The development of this learning module was made possible through a
Gero Innovations Grant from the CSWE Gero-Ed Center’s Master’s
Advanced Curriculum (MAC) Project and the
John A. Hartford Foundation.
Dementia and
Other Cognitive
Disorders in Older Adults
Funded by Master’s Advanced Curriculum Project
University of Texas at Arlington
Selective Glossary/Abbreviations
 Etiology - Causes of a condition
 Symptoms - Characteristics of a condition
 Prognosis - Expected outcome of a condition
 Soft signs - Observable indicators of neurological
deficits
 R/O - Abbreviation for “rule out”
 NOS - Abbreviation for “not otherwise specified”
 ADL - Abbreviation for “activities of daily living”
 DSM-IV – Diagnostic and Statistical Manual - 4th
Edition
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Shared Features of the Cognitive
Disorders DSM Class
 These disorders constitute a “clinically
significant deficit in cognition [that is]
a significant change from a previous
level of functioning” (DSM-IV-TR,
p.135).
 Etiology is either a general medical
condition (GMC), a substance, or
combination.
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Disorder Characteristics
 Delirium - A disturbance of consciousness
and change in cognition over a short
period of time.
 Dementia - Multiple cognitive deficits
including memory impairment.
 Amnestic disorder - Memory impairment
in the absence or other significant
accompanying cognitive impairments.
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Cognitive Disorders
 Delirium due to a GMC
293.0
 Delirium NOS
780.09
 Dementia - Alzheimer’s Type or due to GMC
294.1x
 Vascular Dementia
290.4x
 Dementia NOS
294.8
 Amnestic Disorder due to a GMC
301.13
 Amnestic Disorder NOS
294.8
 Cognitive Disorder NOS
294.9
 Substance-induced Delirium
Subs use code
 Substance-induced Persisting Dementia
Subs use code
 Substance-induced Persisting Amnestic Disorder
Subs use code
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Prevalence and Incidence of
Dementia
 DSM-IV-TR (2000, p. 156) reports increasing prevalence with
increasing age, with a lifetime prevalence of 16-25% for
adults >85 years (11% males; 14% females); 40-60% of
prevalence rates are moderate-severe.
 Clinical Evidence/BMJ (2004) reports lifetime prevalence of
some form of dementia at 30% for those who reach age 90,
with vascular and Alzheimer’s (AD) each accounting for 3550% of all dementia cases.
 According to the Alzheimer's Association the number for AD:
26.6 million in 2006; may quadruple by 2050. They estimate
the incidence to double every 5.5 years; incidence of 835 out
of 3838 pop. Sample
 Estimated lifetime cost of care for a person with AD =
$174,000
Retrieved from the Alzheimer’s Association website:
http://www,alz.org/AboutAD/Statistics.asp
Warner, J., Butler, R., & Arya, P. (2004). Dementia. Clinical
Evidence Mental Health (11), 74-101.
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Dementia Subtypes
 Classification by Age of Onset
 with Early Onset (≤65 years old)
 with Late Onset (>65 years old)
 Classification by
 without Behavioral Disturbance
294.10
(cognitive impairment only)
 with Behavioral Disturbance
294.11
(wandering, agitation, foul language, aggression,
disrobing/exposure, sexual acting out)
 Other prominent features may be coded on Axis I, such
as Personality Change due to Alzheimer’s Disease,
Aggressive Type 310.1
DSM-IV-TR, p.155
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Dementia of the Alzheimer’s
Type
 Few RCTs and meta-analyses are
conducted for people with types of
dementia other than Alzheimer’s disease.
 Symptoms include progressive memory
impairment, aphasia (language
deterioration), apraxia (motor
impairment despite intact motor
abilities), agnosia (failure to recognize
objects), and executive function deficits.
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Slowly Progressive Stages of
Dementia of the Alzheimer’s Type
1.
No observable impairment, but loss of 3-4 points per year on
standardized instrument such as the Mini-Mental State Exam
(MMSE).
2.
Very mild decline, with early deficits in recent memory; if bilingual,
may gradually revert to language of origin.
3.
Mild decline, with increased irritability/personality change beginning
and partial aphasia, apraxia, agnosia after several years, with
progression.
4.
5.
Moderate decline (early stage identifiable AD)
6.
7.
Severe decline (still considered mid-stage)
Moderately severe decline (mid-stage AD), with more pronounced
behavioral/personality changes; may be postponed (average of 7
yrs.) if responsive to medication.
Very severe decline (late stage AD), with pronounced gait/motor
disturbance (risk of falls), eventually mute and bedridden.
Retrieved from Alzheimer’s Association website:
http.//www.alz.org/AD/Stages.asp
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Differential Diagnosis
 In specifying the clinical condition, first
consider and rule out conditions in other
categories, such as the psychoses and
organic brain syndromes.
 Then screen for and distinguish this
person’s symptoms from those for other
disorders in the same Cognitive Disorder
class.
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Differential Diagnosis for AD
 Rule Out (R/O) Mental Retardation
 R/O normal Age-Related Cognitive Decline
 R/O Factitious Disorder/Malingering
 R/O Schizophrenia
 R/O Major Depressive Disorder
 R/O Other Cognitive Disorders
 R/O Substance-Induced Acute or Persistent Dementia
 R/O Systemic Conditions Known to Cause Dementia:
B12/folic acid/niacin deficiency, hypothyroidism,
hypercalcemia, HIV, neurosyphilis.
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Differential Diagnosis for AD,
cont.
 No one diagnostic test currently available
until autopsy.
 CT and FMRI scans show larger cerebral
ventricles and wider cortical sulci than in
normal aging.
 Genetic correlates
 MMSE will show 3-4 point decline
annually (score > 24 points is “normal”).
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Differential Diagnosis for
Vascular Dementia
 Etiology: Multiple strokes at different
times, pre-existing vascular
disease/hypertension (coded on Axis III).
 Onset usually abrupt with fluctuating
course of rapid changes in functioning.
 Variable pattern of cognitive deficits.
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Subtypes of Vascular Dementia
 With Delirium
 With Delusions
 With Depressed Mood
 Uncomplicated
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Specifier of Vascular Dementia
 Uncoded: With Behavioral Disturbance
(wandering, etc., as in AD)
1
5
Differential Diagnosis for Dementias
due to General Medical Condition (GMC)
 Establish presence of a GMC by history, physical
exam, lab results.
 Assess for delirium (MMSE useful) to verify that
deficits do not occur exclusively during the course of
a delirium.
 Common GMCs re: HIV, head trauma, Parkinson’s
(Lewy body dementia), Huntington’s/Pick’s
(frontotemporal dementia), Creutzfeldt-Jakob Disease
 Can occur in children with these GMCs, presenting as
significant delay or deviation in development;
decreased school performance may be an early sign.
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Subtypes for Dementia due to
GMC
 Without Behavioral Disturbance
294.10
 With Behavioral Disturbance
294.11
(as in AD)
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What Does It Look Like?
 Challenges of daily living: Safety, memory
enhancement, support for activities of daily living (ADL hygiene, diet, etc.).
 Common issues for caregivers:
1. As with other chronic mental disorders, caregiving for persons with
dementia contributes to psychiatric/physical illness and increased
mortality risk.
2. Higher levels of behavioral disturbance may pose safety risks for
caregivers/other family members.
3. Spouse caregivers are aging as person with dementia’s health status
is deteriorating.
 Policy applications: Increased need for long-term care
insurance, benefits or programs to cover personal care
aides in earlier stages of the condition, multi-level
housing.
Schulz, R. & Beach, S.R. (1999). Caregiving as a risk factor for mortality: The Caregiver
Health Effects Study. Journal of the American Medical Association, 282, 2215-2219.
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Evidence-Based Treatments
 Beneficial for cognitive symptoms in
adults:
1. Memory medications:
a. Donepezil and
b. Galantamine
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Evidence-Based Treatments
 Likely to be beneficial for cognitive symptoms:
1. Ginkgo biloba
2. Memantine
3. Reality orientation
 Likely to be beneficial for behavioral symptoms.
management and health status:
1. Disease management training and intensive case
management for caregivers documented by one
Randomized Control Trial (RCT)
Warner, J., Butler, R., & Arya, P. (2004). Dementia. Clinical Evidence Mental
Health (11), 74-101.
Vickrey, B., et al. (2006). The effect of a disease management program on
quality and outcomes of dementia care: A randomized controlled trial. Annals
of Internal Medicine, 145, 713-726.
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Evidence-Based Treatments
 Likely to be beneficial for behavioral and
psychological symptoms:
1.Carbamazepine
2.Reality orientation
 Trade off between benefits and harm for
behavioral and psychological symptoms:
1.Haloperidol
2.Olanzapine
3.Risperidone
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Warner, J., Butler, R., & Arya, P. (2004). Dementia. Clinical Evidence Mental Health, 11, 74-101.
Evidence-Based Treatments
 For caregivers, likely to be beneficial for
quality of life:
1.REACH* II multi-faceted community-
based intervention, including enhanced
communication technology (1 RCT)
*REACH = Resources for Enhancing Alzheimer’s
Caregiver Health
Belle, S. et al. (2006). Enhancing the quality of life of dementia caregivers from different
ethnic or racial groups: A randomized controlled trial. Annals of Internal Medicine, 145,
727-738.
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Evidence-Based Treatments
 For caregivers, unknown effectiveness:
1.Caregiver support group
2.Educational interventions (how to prevent
falls; how to provide safe, supportive
environment; how to provide appropriate
activities and routine; how to locate peer
groups for support and recreation for person
with dementia and caregiver)
3.Respite care (adult day care, home health
aide, family care/domiciliary care home,
temporary stay in assisted living facility)
4.Individual and family counseling
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