What is Major Neurocognitive Disorder (Dementia)?
The term dementia has undergone some changes in medical terminology. In the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), used by doctors to diagnose mental disorders, this condition is now known as Major Neurocognitive Disorder (MND). However, you may still hear it referred as dementia due to its widespread use in everyday language and medical texts. It’s important to note though, that referring to this condition as dementia can be limiting. Contrary to general perceptions, dementia is not only associated with older individuals or synonymous with Alzheimer’s disease. MND can affect people of various age groups and doesn’t always mean Alzheimer’s is the cause of their cognitive decline.
MND is basically the significant impairment in one’s cognitive abilities – which is our ability to think, reason, remember, and process information. This can affect different areas including the ability to plan and organize (executive function), pay attention (complex attention), use language, learn and remember things, interpret sensation and movement (perceptual-motor), or understand and react in social situations (social cognition). This decline shows up as a noticeable and continual reduction of abilities compared to what the person was capable of before the impairments. This decline is not part of normal aging and it’s not temporary confusion due to an illness or medical condition, like delirium.
Additionally, a definite diagnosis of dementia also includes the decline in a person’s ability to complete daily tasks. This can be managing finances or medications, or in more serious cases, basic activities like personal grooming or feeding oneself. It’s a progressive condition, which means it gets worse over time, and sadly the people affected often don’t recognize their own difficulties. Unfortunately, we don’t yet have a cure for any of the causes of dementia.
Dementia is a growing issue, especially with increasing life expectancy. Presently, around 47 million people globally are living with dementia, and this number is projected to rise to 131 million by 2050. Particularly in the United States, Alzheimer’s disease, which is a common cause of dementia, is the fifth leading cause of death for people aged 65 and older. The impact of dementia is significant, both in terms of health and finance. The lifetime cost of caring for a person with dementia is nearly $200,000 more than caring for someone without dementia. In 2010, the estimated cost for treating dementia was about $200 billion in the United States, and around $600 billion globally. With growing numbers, these costs are expected to increase further.
What Causes Major Neurocognitive Disorder (Dementia)?
Several conditions can lead to Major Neurocognitive Disorders (MNDs), with Alzheimer’s being the most common cause and comprising approximately 70% of cases. The framework provided in the DSM-5, which is a guide for mental health professionals to diagnose mental illnesses, identifies 13 potential causes of MNDs. These include Alzheimer’s disease, vascular disease (which affects the blood vessels), diseases that affect the brains, such as frontotemporal lobar degeneration and Lewy body disease, as well as Parkinson’s disease, HIV infection, and Huntington’s disease. Other potential causes for MNDs include prion disease, substance or medication misuse, brain injury from trauma, or other medical conditions. A person may even have more than one cause contributing to MND. For instance, a person could have both Alzheimer’s disease and vascular disease at the same time.
Other medical conditions that can lead to dementia, which is a type of MND, include progressive supranuclear palsy (a disorder that affects movement and balance), corticobasal syndrome (a rare neurological disorder), and, on rarer occasions, multiple system atrophy (a disorder that affects the nervous system).
The exact cause of MND can be described as “possibly” or “probably” depending on how sure doctors are about the cause. It often takes some time to determine the exact cause and a combination of factors can assist with this. These include results from medical scans, laboratory tests, genetic markers, a person’s existing health conditions, their personal and family medical history, and findings from clinical examinations.
Risk Factors and Frequency for Major Neurocognitive Disorder (Dementia)
Alzheimer’s disease is the leading cause of dementia, making up 70 to 80% of all cases. It can occur randomly or it can run in families. Vascular dementia makes up about 15% of all dementia cases, and it becomes more common as people get older. Diagnosing Lewy body dementia can be challenging, and because of this, its accurate representation in the data is unclear, but it makes up about 5% of all cases. Parkinson’s disease dementia accounts for about 10% of all cases. Dementia in people over 65 is often frontotemporal dementia, which makes up 25% of cases in this group. However, it’s also the second most common type of dementia in people under 65, although it’s difficult to identify due to limitations in the studies. Creutzfeldt-Jakob disease is rare and affects only 1 to 2 people per million each year worldwide. There’s also the possibility of having mixed dementia, which is when a person has more than one type. The most common combination is Alzheimer’s disease with vascular dementia.
- Alzheimer’s disease is the leading cause of dementia, accounting for 70-80% of all cases.
- Vascular dementia makes up about 15% of all dementia cases and becomes more common with age.
- Lewy body dementia can be challenging to diagnose and accounts for around 5% of all dementia cases.
- Parkinson’s disease dementia contributes to approximately 10% of all dementia cases.
- Frontotemporal dementia accounts for 25% of dementia cases in individuals over 65 years old and is the second most common type in people under 65.
- Creutzfeldt-Jakob disease is a rare form of dementia, affecting 1-2 people per million each year worldwide.
- Mixed dementia is when a person has more than one type of dementia, with Alzheimer’s and vascular dementia being the most common combination.
Signs and Symptoms of Major Neurocognitive Disorder (Dementia)
When talking to a patient (or those close to them) who may be suffering from dementia, it’s crucial to understand their history and current behaviors. They may experience changes in their behavior, memory loss, difficulty with familiar tasks, mood swings, aggression, withdrawing from social activities, neglecting personal care, difficulty communicating, and a loss of independence, among other things. It’s important to know a patient’s medical history, including past illnesses, medications, family history, and substance use. Interestingly, the patient’s perception of their cognitive decline can often differ from that of their caregivers or companions. It’s also essential to gauge their current ability to perform everyday tasks and whether they’re at risk in their home environment. Ask questions about their ability to use everyday appliances, if they can evacuate the house safely in case of an emergency, or if they are prone to exploitation.
Apart from common dementia symptoms, there are other specific symptoms associated with different types of dementia:
- Lewy body dementia: well-formed visual hallucinations, sleep behavior disorder, parkinsonian-like symptoms, fluctuating cognition, attention, and alertness.
- Frontotemporal dementia: behavior changes like disinhibition and apathy, and speech difficulties.
- Creutzfeld-Jakob disease: myoclonic jerks, visual changes, ataxia, and memory and behavior changes.
- Huntington disease: chorea (irregular, rapid, jerky movements), irritability, and depression.
- Vascular dementia: stepwise declines in cognitive function.
- Parkinson disease dementia: symptoms of parkinsonism such as slow movement (bradykinesia), resting tremor, and muscle rigidity appear, along with visual hallucinations and delusions in the later stages.
- Multiple system atrophy: symptoms of autonomic failure and cerebellar ataxia.
- Progressive supranuclear palsy: frequent falls (often backward) and vertical supranuclear gaze palsy.
- Corticobasal syndrome: progressive asymmetric muscle rigidity and alien limb phenomenon.
The physical exam for dementia patients should be thorough, including a full neurological assessment and analysis of the patient’s walking patterns.
Testing for Major Neurocognitive Disorder (Dementia)
The exact type of dementia can only be determined after a person’s death. However, doctors can often make a probable diagnosis based on a patient’s medical history, along with brain imaging tests and other lab evaluations. It’s also necessary to rule out any other conditions that could be causing memory or thinking problems. To do this, all areas of a person’s mental ability must be checked.
There are several ways doctors can evaluate cognitive impairment, or problems with thinking and memory. These include tools like the Mini-mental status examination, the Montreal Cognitive Assessment, and the Rowland Universal Dementia Assessment Scale, among others.
Each method has its advantages. The Montreal cognitive assessment is great for detecting mild memory problems and takes about 10 minutes. The Mini-Cog is often used to check for Major Neurocognitive Disorder (MND) and only takes about 3 minutes. The Rowland scale is used for comparing results across different cultures, and can be done with a translator. However, these tests on their own can’t diagnose dementia, as they also need to show a decrease in the person’s ability to perform daily tasks. These tests can be done again over time to monitor the person’s condition and help understand the severity of the problem, along with identifying which mental abilities are affected. More detailed, specialized tests can provide additional diagnostic information and pick up subtle differences or hard-to-diagnose cases.
Doctors often order lab tests to evaluate a person for dementia. These include tests to check blood count, urine, Vitamin B12 and folic acid levels, thyroid function, and tests for infections like syphilis and HIV. Depending on the individual, a doctor might also request tests for inflammation, spinal fluid, heavy metals, Wilson’s disease (a genetic disorder causing copper buildup), Lyme disease, or abnormal proteins in the blood.
Brain imaging is another technique doctors may use. This is especially true if the dementia symptoms started at a young age, progress quickly, or are unusual. A brain MRI can provide valuable information about changes in the brain due to issues like stroke or overall shrinkage of the brain. A DaTscan uses a radioactive tracer and a type of brain imaging called a SPECT scan to show if the brain is having problems processing dopamine, a chemical that helps send information in the brain. This can help diagnose disorders like Parkinson’s disease and Lewy Body dementia. More complex brain scans like PET, SPECT, and fMRI, can also help identify dementia early on and monitor its progression. Additionally, they can help distinguish between causes of dementia. These tests are only used in specific cases as they can be expensive.
Research is being conducted on new tests that look at cerebrospinal fluid and blood to identify Alzheimer’s disease, a common cause of dementia. These tests look at different proteins related to Alzheimer’s and other indicators of damage to the nerve cells in the brain. However, these tests are not yet ready to be used in regular clinical practice.
Treatment Options for Major Neurocognitive Disorder (Dementia)
There are several FDA-approved medications available to improve cognitive function in patients with Alzheimer’s disease, including cholinesterase inhibitors and a drug called memantine. Cholinesterase inhibitors, which include donepezil, galantamine, and rivastigmine, work by preventing the breakdown of a chemical in the brain called acetylcholine. The goal of these drugs is to slow or delay the worsening of Alzheimer’s symptoms.
Memantine, on the other hand, is an NMDA antagonist. It works by decreasing the activity of a brain chemical called glutamine. These medications can be used in different stages of Alzheimer’s disease. For example, donepezil and the patch form of rivastigmine are approved for all stages of the disease, while galantamine is approved for the early to middle stages and memantine for the middle to late stages.
It’s important to note that these drugs may not work for everyone, and they can also have significant side effects, including the potential for heart problems, stomach ulcers, and weight loss. In addition, memantine may also have neuroprotective benefits by preventing harmful chemical imbalances and excess calcium from damaging brain cells.
A newer Alzheimer’s medication called aducanumab, which targets a protein in the brain called amyloid beta, was also recently approved by the FDA. However, the use of aducanumab is currently a topic of debate. Its high cost and unclear clinical benefits have been points of concern. Aducanumab was approved because it showed positive results in only one of two major clinical trials and because it can reduce amyloid beta plaques in the brain, but it’s not proven that this effect is significant in improving symptoms.
In addition to medication, lifestyle changes can also benefit cognitive function. This includes improving sleep habits, following an anti-inflammatory diet, getting regular exercise, treating any hearing or vision loss, managing stress, and maintaining normal levels of blood sugar, cholesterol, and blood pressure. When someone is dealing with Alzheimer’s, they may also experience behavioral changes such as irritability, anxiety, and depression. Antidepressants or antipsychotic medications might be used to help manage these symptoms.
Non-drug services, like supportive care, memory training, exercise programs, and activities that mentally and socially stimulate patients are also recommended. It’s very important for patients and their families to understand the disease and its impacts. They should be given all needed information about what to expect and how to respond. Caregivers should also be trained on how to manage patient behavior effectively and how to navigate potential challenges that may arise as the disease progresses. For safety reasons, restrictions on patients’ ability to drive may be needed in some cases.
What else can Major Neurocognitive Disorder (Dementia) be?
When evaluating someone for dementia, which is a major neurocognitive disorder, doctors need to consider several other conditions that can show similar symptoms. These conditions can include:
- Delirium
- Depression
- Drug use
- Normal changes in memory associated with aging
- Mild cognitive impairment
- Stress
- Structural brain abnormalities like brain tumors, subdural hematoma, or normal pressure hydrocephalus
- Infections such as HIV and neurosyphilis
- Thiamine deficiency
- Deficiencies in Vitamin B12, folic acid, or Vitamin E
- Thyroid disorders
- Metabolic abnormalities and derangements
- Medication-induced conditions
What to expect with Major Neurocognitive Disorder (Dementia)
Dementia generally has a poor prognosis. This means the outlook isn’t usually optimistic as it generally worsens over time and there is currently no cure or treatment. Within one year of having dementia, it is estimated that 30 to 40% of individuals pass away, and within five years, this increases to 60 to 65%. Men tend to have a higher risk of mortality due to dementia as compared to women. The mortality rates for patients who have been hospitalized with dementia are found to be higher than for those present with cardiovascular diseases.
Possible Complications When Diagnosed with Major Neurocognitive Disorder (Dementia)
Dementia is a condition that can impact various parts of the body leading to different complications. These complications include:
- Poor nutrition
- Pneumonia
- Difficulty carrying out self-care routines
- Problems related to personal safety
- Bone fractures due to falls
- Experiencing hallucinations and false beliefs
- Lack of interest or enthusiasm
- Restlessness and irritability
- Difficulty in swallowing
- Death
- Depression
- Involuntary urination or defecation
- Changes in personality
- Infections
Preventing Major Neurocognitive Disorder (Dementia)
Being diagnosed with dementia is often a challenging and demanding experience for both the patient and their loved ones. That’s why it’s so crucial to educate patients and their caregivers on the ways to manage this condition. This includes understanding the importance of regular visits to the doctor, taking prescribed medication correctly, maintaining a healthy diet, exercising, and ensuring proper sleep routines.
As the condition advances, safety becomes a more serious concern. It’s vital to consider potential safety issues. For instance, it may become necessary to stop driving, or there could be risks, like getting lost or having an accident while cooking. Sometimes, people with dementia might not realize their limitations, which can present extra challenges.
It can often be more effective for caregivers to gently guide or comfort the patients, rather than trying to correct them. Support groups can be very beneficial in helping manage feelings of anxiety, loneliness, anger, frustration, and depression that might come up.
It’s important for both the patient and the caregiver to have a clear understanding of the diagnosis, and what to expect as the condition progresses. Crafting a personalized care plan can equip the patient in dealing with dementia.
