21.3 Dementia (Major Neurocognitive Disorder)
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Table 21.3-5
DSM-5 Diagnostic Criteria for Major Neurocognitive Disorder (Dementia)
A. Evidence of 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 significant decline in cognitive
function; and
2. A substantial impairment in cognitive performance, preferably documented by standardized neuropsychological testing or, in
its absence, another quantified clinical assessment.
B. The cognitive deficits 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).
C. The cognitive deficits do not occur exclusively in the context of a delirium.
D. The cognitive deficits are not better explained by another mental disorder (e.g., major depressive disorder, schizophrenia).
Specify
whether due to:
Alzheimer’s disease
Frontotemporal lobar degeneration
Lewy body disease
Vascular disease
Traumatic brain injury
Substance/medication use
HIV infection
Prion disease
Parkinson’s disease
Huntington’s disease
Another medical condition
Multiple etiologies
Unspecified
Coding note:
Code based on medical or substance etiology. In some cases, there is a need for an additional code for the etiological
medical condition, which must immediately precede the diagnostic code for major neurocognitive disorder.
Specify:
Without behavioral disturbance:
If the cognitive disturbance is not accompanied by any clinically significant behavioral
disturbance.
With behavioral disturbance
(
specify
disturbance): If the cognitive disturbance is accompanied by a clinically significant
behavioral disturbance (e.g., psychotic symptoms, mood disturbance, agitation, apathy, or other behavioral symptoms).
Specify
current severity:
Mild:
Difficulties with instrumental activities of daily living (e.g., housework, managing money).
Moderate:
Difficulties with basic activities of daily living (e.g., feeding, dressing).
Severe:
Fully dependent.
(Reprinted with permission from the
Diagnostic and Statistical Manual of Mental Disorders,
Fifth Edition, (Copyright ©2013). American Psychiatric
Association. All Rights Reserved.)
earliest learned information (e.g., a person’s place of birth) is
retained.
Inasmuch as memory is important for orientation to person,
place, and time, orientation can be progressively affected dur-
ing the course of a dementing illness. For example, patients
with dementia may forget how to get back to their rooms after
going to the bathroom. No matter how severe the disorientation
seems, however, patients show no impairment in their level of
consciousness.
Dementing processes that affect the cortex, primarily demen-
tia of the Alzheimer’s type and vascular dementia, can affect
patients’ language abilities.
Psychiatric and Neurological Changes
Personality.
Changes in the personality of a person with
dementia are especially disturbing for their families. Preexist-
ing personality traits may be accentuated during the develop-
ment of a dementia. Patients with dementia may also become
introverted and seem to be less concerned than they previously
were about the effects of their behavior on others. Persons with
dementia who have paranoid delusions are generally hostile to
family members and caretakers. Patients with frontal and tem-
poral involvement are likely to have marked personality changes
and may be irritable and explosive.
Hallucinations and Delusions.
An estimated 20 to
30 percent of patients with dementia (primarily patients with
dementia of the Alzheimer’s type) have hallucinations, and
30 to 40 percent have delusions, primarily of a paranoid or
persecutory and unsystematized nature, although complex,
sustained, and well-systematized delusions are also reported
by these patients. Physical aggression and other forms of
violence are common in demented patients who also have
psychotic symptoms.
Mood.
In addition to psychosis and personality changes,
depression and anxiety are major symptoms in an estimated
40 to 50 percent of patients with dementia, although the full
syndrome of depressive disorder may be present in only 10 to
20 percent. Patients with dementia also may exhibit pathologi-
cal laughter or crying—that is, extremes of emotions—with no
apparent provocation.
Cognitive Change.
In addition to the aphasias in patients with
dementia, apraxias and agnosias are common. Other neurological
