Major Neurocognitive Disorder

Additional Considerations are given when Dosing Medications for Children and Seniors

Pediatric and geriatric patients have pharmacokinetic properties that differ from the adult population, necessitating tailored dosage. Medications beneficial in pediatric and elderly medicine frequently lack a clinical indication and dose recommendation for this group. According to Yatham et al. (2018), the lack of a pediatric and geriatric dose form for several pharmaceuticals increases the possibility of dosing mistakes and can result in significant, sometimes deadly effects.

It is critical to choose a suitable medicine and dose based on personalized pharmacokinetic considerations: a patient’s age, size, and level of organ development and functioning must all be considered. To improve treatment efficacy and avoid or prevent major adverse side effects, specialized dosing recommendations and suitable dosage forms for children and patients must be created.

Beers Criteria

Beers Criteria, according to Nurmainah and Astuti (2022), are criteria that clinicians should follow when prescribing or recommending medications to seniors. It comprises a list of all possibly dangerous drugs for those over the age of 65, commonly classified as people over 65. There are around 100 drugs on the list as of 2019. The purpose of the AGS Beers Criteria is to ensure that all geriatric patients receive safe and appropriate medications for their overall health by taking three important factors into account.

Differential Diagnoses

Delirium. Major NCD may be challenging to distinguish from persistent delirium, that might occur concurrently (American Psychiatric Association, 2018). Making the differentiation will be easier with a comprehensive examination of attention and arousal.

Major depressive episode. It can often be difficult to tell the difference between a major NCD and a severe depressive disorder, which can co-occur with NCD. Specific cognitive deficit patterns may help distinguish NCD from depression (American Psychiatric Association, 2018). Alzheimer’s disease, for example, is distinguished by chronic memory and executive function deficits, whereas severe depression is distinguished by nonspecific or fluctuating performance.

Diagnosis and Reasoning

My diagnosis, based on the American Psychiatric Association (2018) provisions, is Major Neurocognitive Disorder. The diagnostic criteria according to DSM-5 are;

Confirmation of considerable mental impairment from a prior level of functioning in one or more intellectual domains, such as focus, functioning, learning and memory, communication, perceptual-motor, and social cognition, as measured by:
Alarm expressed by the subject, a competent observer, or the physician about a major deterioration in cognitive function.
Significant impairment in cognitive functioning, preferably demonstrated by conventional neuropsychological testing or, in the absence of such testing, by another quantifiable clinical evaluation. (He reports that she was in her usual state of good mental health until a few months ago when she started complaining about her housekeeper stealing items from her home. Later, when the same items were found, she insists that they had been stolen and returned rather than just misplaced.)
Cognitive deficiencies impair independence in daily tasks, requiring the patient to seek assistance with the difficult activity of everyday living such as bill payments or managing prescriptions. (She has become steadily worse since then, to the point that she can’t recall where she put her possessions. She has left the stove and shower running multiple times. Her speech has been described as slower and more hesitant as she searches for words.)
Cognitive impairments do not always arise in the context of delirium.
The cognitive deficiencies are not explained better by another mental disorder.

Additional Questions Asked

Additional questions include the time course of the symptoms, the impacted domains, and the related symptoms. To make an accurate diagnosis, look for the existence of a possible causal entity, such as Parkinson’s or Huntington’s disease, or a traumatic brain injury or stroke, in the right time frame(American Psychiatric Association, 2018). NCDs are typically handled by doctors from a variety of specialties and ask the caregiver if they have visited another specialist and the ER for treatment and diagnosis

Mood swings such as melancholy, anxiety, and elation are possible in major NCD. Depression is typical in the early stages of NCD. Agitation is widespread in a wide range of NCDs, especially major NCDs with moderate to severe severity, and it frequently occurs in the context of bewilderment or dissatisfaction(American Psychiatric Association, 2018).

It might manifest as confrontational actions, particularly when refusing caregiving chores like washing and dressing. Agitation is defined as disruptive physical or verbal activity and is associated with advanced stages of cognitive impairment in all NCDs, and the nurse should inquire about all these.

Medication Recommendations

The majority of the medications used to treat serious NCDs can temporarily alleviate symptoms. Acetylcholinesterase inhibitors hinder enzymatic activity in the brain from disintegrating acetylcholine, a chemical that lets nerve cells interact with one another. NCD symptoms are treated with donepezil, rivastigmine, and galantamine.

If hallucinations are one of the predominant symptoms, rivastigmine is preferable (Townsend & Morgan, 2018). Nausea and lack of appetite are possible side effects. These normally improve after two weeks of taking the medication.

Memantine is appropriate for people who cannot tolerate acetylcholinesterase inhibitors. It works by preventing the effect of an excess of glutamate in the brain (Townsend & Morgan, 2018). Headaches, dizziness, and constipation are possible side effects. However, they are typically relatively temporary.

Laboratory Diagnosis

Nurses may perform a number of laboratory tests to assist in identifying NCD and rule out other disorders that might lead to symptomatology, such as vitamin B12 deficiency or hormone balance. A complete blood count, blood glucose test, urinalysis, toxicology screen, cerebrospinal fluid analysis to rule out particular illnesses that might impact the brain, and thyroid and thyroid-stimulating hormone levels are among the tests available.

Certain illnesses known to induce dementia, such as HIV and syphilis, as well as other tests, may be requested depending on the patient’s individual condition (Stanford Health Care, 2022). A lumbar puncture is sometimes used to extract cerebrospinal fluid, which is subsequently tested for signs of Alzheimer’s illness plaques, inflammatory illnesses, or diseases that may cause dementia.

Screener Scales

The Mini-Mental State Examination (MMSE) is now the most widely used instrument for evaluating cognitive ability (Lucza et al., 2018). Although it can assess orientation, memory, visual abilities, attention and calculation, language, writing, reading, and constructive talents, it is insufficiently sensitive to identify frontal and executive impairments and visuospatial dysfunctions.

Furthermore, it has a low sensitivity for diagnosing dementia in its early stages and is unable to distinguish between the main kinds of dementia when used alone. The best cut-off value for MMSE is 26 points with a sensitivity of 79.9% and a specificity of 74.0% for identifying PDD, however, it is still inappropriate for screening PD-MCI (Lucza et al., 2018).

Additional Therapy Modalities

As per Townsend and Morgan (2018), Naomi Feil, a gerontological social worker, invented Validation Therapy (VT), which she summarizes as conversing with a distorted older person by validating and honoring their sentiments at any time or specific moment is authentic to them at the moment, even if this does not correlate with our ‘here and now existence. Since people have different levels of consciousness, Feil believes that the validation principle applies to those with NCD.

Validation treatment affirms a person with NCD’s experiences and emotions. It frequently incorporates redirection strategies. According to Townsend and Morgan (2018), the idea is to agree with what they desire but to guide them to do something else without them noticing they are being redirected. This is a combination of validation and redirection treatment.

References

American Psychiatric Association. (2018). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013. Hakjisa.Co.Kr. http://www.hakjisa.co.kr/common_file/bbs_DSM-5_Update_October2018_NewMaster.pdf

Lucza, T., Karádi, K., Kállai, J., Weintraut, R., Janszky, J., Makkos, A., Komoly, S., & Kovács, N. (2018). Screening mild and major neurocognitive disorders in Parkinson’s disease. Behavioral Neurology, 2015, 983606. https://doi.org/10.1155/2015/983606

Nurmainah, N., & Astuti, R. (2022). Detection of Potentially Inappropriate Medication in elderly outpatient based on the beer’s criteria 2019. Jurnal Farmasi Dan Ilmu Kefarmasian Indonesia, 9(1), 82–91. https://doi.org/10.20473/jfiki.v9i12022.82-91

Stanford Health Care. (2022). Laboratory Tests for Dementia. Stanfordhealthcare.org. https://stanfordhealthcare.org/medical-conditions/brain-and-nerves/dementia/diagnosis/laboratory-tests.html

Townsend, M. C., & Morgan, K. I. (2018). Psychiatric mental health nursing: Concepts of care in evidence-based practice. F.A. Davis.

Yatham, L. N., Kennedy, S. H., Parikh, S. V., Schaffer, A., Bond, D. J., Frey, B. N., Sharma, V., Goldstein, B. I., Rej, S., Beaulieu, S., Alda, M., MacQueen, G., Milev, R. V., Ravindran, A., O’Donovan, C., McIntosh, D., Lam, R. W., Vazquez, G., Kapczinski, F., … Berk, M. (2018). Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. Bipolar Disorders, 20(2), 97–170. https://doi.org/10.1111/bdi.12609

Major Neurocognitive Disorder Instructions

Answer the following 2 questions, no more than 1 paragraph and 1 reference per question

What additional considerations should be given when dosing medications for children and seniors and why?

What is the Beers Criteria?

Case Study

A 71 y/o woman presents with her husband to your office with complaints of memory impairment and increased irritability. The pt. minimizes her complaints and insists that the evaluation is unnecessary. Her husband is able to provide an account of what has been happening at home. He reports that she was in her usual state of good mental health until a few months ago when she started complaining about her housekeeper stealing items from her home. Later, when the same items were found, she insists that they had been stolen and returned rather than just misplaced. Since that time she has progressively worsened to the point that she cannot remember where her belongings are located. On several occasions she has left the stove on and the shower running. Her speech has been noted to be slower with more hesitations as she searches for words. In the past she did all the houses bookkeeping until her husband identified some major errors. She insisted that she had paid the bills when she had not. She stopped driving at her children’s insistence because she was “all over the road”.

Pt is a college graduate with a long and successful career as a business woman. She retired 7 years ago. She has no significant psychiatric hx and denies any cardiac family history.

Pt is a healthy looking female who appears her stated age. She is alert and oriented x 4. Her eye contact is fair. She is cooperative and engaging. She shows no psychomotor agitation or retardation. Her speech is of normal volume and tone and complains of word-finding difficulty. She describes her mood as good and appears Euthymic. Her affect is mood congruent and stable. Thought process linear and organized.

Denies suicidal, homicidal ideation. Denies A/V hallucinations. Insight poor-judgment-limited. Her Folstein is 24/30; she is unable to do serial 7’s and has zero recall after 5 min. of three words.

Include:

Any differential diagnoses

Your diagnosis and reasoning

Any additional questions you would have asked

Medication recommendations along with your rationale. Note possible side effects or issues to address if attempting to obtain consent.

Any labs and why they may be indicated

Screener scales or diagnostic tools that may be beneficial

Additional resources to give (Therapy modalities, support groups, activities, etc.)