abnormalities. The primary focus is to address the underlying metabolic abnormality that is contributing to the neurocognitive symptoms. The choice of treatment depends on the specific metabolic disorder diagnosed through laboratory tests and clinical evaluation. Balancing electrolyte levels and correcting fluid imbalances is used in cases of metabolic encephalopathy. Treating hypothyroidism with thyroid hormone replacement therapy is needed to treat thyroid-induced neurocognitive symptoms. Correcting vitamin deficiencies through supplementation or dietary modifications is required for vitamin B deficiencies (Weinberg & Holiman, 2023).

In cases where nutritional deficiencies contribute to neurocognitive disorders, optimizing nutrition and dietary intake is essential. This may involve working with a registered dietitian to ensure adequate intake of essential nutrients through a well-balanced diet or considering specific supplements as needed. Patients may also require a referral to endocrinology (Weinberg & Holiman, 2023).


General Treatment Interventions

Non-pharmacological approaches are employed to manage symptoms associated with neurocognitive disorders. This includes implementing strategies to support memory, communication, and daily functioning. Occupational therapy, cognitive rehabilitation, speech therapy, and other interventions may be used to address specific areas of impairment and enhance overall functioning (Weinberg & Holiman, 2023).


Supportive Care

Comprehensive supportive care is essential for individuals with neurocognitive disorders and their caregivers. Supportive care may involve assistance with activities of daily living, managing behavioral and psychological symptoms, providing emotional support, and offering education and resources for both the individual and their caregivers. Support groups and counseling can provide valuable emotional support and education. These resources can help manage the emotional and psychological impact of neurocognitive disorders and provide practical strategies for coping with the challenges it presents (Weinberg & Holiman, 2023).


Lifestyle Modifications

Adopting a healthy lifestyle can have a positive impact on overall well-being and may potentially slow down cognitive decline. This includes regular physical exercise, a balanced diet, adequate sleep, social engagement, and mental stimulation (Weinberg & Holiman, 2023).


Sleep Management

Sleep disturbances are common in certain types of neurocognitive disorders. Strategies to promote healthy sleep patterns may include establishing a regular sleep schedule, avoiding stimulants close to bedtime, and creating a comfortable sleep environment. In some cases, medications may be prescribed to manage sleep-related symptoms (Weinberg & Holiman, 2023).


Mood and Behavioral Changes

Medications for changes in mood and affect may include antidepressants, antipsychotics, or mood stabilizers depending on the symptoms and individual needs. Careful monitoring of medication response and potential side effects is essential (Weinberg & Holiman, 2023).


Medication Reconciliation

In some cases, neurocognitive symptoms may be worsened by certain medications or polypharmacy. Reviewing the medication regimen and adjusting or discontinuing medications that may contribute to cognitive impairment can be beneficial. This is especially true in the older adult population (Weinberg & Holiman, 2023).


Research and Clinical Trials

Research in neurocognitive disorders is quickly growing. Participation in research studies and clinical trials can provide access to potential new treatments and contribute to advancements in the field of neurocognitive disorders. These trials investigate various approaches, including disease-modifying treatments and interventions targeting specific causes or mechanisms (Weinberg & Holiman, 2023).


Behavioral and Psychological Interventions

Behavioral interventions, counseling, and psychoeducation for both patients and their caregivers are crucial in managing changes in mood, affect, and behavior. Strategies to manage challenging behaviors, enhance communication, and optimize daily functioning are implemented (Weinberg & Holiman, 2023).


Rehabilitation

Speech and Language Therapy

As neurocognitive disorders can impact language abilities, speech and language therapy may be beneficial. Speech-language pathologists (SLPs) can work with individuals to address communication difficulties, improve speech clarity, and develop strategies for maintaining functional communication. They can also treat patients who have difficulty swallowing and perform cognitive evaluations (Gupta, Prakash, & Sannyasi, 2021; Weinberg & Holiman, 2023).


Occupational Therapy

Occupational therapists (OT) can help individuals with neurocognitive disorders to maintain independence and optimize daily functioning. They may provide strategies to compensate for cognitive and behavioral changes, address difficulties with executive function, and promote engagement in meaningful activities (Weinberg & Holiman, 2023). OTs work with individuals with neurocognitive disorders to enhance their ability to perform self-care activities independently. This includes tasks such as dressing, bathing, grooming, toileting, and feeding. They may introduce adaptive strategies, modifications to the environment, and specialized equipment to promote independence and safety in daily activities (Gupta, Prakash, & Sannyasi, 2021).

OTs assess the living environment and make recommendations for modifications to promote safety, accessibility, and orientation. They provide education and support to caregivers, equipping them with strategies to manage the challenges associated with caring for someone with neurocognitive disorders. They educate caregivers about environmental modifications, activity adaptations, and techniques for promoting independence and managing behavioral symptoms. OTs may also offer stress management techniques and resources to support caregiver well-being (Gupta, Prakash, & Sannyasi, 2021).


Physical Therapy

Physical therapists (PTs) play a valuable role in supporting individuals with neurocognitive disorders to maintain their physical function, mobility, and overall well-being. They assess the individual's mobility and gait abilities and develop appropriate exercise and training programs to promote safe and independent movement. This may involve exercises to improve strength, balance, coordination, and flexibility. PTs may also provide gait aids or assistive devices, such as canes or walkers, to enhance stability and mobility (Gupta, Prakash, & Sannyasi, 2021).

PTs evaluate the risk of falls and implement interventions to minimize fall risk. They may provide exercises to improve strength and balance, recommend environmental modifications to reduce hazards and teach strategies for safe transfers and mobility. They focus on improving or maintaining the ability to perform functional activities. They work with individuals to enhance their capacity to perform daily tasks such as getting in and out of bed, sitting and standing, and navigating stairs. PTs may use task-specific training and adaptive techniques to maximize independence. They provide education and training to caregivers, offering strategies and techniques to assist individuals with neurocognitive disorders in their mobility and physical functioning. Caregivers learn proper techniques for transfers, mobility assistance, and exercises to support their loved ones' physical well-being (Gupta, Prakash, & Sannyasi, 2021).


Nursing Interventions

Nurses care for patients with neurocognitive disorders in a myriad of practice settings from acute care, to long-term care, to ambulatory care. Nurses can promote quality of life for individuals with neurocognitive disorders through nursing interventions that focus on providing comprehensive care, ensuring safety, promoting functional abilities, managing behavioral symptoms, and enhancing daily life (Ignatavicius, et al., 2021).


Person-Centered Care

Patient-centered care is an approach to healthcare that places the patient at the center of their own care and emphasizes their individual preferences, needs, values, and goals. It is a collaborative approach that involves healthcare providers working in partnership with patients and their families to make decisions about their care (Gupta, Prakash, & Sannyasi, 2021). Recognizing and respecting the unique values, beliefs, and cultural background of each patient, using active listening strategies, involving them in decision-making, providing education so that they can make informed decisions, and considering their preferences when developing the plan of care (Ignatavicius, et al., 2021).


Continuity and Coordination of Care

Ensuring smooth transitions between different healthcare settings and providers is an essential part of nursing care in this population. This involves effective communication and coordination among healthcare professionals, reconciling medications, sharing of relevant information, and involving patients in care transitions. Many interdisciplinary team members will be involved in the care of these patients and often a particularly significant family involvement (Ignatavicius, et al., 2021).

Emotional Support

Nurses must address the emotional and psychosocial needs of patients and their families. This includes providing empathy, compassion, and support, as well as addressing emotional and mental health concerns that may arise during the course of treatment (Gupta, Prakash, & Sannyasi, 2021). Early on, reorientation is usually appropriate. Validation therapy is used in mid to late-stage neurocognitive disorders. In these patients, reorientation attempts may only lead to increased agitation. Instead of reorienting, nurses should validate the patient’s feelings and concerns without reinforcing their confused thoughts. Actions to avoid when the patient is agitated include speaking loudly, being confrontational or argumentative, trying to reason with them, taking offense, or explaining (Ignatavicius, et al., 2021).


Access to Care

Nurses can facilitate timely access to appropriate care and services by reducing barriers to access, such as language barriers, transportation issues, or financial constraints. Since patients with neurocognitive disorders often transition through multiple care settings, this is particularly important (Ignatavicius, et al., 2021).


Safety Measures

Nurses should implement safety measures to prevent falls, injuries, and wandering. This may include modifying the environment, installing safety devices, ensuring proper lighting, applying non-skid footwear, and using assistive devices such as beds, chairs, door alarm locks, or motion sensors. Patients living in the community at risk for wandering should wear a medical alert bracelet indicating memory problems. Items that may cause injury if misused should be removed from the home including weapons or car keys for patients who should not drive. (Ignatavicius, et al., 2021).

Homes should have working smoke, natural gas, and fire alarms in case the individual with neurocognitive deficits accidentally sets a fire. They may turn on the stove to cook but forget that the burner is on. Nightlights can be installed to make walking in the dark easier and bathroom handlebars near the toilet and shower. Clutter and items such as throw rugs should be removed (Ignatavicius, et al., 2021; Gupta, Prakash, & Sannyasi, 2021).


Cognitive Stimulation

Cognitive stimulation activities help to maintain cognitive function and enhance quality of life. This can include puzzles, games, reminiscence therapy, music therapy, and sensory stimulation. Activities should be tailored to the individual’s abilities and interests. Some communities have adult daytime programs for those living in the community as a safe place to participate in activities. Nurses can also help families caring for loved ones with neurocognitive disorders choose appropriate activities (Ignatavicius, et al., 2021).


Daily Routine and Structured Environment

Establishing a structured and predictable daily routine can provide a sense of familiarity and reduce confusion and anxiety. When caring for patients with neurocognitive disorders, nurses maintain consistency in daily activities, mealtimes, and sleep patterns to promote a stable and predictable environment. Frequently used items, such as keys or glasses, should be put in the same place every day. For patients with mild neurocognitive deficits, a large clock and single-day calendar can help patients keep track of the day. Nurses should encourage family members and other caregivers to do the same (Ignatavicius, et al., 2021).


Communication Techniques

Nurses should use effective communication strategies to enhance understanding and minimize frustration. Speak clearly and slowly, use simple language, maintain eye contact, and provide visual cues. Non-verbal communication, such as touch and gestures, can also be valuable. When explaining complex instructions to patients, nurses should break them down into short and easy steps (Ignatavicius, et al., 2021).


Behavior Management

Nurses can help to develop individualized behavior management plans to address challenging behaviors, such as agitation, aggression, or wandering. Identify triggers, implement redirection techniques, provide a calm environment, and use validation and reassurance approaches (Ignatavicius, et al., 2021).

Assistance with Activities of Daily Living (ADLs)

Supporting patients with ADLs such as bathing, dressing, toileting, and eating is a big part of nursing care in long-term care, rehabilitation, and acute care settings. Provide the patient with appropriate cues, simplify tasks, and promote independence to the extent possible (Ignatavicius, et al., 2021). For example, the patient can choose what they’d like to wear, but caregivers can put complete outfits on hangers so that the choices don’t get overwhelming. Adapt to the environment and use assistive devices when needed. Coordinate the plan of care with an occupational therapist to maximize independence (Ignatavicius, et al., 2021).


Medication Management

The nurse should administer medications as prescribed, monitor responses, and manage any side effects. Nurses must work closely with healthcare providers to ensure appropriate medication management for cognitive symptoms and co-existing conditions (Ignatavicius, et al., 2021).


Family and Caregiver Support

The nurse should offer support, education, and regular communication to families and caregivers. Nurses provide information about the disease progression, coping strategies, and available resources. Involve families in care planning and encourage their participation in activities and visits (Ignatavicius, et al., 2021).

Nurses can counsel family members to maintain realistic expectations for the person with neurocognitive disorders. For irreversible causes of neurocognitive disorders, the patient and family should research alternative care settings early in the disease process to be used later if needed. Advanced directives should also be completed early on. Caregivers should prioritize self-care practices by setting aside time away from their loved ones. For longer periods of time, respite care should be considered. Not only is a nutritious diet, physical activity, and adequate rest important for the patient, but it is critically important for the caregiver as well. Accepting help from other loved ones and community resources can give the caregiver a much-needed break. Caregivers can seek support from support groups or religious support if desired (Ignatavicius, et al., 2021).


Cultural Considerations

Cultural considerations play a vital role in the care of patients with neurocognitive disorders as they influence an individual's beliefs, values, preferences, and attitudes toward health and care (Gupta, Prakash, & Sannyasi, 2021). Language barriers can impair communication and understanding between caregivers, healthcare professionals, and individuals. It is crucial to use professional interpreters or translators when necessary to ensure effective communication. Additionally, considering cultural norms around communication styles, such as respect for elders or the use of non-verbal cues, can help establish rapport and understanding. In many cultures, the family plays a central role in caregiving. Involving family members in care decisions and providing support and education can help ensure a person-centered approach. Recognize and respect the dynamics of the family unit and consider involving designated family caregivers in care planning and providing cultural support (Ignatavicius, et al., 2021).

Cultural dietary practices and preferences should be respected when providing meals and snacks. Be aware of dietary restrictions or preferences based on cultural or religious beliefs and provide culturally appropriate meal options whenever possible. This may involve avoiding certain foods, accommodating special diets, or considering cultural traditions around mealtimes. Spirituality and religious beliefs may provide comfort and support. Respect and facilitate the person's spiritual practices and consider incorporating spiritual or religious rituals into their care, if desired. This may involve arranging visits from religious leaders, providing space for prayer or meditation, or offering access to religious texts (Ignatavicius, et al., 2021).

Some cultures prioritize community and social connections. Encourage involvement in cultural or community activities that promote engagement and socialization. This may include connecting individuals to cultural or religious organizations, community groups, or support networks that understand and respect their cultural background. In certain cultures, traditional healing practices may be sought alongside conventional medical care. It is important to acknowledge and respect these practices while ensuring their compatibility with evidence-based approaches. Collaborate with healthcare providers and cultural liaisons to understand traditional healing practices and find ways to integrate them effectively into the care plan (Ignatavicius, et al., 2021).

Cultural beliefs and attitudes surrounding mental health and neurocognitive disorders may contribute to stigma and impact help-seeking behaviors. Addressing stigma and promoting mental health awareness within cultural contexts is essential. Providing education about neurocognitive disorders, dispelling misconceptions, and offering culturally sensitive support and counseling can help individuals and families overcome stigma and seek appropriate care (Ignatavicius, et al., 2021).


End-of-Life Care

End-of-life care for individuals with advanced neurocognitive disorders requires a compassionate and holistic approach that focuses on providing comfort, dignity, and support (Gupta, Prakash, & Sannyasi, 2021). Nurses should encourage early discussions about end-of-life wishes and preferences, including medical interventions, life-sustaining treatments, and palliative care options. Help individuals and their families make informed decisions and create advance directives, such as living wills or durable power of attorney for healthcare, while the person can still actively participate (Ignatavicius, et al., 2021).

The focus of care should be on relieving distressing symptoms and maximizing comfort. This may involve managing pain, addressing agitation or restlessness, managing breathing difficulties, and providing appropriate nutrition and hydration. Nurses work closely with healthcare providers, including palliative care specialists, to develop a personalized symptom management plan. Counseling, reassurance, and validation of emotions should be provided. The involvement of social workers, psychologists, or counselors to assist with emotional support and to help families navigate the end-of-life process may be necessary (Ignatavicius, et al., 2021).

Nurses should maintain communication and social interaction as much as possible by adapting strategies to the individual's cognitive abilities. They can use touch, music, familiar voices, and non-verbal cues to connect with the person. Encourage family and friends to visit, share memories, and provide emotional support. Education, guidance, and counseling can be offered to help them understand the progression of the disease and cope with the challenges they may face. Involve family members in care decisions to ensure they have opportunities to say goodbye and participate in meaningful ways (Ignatavicius, et al., 2021).

Create a calm and comfortable environment that promotes relaxation and reduces agitation. Control noise levels, adjust lighting, and provide familiar objects or photographs to create a sense of familiarity and comfort. Consider the person's cultural and spiritual beliefs when arranging the environment. Collaborate with palliative care or hospice teams to ensure comprehensive care. Palliative care focuses on managing symptoms and providing support throughout the disease trajectory, while hospice care specifically addresses end-of-life care. These specialized teams can provide expertise in pain and symptom management, psychosocial support, and coordination of care (Ignatavicius, et al., 2021).

Incorporate cultural and spiritual practices that are important to the person and their family. Respect their beliefs and traditions around death, dying, and bereavement. Collaborate with spiritual advisors or cultural liaisons to provide appropriate support and rituals as desired. Offer bereavement support to the family following the death of their loved one. Provide information about grief support groups, counseling services, and resources to help them navigate the grieving process (Ignatavicius, et al., 2021).


Conclusion

Caring for patients with neurocognitive disorders requires a comprehensive approach to nursing care that addresses their unique needs and challenges. It is a complex and multifaceted task that demands knowledge, compassion, and adaptability. From early detection and accurate diagnosis to providing appropriate interventions and support, healthcare professionals and caregivers play a crucial role in improving the quality of life for individuals with neurocognitive disorders. Ongoing research and advancements continue to provide hope for better understanding, prevention, and treatment in the future.


References

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Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2021). Medical-surgical nursing: Concepts for interprofessional collaborative care (10th ed.). Elsevier: St. Louis, MO.

Orchowski, L. M. & López, G. (2023). Clinical overview: Acute stress disorder. Clinical Key for Nursing. Retrieved on May 1, 2023 from https://www.clinicalkey.com/nursing/#!/content/derived_clinical_overview/76-s2.0-B9780323755733000317

Jitender S. (2023). Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical manifestations, course, assessment, and diagnosis. Up to Date. Retrieved on April 24, 2023 from https://www.uptodate.com/contents/posttraumatic-stress-disorder-in-adults-epidemiology-pathophysiology-clinical-manifestations-course-assessment-and-diagnosis