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A Didactic Presentation

Mild & Major Neurocognitive Disorders

DSM-V Diagnostic Criteria

Mild/Major NCD

Specifiers:

  • Due to... (type/condition/unspecified)
  • With/Without behavioral disturbance (more than one symptom)
  • Specify disturbance
  • Current severity:
  • Mild: Difficulties with instrumental activities of daily living (chores, finances)
  • Moderate: Difficulties with basic activities of daily living (feeding, dressing)
  • Severe: Fully dependent

Neuropsychiatric Symptoms

Mood, anxiety, apathy, and behavioral disturbances occur in 80% of AD patients in clinical care, and are often the focus of clinical attention, given the degenerative course of most neurocognitive disorders.

NPS are considered to be usual in NCD patients, and these symptoms are typically the reason for clinical admissions to higher levels of care. (Cohen-Mansfield, Dakheel-Ali, Jensen, Marx., & Thein, 2012; Carrion, C., Aymerich, M., Bailles, E., Lopez-Bermejo, A., 2013.)

Estimated Prevalence of Associated Behavioral & Psychological Symptoms (BPSD) in patients with dementia diagnoses:

  • Sleep disturbance (most common)
  • Apathy (24%)
  • Depression (27%)
  • Agitation/Aggression (24%)
  • Anxiety (35-40%)

Traditional Cognitive-Behavioral Formulation

Situational

Cognitions - Affect - Behavior

Accusatory/Persecutory thoughts

"These people are always screwing with me."

Misidentification of people

"Who is this person trying to control me?"

Concerns about needs

"Why don't I have more space for my things?"

Misremembering/Remembering

"My husband hasn't visited in years."

"I just learned that my mother passed away."

Aging and loss processes

"I used to be able to work."

Anger

Confusion --> Frustration

Depression

Apathy

Anxiety

Elation

Expressed agitation

(vocalization, pacing, violence)

Behavioral inhibition / Withdrawal / Isolation

(avoidance of community, silence)

Complaining

Ruminating

The cognitive-behavioral formulation applies--But a major challenge arises in treatment at the cognitive level.

Cognitive restructuring is subject to an important functional ability.

Interference of Cognitive Symptoms

Explicit memory

Episodic

Semantic

Short-term memory

Within-session

Between sessions

Anosognosia

Lack of awareness of impairment

Aphasia

Lack of ability to express symptoms verbally

Lack of ability to receive content verbally

Agnosia

Unstable interpersonal continuity

CBT Adjustments for Cognitive Symptoms

  • Challenges with cognitive monitoring and restructuring
  • Compensate with behavioral interventions; visual cues
  • Emphasis on mindfulness and acceptance

(Kangas & McDonald, 2011)

  • To challenge experiences, to increase flexibility in interpreting experiences, to accept experiences...
  • Lost eye-glasses (problem-solve)

vs. lost family (existential)

  • Acceptance & Commitment Therapy:
  • Recruitment of caregivers

Piloted (mild-to-moderate) NCD CBT programs:

*MMSE scores typically determine validity of self-report:

12+: Most readily accepted range

3-11: Have been validated for QOL-AD and others

*Best practice is to use proxy reporter, when applicable, in addition and re-interview if discrepancies arise.

Measures of Behavioral & Psychological Symptoms

  • BDI/GDS (equivalent in nursing home populations)
  • Cornell Scale for Depression in Dementia (CSDD)
  • Apathy Evaluation Scale (AES)
  • Neuropsychiatric Inventory (NPI)
  • Quality of Life Measures (Patient and/or Proxy)
  • DEMQOL
  • Quality of Life in Alzheimer’s Disease (QOL-AD)
  • QUALID (proxy only)

NPI measures:

Delusions

Hallucinations

Agitation/Aggression

Depression/Dysphoria

Anxiety

Elation/Euphoria

Apathy/Indifference

Disinhibition

Irritability/Lability

Aberrant motor behavior

Sleep and Nighttime Behavior Disorders

Appetite and Eating Disorders

A Case of Nicholas

Case Illustration

Demographic Information

Age: 76.5

Ethnicity: Jewish

Religion: Agnostic

Marital: Divorced twice; dating

Education: Some college

Service: U.S. Navy

Occupation: Salesman

Date of admission: Jan, 2013

Multiaxial Diagnosis

I 331.83 Mild Neurocognitive Disorder due to myocardial infarction

With behavioral disturbances (agitation, apathy, insomnia);

304.20 Stimulant Use Disorder, Moderate, in sustained remission

II 310.1 Personality Change Due to Another Medical Condition

Disinhibited type

III Brain injury: Myocardial infarction with prolonged cerebral anoxia

Diabetes mellitus type 2

Hypothyroidism

Unsteady gait due to cerebellar damage

IV V61.8 High Expressed Emotion Level Within Family

V60.6 Problem Related to Living in a Residential Institution

V GAF = 40

Etiology:

Successful, independent, substance-abusing loss of functional ability regained autonomy sudden loss of autonomy

Requires new adaptive skills, as old ways of being are causing distress.

Maintenance:

Perseverating on unwanted changes and lack of control

Disregards potential areas of growth or new pleasures based on past lifestyle/ideas about identity

Goals:

Re-establish or otherwise cope with level of autonomy

Support identity and interpersonal development during transition into community

Disability/Cognitive Disorder:

Accepting multiple losses (material losses, loss of known identity, loss of social dignity, loss of choice).

Older Age:

Nicholas faces both a childlike sense of freedom and also "adult problems" that cannot always be offset.

Dominant U.S. Culture/Male/Business:

Perceives dominance as a viable, even necessary, quality.

Perceives vulnerability/dependency and lack of autonomy, respect as negative.

CBT Interventions

Empathy: Examples of anger-inducing experiences, if only to support this element of the therapeutic relationship. (...And draw the line.)

There is no “gold standard” anger intervention, but it is generally agreed-upon that the client must begin to accept anger as the client’s own problem.

Clinicians support the identification of anger-engendering cognitions and the replacement of these with realistic, value-based, coping self-instruction. (Deffenbacher, 2011).

Intervention in domains of behavior, affect, cognition...

Bx:

Activities and Pleasure Prediction

Verbal x: "Bullshit."

Verbal y: "Bullshit, but interesting."

(Qualitative: Referred to idea again later.)

Af:

Humor work: Cultural considerations (aging) (Greengross, 2013).

Awareness

Cog:

Socratic questioning

Philosophy: "Better to ride the horse in the direction it's going."

List-making: Problem-solve/Exercise control where possible.

Teaches prioritization, problem-solving, and acceptance. (Deffenbacher, 2011; Hughes, 2013).

Goal for Nicholas' Anger:

  • Practice distinguishing between problem-solving and ruminating
  • Increase effective ways with which to handle provocative situations
  • Increase exposure to "resistance"-laden components of change

Self-efficacy increases; emotional arousal and negative consequences decrease. (Deffenbacher, 2011).

Psychological Flexibility (ACT):

(from Kangas & McDonald, 2011)

1. Acceptance: learning to accept both positive and negative feelings and thoughts, particularly pertaining to events and circumstances one has no control over or cannot change.

2. Cognitive defusion: techniques aim to alter the undesirable function of thoughts, rather than trying to alter their form and frequency, as is the case with CR strategies.

...

6. Committed action: conventional behavioral strategies to initiate and maintain behavioral change.

E.g. Exposure, skills acquisition, shaping methods and goal setting.

Additional Interventions:

  • Relaxation and Visualization Exposure (Gorenstein, Tager, Shapiro, Monk, & Sloan, 2007)

  • Metaphoric identity mapping (MIM) model (ACT) (Ylvisaker as presented by Kangas & McDonald, 2011)

  • Thought records with mood ratings

  • Homework

brother

wife #1

wife #2

current partner

LT love

Conceptualization - Anger/Apathy

Thoughts

  • "I was a successful businessman, and I rehabilitated myself when the doctors predicted I wouldn't. I don't belong here."

  • "I don't like group living. I never have."

  • "I took care of myself and my home perfectly well. I was happy there. What gives them the right to place me here?

  • "My stuff is gone. I need that stuff. I can't write anyone a letter or give Josie any of the beautiful things I've bought."

CBT Interventions

Situation

Since moving to assisted living facility:

  • Lost sense of privacy
  • When roommate/groups present conflict
  • Lost sense of autonomy
  • When denied control over living
  • When denied control over sleep medication
  • Coming to terms with financial situation
  • Lost sense of security
  • Belongings missing
  • Lost sense of "home"

Behaviors

Feelings

Rumination

lost belongings

mishaps with service staff and residents

questions about cost of living

evidenced by list-writing

Interpersonal Conflict

arguments with brother, son

perseverates: past/ongoing conflicts with others

Isolative behavior in A.L.:

Emerges for meals and few groups

Watches television rather than socializing

Apathy:

  • Lowered goal-directed behavior.
  • Lack of perceived pleasure derived from social connections in living environment.

Anger:

  • Resentment for placement in group environment.
  • Lack of control over privacy/activities/living mates.
  • Loss of belongings and sense of home.

Noteworthy adaptations from Peaceful Mind protocol:

  • Emphasizes behavioral intervention
  • Sound-bite approach
  • Limiting material to be learned
  • Repetition, practice, and observation by therapist
  • Agenda cards for orientation:
  • Clinician’s name, client's name and purpose of the program, date, session number, and goals of the meeting.
  • Providing services in living environment to support generalization of skills
  • Telephone check-in sessions with collateral.

Collateral:

  • Caregiver/relative/spouse/etc/ (person having 8+ hrs/wk contact with client)
  • Involvement is flexible (range from 'being with' to 'checking in') & fluctuating:
  • Level/frequency/method of involvement established during sessions.
  • Role of collateral may fluctuate over the course of therapy.
  • Clinician guides the client and collateral in formulating a plan for practicing the skills over the next week.
  • Maintenance of the collateral-client-therapist relationship:
  • Incidences of frustration and disappointment should be discussed.
  • Model for managing emotional responses.

Example of Awareness Form:

NCD CBT Skills

Awareness (usually provided first)

Breathing (usually provided second)

Then, flexibly, the following modules:

  • Calming self-statements
  • Increasing activity
  • Sleep management

STAR-VA (behavioral intervention)

Peaceful Mind (CBT for anxiety)

Piloted: N = 9 (Paukert et al, 2010)

Small RCT: N = 32 (Stanley et al., 2012)

1. Challenging behaviors:

Activators & Consequences

2. Personally relevant and meaningful pleasant events that fit with the resident’s current life circumstances.

3. Promoting effective communication and creating realistic expectations of individuals with dementia among direct care staff.

Average of nine sessions over 3 months.

Results:

Rated as less anxious by caregivers.

Rated self as better quality of life.

Caregiver reported better well-being.

Honig is aware of his memory deficits, but not all NCD patients are...

Cognitive restructuring requires the willful use of attention and memory--no simple matter with NCDs.

Cognitive-Behavioral Formulation & Treatment

with Neurocognitive Disorders

Stephanie Gebhardt

CSPP-SF

Cognitions

Affect

Forgetfulness gets in the way of managing thoughts and behaviors.

Dementia, According to WHO

What's a cognitive-behavioral therapist to do in the case of a cognitive disorder?

NPS often develop in the context of confusion and frustration...

So they are often interpersonal in nature.

Behavior

With so much confusion, feelings and behaviors get out of control.

NCD Population Boom?

  • An estimated 5.2 million Americans (2013)
  • 5 million people age 65 and older
  • 200,000 individuals under age 65
  • Worldwide in 2010, estimated at 35.6 m.
  • 58% live in low-middle-income countries
  • Projection: 71% by 2050.

Traumatic brain injury

Substance/medication use

HIV infection

Prion disease

Parkinson’s disease

Huntington’s disease

Alzheimer’s disease

Frontotemporal lobar degeneration

Lewy body disease

Vascular disease

Another medical condition

Multiple etiologies

Unspecified

(Carrion, Aymerich, Bailles, Lopez-Bermejo, 2013).

Behavioral symptoms can be conceptualized as behavioral expressions.

(Cohen-Mansfield, J., Dakheel-Ali, M., Jensen, B., Marx, M. S., & Thein, K., 2012).

Quality of life (QoL) in individuals with NCDs is not necessarily associated with cognitive ability.

The prognosis in most cases of NC disorder is persistent and/or progressive cognitive decline.

A. Evidence of moderate/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 mild/significant decline in cognitive function; and

2. A moderate/substantial impairment in cognitive performance, preferably documented by standardized neuropsychological testing or, in its absence, another quantified clinical assessment.

B. The cognitive deficits do not/do 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).

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