PSY 6670 Diagnosis & Treatment Planning Lecture 2: Neurocognitive Disorders Treatment Planning

1. PSY 6670Diagnosis & Treatment Planning Lecture 2: Neurocognitive Disorders Treatment Planning Joel Fairbanks, Ph.D.

2. Epidemiology • 35 million Americans over 65 with dementia. • Prevalence rate 15% after age 65. • Incident rate rises between 70 – 80 years. • Prevalence rate 25 % for those 65 – 74 years. • Prevalence rate 45 % for those over 80. • Over half of all hospitalized elderly mental patients have dementia.

3. 2016 Study of Prevalence Rate for Dementia • Rate for Dementia fell from 12 % of the elder population in 2000 to 9% in 2014. • That equates to a reduction of 1 Million cases reported per year in 2014.

15. DSM – IV Diagnoses for Dementia • Dementia, Uncomplicated • Dementia, with Depression • Dementia, with Delusions • Dementia, with Delirium

16. DSM-5 Diagnosis Criteria for Dementia • Neurocognitive Disorders (Dementia) is a syndrome due to disease of the brain in which there is a disturbance of multiple higher cortical functions, including Memory, Thinking, Orientation, Comprehension, Calculation, Learning Capacity, Language, and Judgment.

17. Diagnosis Criteria for Dementia • The decline of higher cortical functions interferes with personal activities of Daily Living; such as washing, dressing, eating, personal hygiene, excretory and toilet activities. • How such a decline manifests itself will depend largely on the social and cultural setting in which the patient lives.

18. Types of Dementia Symptoms and presentation (pg. 299/602) • Alzheimer’s Type • Lewy Bodies • Vascular Disease (CVA) • Neurological Disorders (e.g. Parkinson’s Dx.) • Drug/Alcohol Abuse (Korsakoff’s Dx.) • Traumatic Brain Injury (TBI)

20. Mild vs. Major Neurocognitive Disorder • According to the DSM-5, Mild Neurological Disorders differ from Major N.D. in that the cognitive decline and deficits in one or more cognitive domains are modest and Do Not sufficiently interfere with personal activities so as to lose the capacity for independence.

23. Additional Treatment Concerns • Most of these patients will also have significant other medical problems, conditions, or physical disabilities that will challenge their independence and treatment. • Substance Use (especially alcohol or prescription medications) is a common comorbid condition that will also need to be addressed.

24. Differential Diagnosis • Delirium (infections or poisons/heavy metals) • Autoimmune Diseases • Metabolic Disorders • Vitamin B1, B12, Niacin, Folic Acid Deficiencies • Neoplasms (tumors) • Mechanical Disorders (hydrocephalus or hematoma) • Psychosis • Pseudo-Dementia • Normal Aging

25. TAP Program (Tailored Activity Program)Cognitive Rehabilitation & Occupational Therapy Services provided in home.Dr. Gitlin (UK) • TAP aims to reduce the troubling behaviors that can accompany dementia: repeating questions, wandering, rejecting assistance, verbal or physical aggression in order to maintain the patient in the home as long as possible and reduce the anxieties and fears of losing cognitive abilities by focusing on the cognitive skills that they still retain.

26. Psychosocial Interventions • Patient Care: The primary goal is to make the patient as comfortable and safe as possible. The environment should be kept simple and helpful. Clocks, calendars, labels, lists, familiar routines, short-term tasks, brief walks and simple exercise. • Family Counseling: Supportive and help to develop Behavioral Interventions for the patient in the home.

27. Safety Awareness and Planning • Removable of risk conditions such as: alcohol use, poor nutrition, exposure to toxins (cleaners), falls, wandering, stoves/ovens, self medication/over medication, and “noncompliance” with medications.

30. Cognitive Medications • Donepezil (Aricept 5 and10 mg) • Galantamine (Razadyne 8 – 24 mg) • Memantine (Namenda XR 5 – 28 mg) • Rivastigmine (Exelon patch 6 – 12 mg) • Studies of amyloid plaque inhibitors

31. Pseudobulbar Affect Disorder (PBA) • Symptoms include frequent and often inappropriate, excessive, and uncontrollable, crying or laughing outbursts. • Nuedexta 20/10 (dextromethorphan 20 mg/ quinidine 10 mg)

32. tACS Brain Stimulation • tACS has demonstrated a reverse in decline of working memory (by 15 %) through “tuning” the synchronized neural circuits to each other using an implant that produces low-frequency rhythms called theta waves. • Researchers are working on a Head Net device to accomplish similar stimulation.

33. Case Study • Video : Vivian

34. Vivian Case Study • What are Vivian’s • Symptoms • Impairments in functioning • Treatment Needs • Possible Goals for Treatment

35. What are Vivian’s “Strengths” and available Resources ?

36. Who else would you consult regarding the care and treatment of Vivian ? • Primary Care Physician • In-Home medical/nursing services • Social Worker or Case Manager • Council on Aging • State Senior Services Department • Meals on Wheels • Community Transportation • Family or neighbors

37. If the goal is to maintain Vivian living “independently” in her own home, what would be 3 Objectives (or short-term goals) for at this time ? • 1. • 2. • 3.

38. Goal 1: Create a safe environment to maintain the patient in the home, living “independently” with her spouse for the next 6 months. • 1. Family will conduct a Home Safety Check (2 weeks) • 2. Patient will be complaint with the taking of her daily medications as prescribed by her PHC (6 months) • 3. Refer the patient to neurologist to assess her ability to safely operate a motor vehicle (1 month).

39. What Interventions would you employ to protect/maintain cognitive functioning?

40. What Safety Concerns need to be included into her Treatment Plan ?

41. How would monitor and assess the effectiveness of this Treatment Plan?