The DSM-5 and Neurocognitive Disorder: Diagnosis and Treatment Options

Speaker:

George T. Grossberg, MD, Samuel W. Fordyce professor, department of neurology and psychiatry, department of anatomy and neurobiology, department of internal medicine, division of geriatric medicine, dementia, health aging, Saint Louis University School of Medicine, St. Louis, MO 

Diagnosis and Management of Neurocognitive Disorders

Two years ago the American Psychiatric Association released the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)—the guidebook used by clinicians and researchers to diagnose and classify mental disorders. During a session at Psych Congress, George T. Grossberg, MD, will discuss neurocognitive disorders in relation to DSM-5 and review diagnosis and treatment options, with a focus on Alzheimer’s disease. 

Diagnosis of neurocognitive disorders can be guided by new diagnostic language in the DSM-5 and when appropriate, by imaging or biomarkers, according to the presentation. Terminology in the DSM-5 has been updated with the division of neurocognitive disorders into delirium, mild neurocognitive disorder, and major neurocognitive disorder. Major and mild neurocognitive disorders exist on a spectrum of cognitive and functional impairment. Major neurocognitive disorders corresponds to the condition referred to in DSM-IV as dementia. Furthermore, DSM-5 recognizes specific etiologic subtypes of neurocognitive dysfunction, such as Alzheimer’s disease. The DSM-5 defines 6 key domains of cognitive function:

• Complex attention
• Executive function
• Learning and memory
• Language
• Perceptual-motor function
• Social cognition 

Neuropsychological testing, with performance compared with norms appropriate to the patient’s age, educational attainment, and cultural background, ideally is part of the standard evaluation of neurocognitive disorders. It is particularly critical in the evaluation of mild neurocognitive disorders. If neuropsychological testing is unavailable, a variety of brief office-based cognitive assessments are available,  as well as  activities of daily living screening. 

Dr. Grossberg will discuss the latest available treatment approaches as part of an individualized treatment plan aligned to the particular stage of Alzheimer’s disease, including nonpharmacologic and pharmacologic approaches. Psychosocial intervention for treatment of Alzheimer’s disease is one approach that is best accomplished in a collaborative care network. Psychosocial interventions include cognitive and social stimulation, behavioral-oriented therapies, and caregiver support. Other approaches include validation therapy, reminiscence therapy, and reality orientation. Studies have demonstrated improved self-care, emotional well-being, and cognitive function as well as a reduction in risk for, or delay in, nursing home placement. It is also universally recommended as initial approach for behavioral symptoms of neurocognitive disorders. 

In terms of pharmacological treatment, Alzheimer’s disease treatments comprise 2 categories: cholinesterase inhibitors (ChEIs) and N-methyl-D-aspartate receptor antagonists (Table). However, there are few FDA-approved treatments for Alzheimer’s disease and current treatments offer modest benefits. Higher doses of agents have been approved and may be an option for patients who have “maxed out” on their Alzheimer’s disease therapy or no longer respond to lower doses, according to the presentation. Dr. Grossberg will also review the evidence to determine if there is a rationale for combination treatment of ChEI and memantine. The session will also touch on the landscape of Alzheimer’s disease drugs in development. 

Sharing the diagnosis of Alzheimer’s disease with patients and their families and communicating with them over the course of the illness concerning issues that arise is a challenge for clinicians. Dr. Grossberg will outline suggestions on how to best communicate with patients, caregivers, and other family members regarding the diagnosis and management of Alzheimer’s disease. When sharing results of diagnosis with patients and families, one recommendation for clinicians is to find out about their concern and understanding of the disease and meaning of tests. In managing the patient and caregivers, for example, clinicians should ensure that the patient and caregivers understand that there is a problem that can be addressed by medical treatment and that will require additional resources to manage appropriately.—Eileen Koutnik-Fotopoulos

Table. FDA-Approved Treatments for AD

Source: Singh I, Grossberg GT. Curr Psychiatry. 2012;11(6):20-29.