860 suggest that markers of cognitive resources that are important for delirium may be different from those important for dementia. Somatic States Delirium is by definition associated with coexisting medical or surgical illness. Older adults are thought to have less physiological resources and therefore less capacity to maintain homeostasis in the face of stress than younger adults. There appears to be a role for neuroinflammation in delirium syndrome, perhaps related to changes in the blood–brain barrier. Relationship Patterns Relationships are generally stressed and disrupted. It can be particularly distressing for family members and friends to see their loved ones in such an altered state, perhaps expressing ideas that are based on delusions or misidentifications. Clinical Illustration An 85-year-old widowed man with mild cognitive impairment underwent elective knee surgery. During postoperative recovery, he developed delirium manifested by agitation and inability to cooperate with hospital staff. His subjective experience shifted dramatically, as he seemed quite frightened and irritable at some times and relatively calm and comfortable at others. With frequent visits from his adult children, reassurance and orienting discussions by the hospital staff, and low-dose antipsychotic medication, the delirium resolved, and he was able to recover psychologically as well as physically. SE132 Mild Neurocognitive Disorder (Mild Cognitive Impairment) In DSM-5, the new category of neurocognitive disorders covers both mild and severe forms of dysfunction. Major neurocognitive disorder replaces the term “dementia,” and mild neurocognitive disorder replaces the term most often used in the literature, “mild cognitive impairment” (or, in DSM-IV, cognitive disorder not otherwise specified). This confusing set of changes is further complicated by the claim of DSM-5 that neurocognitive disorders “are unique among DSM-5 categories in that these are syndromes for which the underlying pathology, and frequently the etiology as well, can potentially be determined” (American Psychiatric Association, 2013, p. 591). Such a claim is not supported by real-life clinical situations in real time. Indeed, the diagnosis of major or mild neurocognitive disorder remains clinical, as there are no laboratory, genetic, or imaging studies that can allow definitive diagnosis in a living patient. Furthermore, these diagnostic considerations often require longitudinal follow- p. There u is currently intense investigation of putative biomarkers, but such an approach is not ready for clinical use. Regardless of diagnostic nomenclature, the syndrome of mild neurocognitive disorder (mild cognitive impairment) denotes subtle features of impairment that are distinct from aging, but do not interfere with functional status and do not represent dementia. Not surprisingly, there are large numbers of older individuals (young-old as well as old-old) who experience subjective and/or objective mild cognitive impairment,
ymptom Patterns in the Elderly: The Subjective Experience—SE Axis 861 many of whom suffer from fear of developing major neurocognitive disorder (dementia due to Alzheimer’s disease or other causes). Prevalence estimates range from 11 to 42%, with an average of 19%. The course of mild neurocognitive disorder is variable: It can stabilize, remit, fluctuate, or develop into major neurocognitive disorder. In primary care settings, about one- uarter of individuals so diagnosed develop major q neurocognitive disorder (or dementia) within 3 years. Currently, there is no accepted treatment for mild neurocognitive disorder, although individuals are often counseled to exercise their bodies and minds and are sometimes prescribed medications indicated for treatment of major neurocognitive disorder. Previous categorizations of mild cognitive impairment into amnestic (i.e., primarily memory) and nonamnestic (executive, language, visual– patial abilities) types have s been of limited value. Perception of one’s own memory is colored by personality and level of insight, as well as by mood symptoms (anxiety and depression). A complicated relationship exists among subjective memory complaints, assessments by observers (e.g., family members), and performance on objective measures of memory and cognition. Changes in subjective memory perceptions are associated with changes in memory performance, but the size of associations between levels of impairment and changes in subjective memory and performance is modulated by personality characteristics and depressive symptoms. Factors other than memory are closely associated with memory perceptions, including overall health status. The Subjective Experience of Mild Neurocognitive Disorder in the Elderly Affective States Symptoms of anxiety, worry, obsessive fears, and dread may accompany mild neurocognitive disorder. The subjective experience is often related to how an individual deals with uncertainty. Denial is common and used to be considered a reliable sign that a true dementing disorder was developing. Although that sign is no longer considered reliable, it can still be a useful barometer. On the other hand, it is common for individuals with apparently mild impairment to portray themselves as having more significant impairment— tendency that is often experienced by others as exaggeration. a Cognitive Patterns Cognitive patterns are inherent to the disorder, and are discussed above. Somatic States As the syndrome occurs in older adults who tend to have multiple chronic medical problems, there is almost always consideration of interactions and of potential etiological effects. Relationship Patterns These problems often cause strain on family and friends, with frustration on both sides. The issues particularly affect close family and friends, especially those with feelings of responsibility toward the individual and/or society (e.g., intense concerns about driving).
862 Clinical Illustration An 82-year-old married woman presented with multiple chronic medical conditions and complaints that she was forgetting people’s names and could not easily come up with words in casual conversation. She recalled one of her grandparents’ becoming “senile” in old age, and she experienced considerable worry that this might happen to her. She was able to function in her usual activities, although they required more effort than previously, and sometimes she needed assistance from a caregiver/assistant. She was taking a dozen medications, some known to have effects on cognition (e.g., a benzodiazepine to help with anxiety and sleep, and an anticholinergic medication for bladder control). Her family vacillated between being dismissive toward what seemed like exaggerated complaints and being (overly) concerned that she was declining quickly. Evaluation and treatment included the patient, her family, and her primary care physician. With close follow- p and careful implementation of only one intervenu tion at a time, the patient’s medication regimen was simplified, and a combination of individual and family therapy resulted in stabilization and slight improvement in her cognitive impairment. SE133 Major Neurocognitive Disorder (Dementia) The publication of DSM-5 brought significant changes in the conceptualization of dementia. Under the new system, DSM-IV diagnoses, such as dementia of the Alzheimer’s type and dementia due to Parkinson’s disease, have been replaced by the global diagnosis of major neurocognitive disorder. Major neurocognitive disorder comprises the definitional core of neurocognitive and behavioral symptoms, such as impairment in encoding, recall of information, or executive dysfunction. Once the diagnosis has been established, it is refined by specifying presumed etiology, such as vascular type or frontotemporal type. As noted in the previous section, DSM-5 has further established the new diagnosis of mild neurocognitive disorder, in which cognitive problems are present but are milder than those of major neurocognitive disorder, and do not carry the functional impairments found in major neurocognitive disorder. The subjective experience of a person with major neurocognitive disorder can vary widely based on premorbid history, etiology of the disorder, and stage of the illness. But the disorder itself often prevents clinicians from developing a substantive sense of the person’s unique reality. The person may well have lost the capacity for insight and the language with which to conceptualize inner psychic life. Nonetheless, the person can experience significant emotional and behavioral concerns that warrant intervention. With current clinical and regulatory standards advising against sole reliance on psychotropic medications in these cases, there is a clear need for additional systems of thought with which to conceptualize the person’s distress and design complementary interventions. Clinicians need a way of understanding the distress of those who can no longer speak for themselves. Emotional and behavioral symptoms of major neurocognitive disorder are not merely manifestations of the illness; they also reflect the social and environmental context, as well as the person’s intrapsychic perceptions and reactions. Current functions and symptoms need to be understood in the context of that individual’s personal narrative. Appreciation of the person’s subjective experience can augment more traditional medical evaluation and identify opportunities to intervene therapeutically that might not otherwise be considered.
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