UNIT III – COGNITIVE DISORDERS IN THE

ELDERLY
NEUROCOGNITIVE DOMAINS
The criteria for neurocognitive disorders are based on defined cognitive domains. The domains
defined below, along with guidelines for clinical thresholds, form the basis on which NCDs, their
levels, and their subtypes maybe diagnosed.

Cognitive Domain Examples of Symptoms

Major: Increased difficulty in environments
with multiple stimuli; easily distracted by
competing events; unable to attend unless
stimulus is restricted; difficulty holding new
information; unable to perform mental
Complex attention: sustained, divided,
calculation; thinking takes longer
selective, processing speed
Mild: normal tasks take longer than previously;
errors in routine tasks; work needs more double
checking than previously; thinking is easier
when not competing with other things
Major: Abandons complex projects; need to
focus on one task at a time; rely on others to
plan instrumental daily living or make decisions

Executive function: planning, decision making, Mild: Increased effort for multistage projects;
working memory, responding to feedback, error difficulty multitasking or resuming interrupted
correction, over-riding habits, inhibition, mental task; increased fatigue from extra effort for
flexibility planning, organizing, decision making; large
social gathering more taxing or less enjoyable
due to increased effort for following shifting
conversations

Major: Repeats self in conversation; forget

short list of items; requires frequent reminders
to orient to task at hand

Learning and memory: immediate, recent – Mild: difficulty recalling recent events; relies
including free recall, cued recall & recognition increasingly on lists and calendar; occasional
memory, long-term – semantic & reminders to keep track of evens in books or
autobiographical, implicit learning movies; occasionally may repeat self over a
week to same person; lose track of whether bill
have been paid

Note: long term memory and implicit learning are relatively

preserved, compared to recent memory, except in severe forms
Cognitive Domain Examples of Symptoms

Language: expressive language – word finding,

naming, fluency, grammar & syntax, receptive Major:
language
MEMORY DISORDERS IN THE ELDERLY
INTRODUCTION
Memory is the ability to retain information or a representation of past experience, based on the mental
processes of learning or encoding, retention across some interval of time, and retrieval or reactivation
of the memory. Thus, memory disorders refer to conditions that impair these functions.
TYPES OF MEMORY DISORDERS
Acute Memory Loss: When memory loss develops acutely, various neurological and psychiatric
aetiologies should be entertained. A vascular aetiology is an important consideration in a person
presenting with an acute memory loss. Causes of acute memory loss include haemorrhages,
particularly from aneurysms involving the anterior communicating artery; migraines; hypoglycaemia;
toxic exposure; drug ingestion; and psychogenic disorders. Another important cause to consider is
transient global amnesia (TGA). Patients with TGA present with anterograde amnesia for a brief
period of time. Acute memory loss may also be caused by infection occurring in a transplant setting.
Sub-acute Memory Loss: A complaint of memory loss occurring over a period of days to weeks
should alert the clinician for aetiologies including infectious, inflammatory, toxic, or metabolic
causes. For instance, the treatable condition Herpes Simplex encephalitis should be considered in
subacute memory loss in accordance with relevant clinical data such as the presence of seizures.
Inflammatory conditions like multiple sclerosis, sarcoidosis, or Jorgen’s syndrome should be
considered in the appropriate context; also, limbic encephalitis meningeal carcinomatosis,
psychiatric aetiologies should be considered based on relevant clinical data.
Chronic Memory Loss: A memory complaint of insidious onset with gradual progression should alert
one for a neurodegenerative disorder such as Alzheimer’s disease (AD). However, other processes
may explain memory problems: slowly growing tumours such as meningiomas often cause gradual
memory loss. Psychiatric conditions such as a major depressive disorder should be entertained.
Patients with depression have difficulty with concentration; hence, it is difficult for them acquire new
information. However, once learned, they are able to access and recall it better than patients with AD.
Another cause of chronic memory loss is Parkinson’s disease, in which the patient has increased
difficulty learning new material. However, they are able to recall previously learned material better
than patients with AD, who struggle with both learning and recall.
COGNITIVE IMPAIRMENTS AND DEMENTIA
Mild and major cognitive impairments (MCI) exist on a spectrum of cognitive and functional
impairment. It roughly corresponds to the condition of dementia. Dementia is a term used to describe
a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with
your daily life. It isn't a specific disease, but several diseases can cause dementia. Though dementia
generally involves memory loss, memory loss has different causes.
AETIOLOGY OF MEMORY DISORDERS
Organic causes
1. Alzheimer’s disease
2. Frontotemporal degradation
3. Lewy body disease
4. Vascular disease
5. Traumatic brain injury
6. Prion disease
7. Parkinson’s disease
8. Huntington’s disease
Other neurological conditions
1. Normal pressure hydrocephalus
2. Cerebral vasculitis
3. Brain tumours
4. Subdural hematoma
Endocrine conditions
1. Hypo or hyperthyroidism
2. Hypo or hypercalcemia
Nutritional causes
1. Vitamin B12, folic acid or thiamine deficiency
Other conditions
1. Hearing loss
2. Vision loss
3. Sleep disturbances
4. Medication side effects
5. Long-term alcohol misuse
SYMPTOMS
Major symptoms
1. Repeats self in conversation
2. Forgets short list of items
3. Requires frequent reminders to orient to task at hand
Mild symptoms
1. Difficulty recalling recent events
2. Relies increasingly on lists and calendar
3. Occasional reminders to keep track of evens in books or movies
4. Occasionally may repeat self over a week to same person
5. Lose track of whether bills have been paid
Psychological symptoms
1. Personality changes
2. Depression
3. Anxiety
4. Inappropriate behaviour
5. Paranoia
6. Agitation
7. Hallucinations

RISK FACTORS
1. Age
2. Genetic factors
3. Lower educational attainment
4. Chronic comorbid diseases: Vascular diseases, CHD, HT
 5. Metabolic syndrome: visceral obesity, elevated triglycerides and LDL
6. Diabetes & Hyperlipidaemia
7. Tobacco and alcohol use
EVALUATION
1. Medical history and physical examination
2. Mental status examination
3. Neuropsychological assessment
4. Ability to repeat a list of words or digits
5. Ability for free and cued recall
6. Recognition memory
7. Memory for facts
8. Memory for personal events or people
9. Implicit learning
INTERVENTION
Pharmacological

There is no cure for dementia nor are there any disease-modifying drugs available to combat
dementia. Certain drugs and only in some cases, address the symptoms of dementia by slowing down,
in the short term, the progression of cognitive loss. These drugs commonly referred to as anti-
dementia drugs, can only ever be prescribed by a medical doctor and the choice of drug will largely
depend on the dementia sub-type.

How these drugs operate relates to the presence of Acetylcholine in the brain. The latter is a
neurotransmitter or brain chemical required to facilitate communication between nerve cells in the
brain. It becomes depleted with dementia. For this reason, it is often treated with a brand of drugs
called Acetylcholine Inhibitors, developed to boost levels of Acetylcholine in the brain.

Non-pharmacological

1. Cognitive stimulation therapy

2. Reminiscence therapy
3. Validation therapy
4. Reality orientation
5. Physical exercise and aromatherapy
6. Multisensory stimulation: Snoezelen rooms

ALZHEIMER’S DISEASE
INTRODUCTION

Alzheimer’s is a neurodegenerative disorder that is characterized by insidious onset and gradual

progression of impairment in one or more cognitive domains. It is the cause of 60-70% of dementia
cases. Both genetic and environmental risk factors play a role in the manifestation of AD. The greatest
risk factor is age. At age 65, the likelihood of having AD is about 3%, rising to over 30% by age 85
(15). The incidence of AD under the age of 65 is less certain, but estimates suggest that this age group
accounts for around 3% of AD cases (15). Although overall numbers are increasing with the ageing
population, age-specific incidence appears to be falling in several countries

The most common early symptom is difficulty in remembering recent events. As the disease
advances, symptoms can include problems with language, disorientation (including easily getting
lost), mood swings, loss of motivation, self-neglect, and behavioral issues. As a person's condition
declines, they often withdraw from family and society. Gradually, bodily functions are lost, ultimately
leading to death. Although the speed of progression can vary, the typical life expectancy following
diagnosis is three to nine years.

Familial Alzheimer's disease is an inherited and uncommon form of Alzheimer's disease. Familial AD
usually strikes earlier in life, defined as before the age of 65. FAD usually implies multiple persons
affected in one or more generation. Sporadic Alzheimer's disease (or Nonfamilial Alzheimer's disease)
describes all other cases, where genetic risk factors are minor or unclear.

DIAGNOSIS

Probable Alzheimer’s disease is diagnosed if there is MCI as well as evidence of a causative

Alzheimer’s disease genetic mutation from family history or genetic testing.

Possible Alzheimer’s disease is diagnosed if there is no evidence of causative genetic mutation but if
all the following are present:

1. Clear evidence of decline in memory and learning

2. Steadily progressive, gradual decline in cognition, without extended plateaus
3. No evidence of mixed etiology, i.e., absence of other neurodegenerative or cerebrovascular
disease, or another neurological or systemic disease or condition likely contributing to
cognitive decline, the effects of a substance, or another mental disorder.

AETIOLOGY

Genetic causes

1. Mutations in APP, PSEN1, or PSEN2 genes

2. Other gene variants such as TREM2, APOE, CLU

Neuropathological causes

1. Aβ plaques
2. Amyloid pathology
3. Neuronal fibrillary tau tangles

SYMPTOMS

Cognitive deficits

1. Repeat statements and questions over and over.

2. Forget conversations, appointments or events.
3. Misplace items, often putting them in places that don't make sense.
4. Get lost in places they used to know well.
5. Eventually forget the names of family members and everyday objects.
6. Have trouble finding the right words for objects, expressing thoughts or taking part in
conversations
 7. Difficulty concentrating and thinking, especially about abstract concepts such as numbers
8. Decline in the ability to make sensible decisions and judgments in everyday situations
9. Routine activities that require completing steps in order become a struggle

Neuropsychiatric symptoms

1. Agitation
2. Apathy
3. Depression
4. Delusions
5. Sleep disorders

Personality and behavioral symptoms

1. Social withdrawal
2. Mood swings
3. Aggression
4. Wandering
5. Loss of inhibition
6. Distrust in others

RISKS FACTORS

1. Down syndrome
2. Inflammation due to trauma, sepsis or infection
3. Cerebral hypoperfusion
4. Traumatic brain injury
5. Cerebrovascular diseases such as ischemia
6. Cardiovascular diseases such as HT and heart attacks
7. Poor diet and obesity
8. High LDL
9. Sedentary lifestyle

EVALUATION

1. Mental status examination

2. Neuropsychological tests
3. Medical history and physical examination
4. Clinical interview with significant others
5. Lab tests
6. Brain imaging tests

INTERVENTION

Pharmacological

There is no cure for dementia in Alzheimer’s disease nor are there any disease-modifying drugs
available to combat dementia. Certain drugs and only in some cases, address the symptoms of
dementia by slowing down, in the short term, the progression of cognitive loss. These drugs
commonly referred to as anti-dementia drugs, can only ever be prescribed by a medical doctor and the
choice of drug will largely depend on the dementia sub-type.
How these drugs operate relates to the presence of Acetylcholine in the brain. The latter is a
neurotransmitter or brain chemical required to facilitate communication between nerve cells in the
brain. It becomes depleted with dementia. For this reason, it is often treated with a brand of drugs
called Acetylcholine Inhibitors, developed to boost levels of Acetylcholine in the brain.

Non-pharmacological

1. Cognitive stimulation therapy

2. Reminiscence therapy
3. Validation therapy
4. Reality orientation
5. Physical exercise and aromatherapy
6. Multisensory stimulation: Snoezelen rooms

VASCULAR DEMENTIA
INTRODUCTION

Vascular dementia refers to changes to memory, thinking, and behavior resulting from conditions that
affect the blood vessels in the brain. Cognition and brain function can be significantly affected by the
size, location, and number of vascular changes.

Symptoms of vascular dementia can begin gradually or can occur suddenly, and then progress over
time, with possible short periods of improvement. Vascular dementia can occur alone or be a part of a
different diagnosis such as Alzheimer's disease or other forms of dementia. When an individual is
diagnosed with vascular dementia, their symptoms can be similar to the symptoms of Alzheimer's.

Vascular dementia is caused by different conditions that interrupt the flow of blood and oxygen supply
to the brain and damage blood vessels in the brain. People with vascular dementia almost always have
abnormalities in the brain that can be seen on MRI scans. These abnormalities can include evidence of
prior strokes, which are often small and sometimes without noticeable symptoms. Major strokes can
also increase the risk for dementia, but not everyone who has had a stroke will develop dementia.
Other abnormalities commonly found in the brains of people with vascular dementia are diseased
small blood vessels and changes in the white matter of the brain.

DIAGNOSIS

Vascular dementia is diagnosed when the criteria for MCI is met, the clinical features are consistent
with a vascular etiology, there is evidence of the presence of cerebrovascular disease from history,
physical examination, or neuroimaging, and the symptoms are not better explained by another brain
disease or systemic disorder.

For a diagnosis of probable vascular dementia, the onset of the cognitive deficits must be temporally
related to one or more cerebrovascular events. Also, evidence for decline should be prominent in
complex attention, including processing speed, and frontal-executive function.

Possible vascular dementia 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.
AETIOLOGY

1. Stroke or infarction blocking a brain artery

2. Brain hemorrhage
3. Narrowed or chronically damaged cerebral blood vessels

SYMPTOMS

1. Confusion
2. Trouble paying attention and concentrating
3. Reduced ability to organize thoughts or actions
4. Decline in ability to analyze a situation, develop an effective plan and communicate that plan
to others
5. Slowed thinking
6. Difficulty with organization
7. Difficulty deciding what to do next
8. Problems with memory
9. Restlessness and agitation
10. Unsteady gait
11. Sudden or frequent urge to urinate or inability to control passing urine
12. Depression or apathy

RISKS FACTORS

1. Increasing age
2. History of heart attacks, strokes, or ministrokes
3. Abnormal aging of blood vessels – atherosclerosis
4. High LDL, obesity
5. High BP, diabetes
6. Smoking
7. Atrial fibrillation

EVALUATION

1. Medical history and neurological examination

2. Neuropsychological assessment
3. Lab tests
4. Brain imaging

INTERVENTION

Pharmacological

1. Medication to reduce BP, LDL

2. Blood thinners
3. Insulin for diabetes

Non-pharmacological

1. Regular physical exercise

 2. Healthy diet
3. Weight management
4. Brain training
5. Limiting alcohol intake

DELIRIUM IN THE ELDERLY

INTRODUCTION

Delirium is a common and serious acute neuropsychiatric syndrome with core features of inattention
and global cognitive dysfunction. The etiologies of delirium are diverse and multifactorial and often
reflect the pathophysiological consequences of an acute medical illness, medical complication or drug
intoxication. Delirium can have a widely variable presentation, and is often missed and
underdiagnosed as a result. At present, the diagnosis of delirium is clinically based and depends on the
presence or absence of certain features. Management strategies for delirium are focused on prevention
and symptom management.

Clinical experience and recent research have shown that delirium can become chronic or result in
permanent sequelae. In elderly individuals, delirium can initiate or otherwise be a key component in a
cascade of events that lead to a downward spiral of functional decline, loss of independence,
institutionalization, and, ultimately, death. Delirium affects an estimated 14–56% of all hospitalized
elderly patients. At least 20% of the 12.5 million patients over 65 years of age hospitalized each year
in the US experience complications during hospitalization because of delirium.

TYPES OF DELIRIUM

Hyperactive delirium

This may be the easiest type to recognize. People with this type may be restless and pace the room.
They also may be anxious, have rapid mood swings or see things that aren't there. People with this
type often resist care.

Hypoactive delirium

People with this type may be inactive or have reduced activity. They tend to be sluggish or drowsy.
They might seem to be in a daze. They don't interact with family or others.

Mixed delirium

Symptoms involve both types of delirium. The person may quickly switch back and forth from being
restless and sluggish.

DIAGNOSIS

Disturbance in attention, i.e., reduced ability to direct, focus, sustain, and shift attention, accompanied
by reduced awareness of the environment. The disturbance needs to have developed over a short
period of time and should represent a change from baseline attention and awareness, and usually
fluctuates in severity during the course of a day. Other additional disturbances in cognition, such as
memory deficit, disorientation, perception may be present.

The diagnosis is made if these symptoms are not better explained by another preexisting, established,
or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of
arousal, such as coma. Further, there needs to be evidence from the history, physical examination, or
lab findings that the disturbance is a direct consequence of another medical condition.

AETIOLOGY

1. Certain medicines or medicine side effects

2. Alcohol or drug use or withdrawal
3. A medical condition such as a stroke, heart attack, worsening lung or liver disease, or an
injury from a fall
4. An imbalance in the body, such as low sodium or low calcium
5. Severe, long-lasting illness or an illness that will lead to death
6. Fever and a new infection, particularly in children
7. Urinary tract infection, pneumonia, the flu or COVID-19, especially in older adults
8. Exposure to a toxin, such as carbon monoxide, cyanide or other poisons
9. Poor nutrition or a loss of too much body fluid
10. Lack of sleep or severe emotional distress
11. Pain
12. Surgery or another medical procedure that requires being put in a sleep-like state

SYMPTOMS

Reduced awareness of surroundings

1. Trouble focusing on a topic or changing topics

2. Getting stuck on an idea rather than responding to questions
3. Being easily distracted
4. Being withdrawn, with little or no activity or little response to surroundings

Cognitive deficits

1. Poor memory, such as forgetting recent events

2. Not knowing where they are or who they are
3. Trouble with speech or recalling words
4. Rambling or nonsense speech
5. Trouble understanding speech
6. Trouble reading or writing

Personality and behavioral changes

1. Anxiety, fear or distrust of others

2. Depression
3. A short temper or anger
4. A sense of feeling elated
5. Lack of interest and emotion
6. Quick changes in mood
7. Personality changes
8. Seeing things that others don't see
9. Being restless, anxious or combative
10. Calling out, moaning or making other sounds
11. Being quiet and withdrawn — especially in older adults
12. Slowed movement or being sluggish
13. Changes in sleep habits
 14. A switched night-day sleep-wake cycle

RISKS FACTORS

1. Sensory impairment (hearing or vision)

2. Immobilization (catheters or restraints)
3. Medications
4. Acute neurological diseases
5. Intercurrent illness
6. Metabolic derangement
7. Surgery
8. Pain
9. Emotional distress
10. Sustained sleep deprivation
11. Dementia or cognitive impairment
12. Advancing age (>65 years)
13. History of delirium, stroke, neurological disease, falls or gait disorder
14. Multiple comorbidities
15. Male sex
16. Chronic renal or hepatic disease

EVALUATION

1. Mental status examination

2. Medical history
3. Physical assessment to find precipitating factors

INTERVENTION

Pharmacological

1. Olanzapine
2. Risperidone
3. Quetiapine
4. Haloperidol

Non-pharmacological

1. Reorient patient frequently

2. Arrange for family members to stay with patient
3. Optimize lighting in room
4. Replace hearing aids, glasses etc.
5. Avoid room or location changes