Psychopathology

seminar
By
Ajeet. M
23PSYB03
TOPIC
• Mild cognitive Impairment and Dementia: Diagnostic
criteria for MCI and major neurocognitive disorder,
subtypes of dementia (Alzheimer's, Vascular, Lewy
body, frontotemporal), Neuropsychological assessment
and neuroimaging, pharmacological and non-
pharmacological interventions
Mild Cognitive Impairment (MCI)
• MCI is a decline in cognitive function that is small but
detectable and that represents a transitional condition
between the cognitive changes typically associated with
normal aging and those changes that meet the criteria
for dementia.
• One or more cognitive domains may be impaired but not
significantly enough to affect every day functioning.
• At least two subtypes of MCI have been identified.
Amnestic MCI Non – Amnestic MCI
It is clinically significant memory It is characterized by impairments in
loss experienced by individuals visuospatial skills, language use, or
whose other cognitive capacities other cognitive functions besides
(e.g., executive function, language memory
use) are largely intact
Such individuals are at increased Individuals with this subtype may be
risk for developing dementia due at risk for other forms of dementia
to Alzheimer’s disease. (e.g., dementia due to Lewy body
disease), known as major
neurocognitive disorder. Also
called mild neurocognitive disorder.
Diagnostic Criteria of MCI
• A. Evidence of modest cognitive decline from a previous
level of performance in one or more cognitive domains
(complex attention, executive function, learning and memory,
language, perceptual-motor, or social cognition) based on:
• 1. Concern of the individual, a knowledgeable informant, or
the clinician that there has been a mild decline in cognitive
function; and
• 2. A modest impairment in cognitive performance, preferably
documented by standardized neuropsychological testing or, in
its absence, another quantified clinical assessment.
Diagnostic Criteria of MCI
• B. The cognitive deficits do not interfere with capacity for
independence in everyday activities (i.e., complex
instrumental activities of daily living such as paying bills or
managing medications are preserved, but greater effort,
compensatory strategies, or accommodation may be
required).
• C. The cognitive deficits do not occur exclusively in the
context of a delirium.
• D. The cognitive deficits are not better explained by another
mental disorder (e.g., major depressive disorder,
schizophrenia).
Dementia or Major Neurocognitive
Disorder
• Dementia is a syndrome that can be caused by a number of
diseases which over time destroy nerve cells and damage the
brain, typically leading to deterioration in cognitive function
(i.e. the ability to process thought) beyond what might be
expected from the usual consequences of biological ageing.
• While consciousness is not affected, the impairment in
cognitive function is commonly accompanied, and
occasionally preceded, by changes in mood, emotional
control, behavior, or motivation.
CONT....
• Dementia has physical, psychological, social and economic
impacts, not only for people living with dementia, but also
for their carers, families and society at large. There is often a
lack of awareness and understanding of dementia, resulting in
stigmatization and barriers to diagnosis and care.
Etiology and Epidemiology of
dementia or NCD
• Currently more than 55 million people have dementia
worldwide, over 60% of whom live in low-and middle-
income countries. Every year, there are nearly 10 million new
cases.
• Dementia results from a variety of diseases and injuries that
affect the brain. Alzheimer disease is the most common form
of dementia and may contribute to 60–70% of cases.
• Dementia is currently the seventh leading cause of death and one
of the major causes of disability and dependency among older
people globally.
CONT...
• In 2019, dementia cost economies globally US$ 1.3 trillion,
approximately 50% of these costs are attributable to care
provided by informal carers (e.g. family members and close
friends), who provide on average 5 hours of care and
supervision per day.
• Women are disproportionately affected by dementia, both
directly and indirectly. Women experience higher disability-
adjusted life years and mortality due to dementia, but also
provide 70% of care hours for people living with dementia.
Prevalence of Dementia or NCD in
India
• Using nationally representative data collected in India
between 2017 and 2020, it is found that an estimated 7.4% of
people aged 60 years and older lived with dementia (8.8
million individuals).
• Dementia prevalence was higher among females than males
(9.0% vs. 5.8%) and higher in rural than in urban areas
(8.4% vs. 5.3%).
RISK FACTORS
• Things that increase the risk of developing dementia include:

1. age (more common in those 65 or older)

2. high blood pressure (hypertension)
3. high blood sugar (diabetes)
4. being overweight or obese
5. smoking
6. drinking too much alcohol
7. being physically inactive
8. being socially isolated
9. depression.
COMMON SYMPTOMS OF DEMENTIA OR NCD
Early signs and symptoms are: Common changes in mood and
• forgetting things or recent events behavior include:
• losing or misplacing things • feeling anxious, sad, or angry about
• getting lost when walking or driving memory loss
• being confused, even in familiar places • personality changes
• losing track of time • inappropriate behaviour
• difficulties solving problems or making • withdrawal from work or social
decisions activities
• problems following conversations or • being less interested in other
trouble finding words people’s emotions
• difficulties performing familiar tasks
• misjudging distances to objects visually.
.
Diagnostic Criteria of Dementia or
Major NCD
• A. Evidence of significant cognitive decline from a previous
level of performance in one or more cognitive domains (complex
attention, executive function, learning and memory, language,
perceptual-motor, or social cognition) based on:
• 1. Concern of the individual, a knowledgeable informant, or the
clinician that there has been a significant decline in cognitive
function; and
• 2. A substantial impairment in cognitive performance, preferably
documented by standardized neuropsychological testing or, in its
absence, another quantified clinical assessment.
• B. The cognitive deficits interfere with independence in
everyday activities (i.e., at a minimum, requiring assistance
with complex instrumental activities of daily living such as
paying bills or managing medications).
• C. The cognitive deficits do not occur exclusively in the
context of a delirium.
• D. The cognitive deficits are not better explained by another
mental disorder (e.g., major depressive disorder,
schizophrenia).​
Subtypes of Dementia
1. Alzheimer’s disease
2. Vascular dementia
3. Frontotemporal dementia
4. Dementia with lewy bodies
5. Alcohol related brain damage
6. Huntington’s disease
7. Parkinson’s
8. Posterior cortical atrophy (PCA)
9. Mixed dementia
1. Alzheimer’s disease
• Alzheimer’s disease is the most common form of dementia. It is
caused by a build-up of proteins in the brain which affect how the
brain cells transmit messages.
• In the early stages, the symptoms of Alzheimer’s disease are often
very mild. The most noticeable symptom is usually memory loss. The
person might:
1. forget recent events or 4. forget the names of people, objects or
conversations places
2. misplace items or put them in the 5. struggle to find the right words
wrong place (eg putting their keys 6. repeat themselves
in the fridge)
3. forget appointments
In the middle stages, symptoms may include:
• increasing confusion and • obsessive or repetitive
disorientation, e.g. getting lost in behaviors
familiar places • speech and language difficulties
• delusions (believing things that • disturbed sleep
are not true, eg that a family • difficulty with spatial awareness,
member is stealing from them) eg judging speed and distance
• hallucinations (seeing or hearing
things that are not real)
• In the late stages, new symptoms may develop including:
• aggressive behavior • loss of speech
• incontinence • mobility problems
• difficulty eating and swallowing • weight loss
• becoming increasingly weak and
frail.
Major or Mild Neurocognitive
Disorder Due to Alzheimer’s Disease
Diagnostic Criteria
A. The criteria are met for major or mild neurocognitive
disorder.
B. There is insidious onset and gradual progression of
impairment in one or more cognitive domains (for major
neurocognitive disorder, at least two domains must be impaired).
C. Criteria are met for either probable or possible Alzheimer’s
disease as follows: For major neurocognitive disorder: Probable
Alzheimer’s disease is diagnosed if either of the following is
present; otherwise, possible Alzheimer’s disease should be
diagnosed.
1. Evidence of a causative Alzheimer’s disease genetic mutation
from family history or genetic testing.
2. All three of the following are present: ​
a. Clear evidence of decline in memory and learning and at least
one other cognitive domain (based on detailed history or serial
neuropsychological testing). ​
b. Steadily progressive, gradual decline in cognition, without
extended plateaus.
c. No evidence of mixed etiology (i.e., absence of other
neurodegenerative or cerebrovascular disease, or another
neurological, mental, or systemic disease or condition likely
contributing to cognitive decline).
2. Vascular dementia
• Vascular dementia is the second most common type of
dementia after Alzheimer’s disease. It is caused by reduced
blood flow to the brain. It can cause problems with
concentration, thinking and carrying out daily activities.
• Vascular dementia is a form of dementia that occurs when the
brain does not receive enough blood supply, meaning it
cannot carry out its normal functions.
• It is caused by damage or disease to the blood vessels in the
brain, often as the result of a stroke or transient ischaemic
attack(s) (TIAs), also known as ‘mini strokes’.
CONT...
• Vascular dementia can also result from other conditions that
affect the supply of blood to the brain, such as high blood
pressure, heart disease and diabetes.
• The main difference between vascular dementia and other
types is that vascular dementia is caused by the brain not
getting enough blood, whereas other common forms
(eg Alzheimer’s disease, frontotemporal dementia and Lewy
body dementia) are caused by abnormal proteins building up in
the brain.
• The early symptoms of vascular dementia also differ from
some other types – for example, changes in mood, behaviour
and personality are initially more common than memory
problems.
How blood flow affects the brain
• Blood carries oxygen and nutrients to the brain, and every
aspect of human functioning depends on the brain having an
adequate blood supply. When this is reduced, the nerve cells
in the brain cannot communicate with each other and
eventually die.
• If the blood flow to the brain is interrupted by a sudden or
gradual blockage or damage to blood vessels, it can lead to
symptoms of vascular dementia.
Common signs and symptoms of
vascular dementia
• Early signs of vascular dementia

• concentration problems • difficulties with understanding

• difficulty with planning • short-term memory problems –
and decision-making although this is less common in
• slowed thought processes the early stages than in other
• changes in mood, behaviour types of dementia, like
and personality Alzheimer’s disease
 Symptoms of advanced vascular
dementia
• As vascular dementia progresses, daily living activities can
become increasingly difficult, and people may struggle to look
after themselves. In the later stages, common symptoms
include:
• increasing difficulty with • distressed behaviour
speech, communication and • mobility problems, including falls
understanding – possibly eventually • difficulty with eating and drinking
losing the ability to speak at all • continence problems
• disorientation in time and place
• loss of recognition of familiar
people and places
Major or Mild Vascular
Neurocognitive Disorder Diagnostic
Criteria
• A. The criteria are met for major or mild neurocognitive
disorder.
• B. The clinical features are consistent with a vascular
etiology, as suggested by either of the following:
1. Onset of the cognitive deficits is temporally related to
one or more cerebrovascular events.
2. Evidence for decline is prominent in complex attention
(including processing speed) and frontal-executive
function.
CONT....
• C. There is evidence of the presence of cerebrovascular
disease from history, physical examination, and/or
neuroimaging considered sufficient to account for the
neurocognitive deficits.
• D. The symptoms are not better explained by another brain
disease or systemic disorder.
CONT.....
• Probable vascular neurocognitive disorder is diagnosed if one
of the following is present; otherwise possible vascular
neurocognitive disorder should be diagnosed:
1. Clinical criteria are supported by neuroimaging evidence
of significant parenchymal injury attributed to
cerebrovascular disease (neuroimaging supported).
2. The neurocognitive syndrome is temporally related to one
or more documented cerebrovascular events.
3. Both clinical and genetic (e.g., cerebral autosomal
dominant arteriopathy with subcortical infarcts and
leukoencephalopathy) evidence of cerebrovascular disease
is present.
CONT...
• Possible vascular neurocognitive disorder is diagnosed if the
clinical criteria are met but neuroimaging is not available and
the temporal relationship of the neurocognitive syndrome
with one or more cerebrovascular events is not established.
3. Frontotemporal dementia

• Frontotemporal dementia (FTD) is an umbrella term for a

group of dementias that mainly affect the frontal and
temporal lobes of the brain, which are responsible for
personality, behaviour, language and speech.
• Unlike other types of dementia, memory loss and
concentration problems are less common in the early stages.
• FTD is a rare form of dementia affecting around one in 20
people with a dementia diagnosis.
• In FTD, there is an abnormal build-up of proteins within the
brain, which damages the cells.
Types of FTD
• There are two types of FTD –
1. behavioral variant FTD (bvFTD) and
2. primary progressive aphasia (PPA).
Symptoms of behavioral variant FTD (bvFTD)
1. reduced motivation 6. obsessive or repetitive behavior, eg
2. lack of interest in things the person repeating phrases or gestures,
used to enjoy hoarding
3. inappropriate behavior, eg making 7. changes in behavior regarding food
suggestive comments, staring, or drink, eg craving sweet foods, poor
being over-familiar with people table manners, overeating, drinking too
4. reduced empathy much alcohol
5. difficulty focusing on tasks 8. difficulty with planning, organising
and decision-making
9. lack of awareness of the changes in
themselves (lack of insight)
Symptoms of primary progressive aphasia (PPA)
• There are three types of PPA, which all tend to affect language
rather than behavior.
Semantic variant or semantic dementia Nonfluent variant or progressive
(SD) nonfluent aphasia (PNFA)
1. difficulty remembering, finding or 1. difficulty using speech, including
understanding words forming sentences and using
2. gradual loss of vocabulary grammar correctly
3. forgetting what common objects are and 2. difficulty conducting conversations
what they do, eg kettle, toaster, keys – eg hesitation, using shortened
4. as SD progresses, the changes are likely sentences or using the wrong
to become similar to those experienced words
in bvFTD
 CONT....
Logopenic variant or logopenic aphasia (LPA)
1. difficulty finding words
2. stopping speaking mid-sentence as they search for the right word
3. unlike in SD, people with early LPA are unlikely to forget the meaning of
words or what common objects do
Major or Mild Frontotemporal Neurocognitive Disorder
Diagnostic Criteria
A. The criteria are met for major or mild neurocognitive disorder.
B. The disturbance has insidious onset and gradual progression.
C. Either (1) or (2):
1. Behavioral variant:
a. Three or more of the following behavioral symptoms:
i. Behavioral disinhibition.
ii. Apathy or inertia.
iii. Loss of sympathy or empathy.
iv. Perseverative, stereotyped or compulsive/ritualistic behavior.
v. Hyperorality and dietary changes
CONT....
b. Prominent decline in social cognition and/or executive abilities.
2. Language variant:
a. Prominent decline in language ability, in the form of speech
production, word finding, object naming, grammar, or word
comprehension.
D. Relative sparing of learning and memory and perceptual-motor
function.
E. The disturbance is not better explained by cerebrovascular
disease, another neurodegenerative disease, the effects of a
substance, or another mental, neurological, or systemic disorder.
CONT...
Probable frontotemporal neurocognitive disorder is diagnosed if
either of the following is present; otherwise, possible
frontotemporal neurocognitive disorder should be diagnosed:
1. Evidence of a causative frontotemporal neurocognitive disorder
genetic mutation, from either family history or genetic testing.
2. Evidence of disproportionate frontal and/or temporal lobe
involvement from neuroimaging.
Possible frontotemporal neurocognitive disorder is diagnosed if
there is no evidence of a genetic mutation, and neuroimaging has
not been performed.
4. Dementia with lewy bodies
• Lewy body dementia is a progressive, complex and
challenging condition which is thought to account for 10-
15% of all those with dementia. Around 10% of
younger people with dementia have dementia with Lewy
bodies. In the early stages it is often mistaken
for Alzheimer’s disease and can be diagnosed wrongly.
• Lewy body dementia includes two subtypes; dementia with
Lewy bodies and Parkinson’s. It particularly affects the
person’s ability to think and move and can
cause hallucinations, fluctuations in alertness
and sleep disturbances which can be extremely distressing for
the person and their family.
CONT...
• The main difference between the two types of Lewy body
dementia is when certain symptoms first occur:
• Dementia with Lewy bodies – changes in thinking, visual
perception (cognitive symptoms) and sleep may be
experienced first and difficulty with movement (Parkinsonian
symptoms) – occur at the same time or later
• Parkinson’s dementia – Parkinsonian symptoms are
experienced first followed by cognitive changes. Not
everyone with Parkinson’s will go onto develop dementia but
the risk of developing dementia is increased
Symptoms of lewy body dementia
1.have recurring visual hallucinations – see 4. have slowed movement,
things that are not there (these can be difficulty walking, shuffling or
pleasant or upsetting) appear rigid (as in Parkinson’s
2.experience disturbed sleep– known as Rapid disease)
Eye Movement (REM) sleep disorder, in 5. experience tremors – usually
which people are restless and can experience in the hands whilst at rest
intense dreams/nightmares 6. have problems with balance
3.experience sudden changes and fluctuations and be prone to falls
in alertness – people may stare blankly into 7. bladder and bowel problems
space for periods of time, seem drowsy and 8. difficulties with swallowing
lethargic and spend a lot of time sleeping
Major or Mild Neurocognitive Disorder With
Lewy Bodies Diagnostic Criteria
• A. The criteria are met for major or mild neurocognitive
disorder.
• B. The disorder has an insidious onset and gradual
progression.
• C. The disorder meets a combination of core diagnostic
features and suggestive diagnostic features for either
probable or possible neurocognitive disorder with Lewy
bodies.
• For probable major or mild neurocognitive disorder with
Lewy bodies, the individual has two core features, or one
suggestive feature with one or more core features.
CONT...
For possible major or mild neurocognitive disorder with
Lewy bodies, the individual has only one core feature, or one
or more suggestive features.
1. Core diagnostic features:
a. Fluctuating cognition with pronounced variations in
attention and alertness.
b. Recurrent visual hallucinations that are well formed
and detailed.
c. Spontaneous features of parkinsonism, with onset
subsequent to the development of cognitive decline.
CONT...
2. Suggestive diagnostic features:
a. Meets criteria for rapid eye movement sleep behavior
disorder.
b. Severe neuroleptic sensitivity.
D. The disturbance is not better explained by cerebrovascular
disease, another neurodegenerative disease, the effects of a
substance, or another mental, neurological, or systemic
disorder.
Neuropsychological assessments for
NCD
General cognitive/screening • Repeatable Battery for the
• Wechsler Test of Adult Reading Assessment of
• Wechsler Adult Scale of Neuropsychological Status
Intelligence 2nd Edition (WASI-II) (RBANS)
Mini-Mental State Examination (MMSE) (30 points)
(administered only at the initial •

visit as an estimate of premorbid

ability)
• Montreal Cognitive Assessment
(MoCA)
• Activities of Daily Living
Questionnaire
Neuropsychological assessments for NCD

Attention Language
• Digit Span (forward, backward) • Boston Naming Test
• Trail Making Test Part A • Lexical fluency total (F-A-S)
• Trail Making Test Part B • WASI-II Vocabulary
• RBANS Coding (number of items) • Semantic fluency (animals)
• Months of Year Forward • RBANS Picture Naming
• Months of Year Backward • RBANS Semantic Fluency
Neuropsychological assessments for NCD
Visuospatial Executive functions
• Target cancellation time • WASI-II Similarities
(errors left/right) • WASI-II Matrix Reasoning
• WASI-II Block Design Mood/behavioral symptoms
• RBANS Figure Copy • Geriatric Depression Scale (GDS)
• RBANS Line Orientation • Beck Anxiety Inventory (BAI)
Memory • Beck Depression Inventory 2nd
• RBANS Update Edition (BDI-II)
• Wechsler Memory Scale 4th • Neuropsychiatric Inventory
Edition (WMS-IV) Questionnaire
Neuroimaging for NCD

• Diffusion tensor imaging (DTI) : DTI can detect changes in

the structural connectivity of white matter tracts, which can
indicate the presence of dementia.
• functional MRI (fMRI) :The use of fMRI can detect
changes in brain activity patterns, which can indicate
functional alterations in the brain associated with dementia.
• Positron emission tomography (PET), and Single-photon
emission computed tomography (SPECT) : PET and
SPECT can detect changes in brain metabolism and blood
flow, improving the accuracy of the diagnosis of dementia.
Pharmacological and non-pharmacological interventions

• Unfortunately, there is no cure for dementia, so the main

goals of treatment are to maintain quality of life, maximize
function in daily activities, enhance recognition, mood and
behavior, foster a safe environment, and promote social
engagement.
Pharmacological interventions for
NCD
There are different medications and treatment regimes for
dementia. The main types of medication that can be used are:
• Cholinesterase Inhibitors
• Memantine
• Risperidone : The only drug listed by the PBS for treating
BPSD is risperidone
Non-pharmacological therapies
• Standard therapies Complementary therapy
Behavioural therapy Aromatherapy
Reality orientation Bright-light therapy
Validation therapy Multisensory approaches
Reminiscence therapy • Brief psychotherapies
• Alternative therapies Cognitive–behavioural therapy
Art therapy Interpersonal therapy
Music therapy
Activity therapy
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