Mild Neurocognitive Disorder DSM-5 331.83 (G31.84) or 799.59 (R41.9) for Unspecified
DSM-5 Category: Neurocognitive Disorders
Introduction
Mild neurocognitive disorder is a sub-diagnosis used to indicate the severity of other mental disorders, including dementia, brain injury, and other cognitive disorders. It is important to note that both major and minor neurocognitive disorder are distinct from developmental and intellectual disabilities (The American Psychiatic Association, 2013).
Symptoms of Mild Neurocognitive Disorder
Mild neurocognitive disorder typically presents as a marked decline in cognitive functioning and significant impairment in cognitive performance. Patients or their caregivers may report symptoms of memory impairment, decline in the ability to perform everyday activities, though still able to perform these activities without assistance, and difficulties with language, perceptual-motor and social skills (The American Psychiatric Association, 2013).
These cognitive deficits should not be better explained by other mental disorders to be considered mild neurocognitive disorder, but this diagnosis is often included in the diagnosis of other disorders as a means of indicating severity. In cases where dementia is also diagnosed, it is not uncommon for the patient to exhibit mood disturbances, such as anxiety and depression, and other psychotic symptoms as well (The American Psychiatric Association, 2013).
One of the earliest symptoms of mild neurocognitive disorder, and many of the co-morbid disorders that lead to the development and progression of mild neurocognitive disorder, are mood disturbances. Sudden increases in anxiety, depression, bi-polar like mood swings, and agitation, or even a sudden sense of apathy, are often early indicators of cognitive decline. It is not uncommon to also see sleep disorders, such as insomnia, hypersomnia, or circadian rhythm disorders, or a sudden sense of disinhibition (The American Psychiatric Association, 2013).
Diagnosis of Mild Neurocognitive Disorder
Mild neurocognitive disorder is diagnosed based on evidence of cognitive decline, reduction in performance of cognitive tasks, and should certainly be referred for standardized neuropsychological testing, including the Mini Mental Status Exam (MMSE) or the Global Assessment of Functioning (GAF) scale (The American Psychiatric Association, 2013). There is some indication that the MMSE, while the historical assessment of choice for cognitive functioning, may actually fail to detect early stage mild neurocognitive disorder, which is better detected through the use of the Saint Louis University Mental Status (SLUMS) assessment (Tariq, Tumosa, Chibnall, Perry, & Morley, 2006).
Other neuropsychological tests of performance may be used, and the results should be compared with those deemed normal for the age, educational level, and cultural background of the patient. It is important to also remember that results that may register within the normal range may in fact still indicate decline within the individual (The American Psychiatric Association, 2013).
Overall, females are at significantly higher risk for dementia, and therefor mild neurocognitive disease. It is interesting to note that diagnosis often differs across ethnic groups, and is typically diagnosed earliest in individuals whose occupation or recreational activities require complex cognitive tasks (The American Psychiatric Association, 2013).
Co-morbidity of Mild Neurocognitive Disorder
Since both major and mild neurocognitive disorders are used as secondary diagnosis to indicate the severity of cognitive decline in other disorders, it is typically co-morbid with at least one other disorder. When coding for mild neurocognitive disorder, it is important to note whether it is accompanied by behavioral disturbances as well (The American Psychiatric Association, 2013).
Mild neurocognitive disorder may be due to an established and co-diagnosed disorder, unspecified cause, or the result of multiple disease processes. It is common to see mild neurocognitive disorder present in individuals also diagnosed with neurodegenerative diseases such as Alzheimer's disease, frontal lobar degeneration, Lewy body disease, and other forms of dementia, or disorders known to impair cognitive functioning, such as Parkinson's disease, Huntington's disease, prion disease, HIV infection, vascular disease, stroke, substance abuse, and traumatic brain injury (The American Psychiatric Association, 2013).
Mild neurocognitive disorder is also associated with mood disorders and bipolar and schizophrenia spectrum disorders, with the strongest predictive correlation occurring in those with episodes of psychosis (Simonsen, et al., 2011). It has also been shown that the severity of major depressive disorder is directly related to the severity of the associated neurocognitive disorders (McClintock, Husain, Greer, & Cullum, 2010).
The relationship between mild neurocognitive disorder and critical illness has been established, showing that impaired cognition following periods of life-threatening, critical illnesses are common and possibly permanent. These impairments in daily function, decreased cognitive speed, and the overall impact on quality of life need to be studied further (Hopkins & Jackson, 2006).
Similarly to the link between critical illness and mild neurocognitive disorder, there has been a well-established link between Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS) and cognitive function as well. This onset of mild neurocognitive disorder in conjunction with HIV/AIDS is commonly referred to as HIV-associated neurocognitive disorder, or HAND (Singh, 2009). There is strong evidence that activated monocytes and macrophages play a roll in HAND despite the use of combination antiretroviral therapy, and monitoring the levels of these critical immune cells through cerebrospinal fluid testing may allow the progression of the associated mild neurocognitive disorder to be monitored (Kamat, et al., 2012).
Prevalence of Mild Neurocognitive Disorder
The prevalence of mild neurocognitive disorder increases sharply with age, with the most significant rise occurring in patients over the age of 60. It is estimated that approximately 1-2% of those aged 65 and older, and as much as 30% of those aged 85 and older, have been diagnosed with dementia. Considering that mild neurocognitive disorder is typically co-diagnosed with dementia, the prevalence of dementia may be a good indicator of mild neurocognitive disorder (The American Psychiatric Association, 2013).
Treatment of Mild Neurocognitive Disorder
While there are no direct treatments for mild neurocognitive disorder or the dementia it is typically associated with, many of the other co-morbid diseases diagnosed along with mild neurocognitive disorder. There is evidence that group-based cognitive remediation treatment in patients with mild neurocognitive disorder and bipolar disorder shows improved verbal memory, attention, executive function, and psychosocial function, indicating that this treatment option may be viable for patients diagnosed with mild neurocognitive disorder caused by other etiologies (Demant, Almer, Vinberg, Kessing, & Miskowiak, 2013).
In addition, there is promising new evidence indicating that the use of metabolic agents that enhance ATP, which is the primary molecule used for cellular energy, may succeed in improving cognitive function while also potentially slowing or even preventing cognitive decline. This new class of medications may hold significant promise for those suffering from mild neurocognitive disorder or other difficulties with cognition (Owen & Sunram, 2011).
Medications typically used to treat the underlying diagnosis, including those used to improve memory in Alzheimer's, to control the symptoms of Parkinson's disease, to improve vascularity and blood pressure, or control viral load in HIV-associated mild neurocognitive disease are still an important part of the treatment regime (The American Psychiatric Association, 2013).
Outcomes for Mild Neurocognitive Disorder
Unfortunately, due to the nature of mild neurocognitive disorder and its link to aging and dementia, it is unlikely that symptoms will stabilize or improve. It is important that patients remain in a life-long relationship with healthcare workers, including psychologists, psychiatrists, neurologists, and any other specialist related to underlying disease processess. If monitored carefully and treated with a multidisciplinary approach, patients with mild neurocognitive disease may be able to stabilize their cognitive function and maintain quality of life (The American Psychiatric Association, 2013).
References
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Demant, K.M., Almer, G.M., Vinberg, M., Kessing, L.V., & Miskowiak, K.W. (2013). Effects of cognitive remediation on cognitive dysfunction in partially or fully remitted patients with bipolar disorder: Study protocol for a randomized controlled trial. Trials, 14, 338.
Hopkins, R.O., & Jackson, J.C. (2006). Long-term neurocognitive function after critical illness. CHEST, 130(3), 869-878.
Kamat, A., Lyons, J.L., Misra, V., Uno, H., Morgello, S., Singer, E.J., & Gabuzda, D. (2012). Monocyte activation markers in cerebrospinal fluid associated with impaired neurocognitive testing in advanced HIV infection. JAIDS-Journal of Acquired Immune Deficiency Syndromes, 60(3), 234-243.
McClintock, S.A., Husain, M.M., Greer, T.L., & Cullum, C.M. (2010). Association between depression severity and neurocognitive function in major depressive disorder: A review and synthesis. Neuropsychology, 24(1), 9-34.
Owen, L. & Subran-Lea, S.I. (2011). Metabolic agents that enhance ATP can improve cognitive functioning: A review of the evidence for glucose, oxygen, pyruvate, creatine, and l-carnitine. Nutrients, 3(8), 735-755.
Simonsen, C., Sundet, K., Vaskinn, A., Birkenaes, A.B., Engh, J.A., Faerden, A., Jonsdottir, H., Ringen, P.A., Opjordsmoen, S., Melle, I., Friis, S., & Andreassen, O.A. (2011). Neurocognitive disfunction in bipolar and schizophrenia spectrum disorders depends on history of psychosis rather than diagnostic group. Schizophrenia Bulletin, 37(1), 73-83.
Singh, D. (2009). Neurocognitive impairment in PLWHA: Clinical features and assessment. Southern African Journal of HIV Medicine, 35, 30-34.
Tariq, S.H., Tumosa, N., Chibnall, J.T., Perry, M.H., & Morley, J.E. (2006). Comparison of the Saint Louis University Mental Status examination and the Mini-Mental State Examination for detecting dementia and mild neurocognitive disorder – A pilot study. American Journal of Geriatric Psychiatry, 14(11), 900-910.
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