And So, DSM-5 Manual Says Goodbye to ‘Dementia’

Abstract

ORLANDO – This month, the hallowed term “dementia” is supposed to be tossed onto the scrapheap of discarded psychiatric nomenclature, replaced by “major neurocognitive disorder.” When the latest version of the Diagnostic and Statistical Manual (DSM-5) was released in May 2013, the American Psychiatric Association gave a year's grace period for the world to absorb the changes before they take effect. “Dementia” was replaced in the DSM-5 because the term was deemed stigmatizing; the rough translation from the Latin roots is “loss of mind.” Acknowledging that old habits die hard, however, the DSM-5 also states that use of the term is not precluded “where that term is standard.” The old DSM-IV category of delirium, dementia, and amnestic and other cognitive disorders has been replaced in the DSM-5 by the neurocognitive-disorders category. Major and mild neurocognitive disorders from Alzheimer's disease are included under this new category. At the annual meeting of the American Association for Geriatric Psychiatry, W. Vaughn McCall, MD, and George T. Grossberg, MD, highlighted the changes. “Major neurocognitive disorder” is a syndrome, which includes what was formerly known as dementia. The distinction between it and the new “mild neurocognitive disorder,” previously known as mild cognitive impairment or MCI, is necessarily somewhat arbitrary. Major neurocognitive disorder requires “significant” cognitive decline in one or more cognitive domains as noted by the patient, family member, or clinician along with objective evidence of “substantial” impaired cognition, compared with normative test values. In contrast, the requirements for mild neurocognitive disorder are “mild” cognitive decline observed by patient, family member, or clinician and “modest” impairment on testing, explained Dr. McCall, professor of psychiatry and health behavior at the Medical College of Georgia, Augusta. Dr. Grossberg offered two practical tips in drawing the distinction between major and mild neurocognitive disorder. One is whether the cognitive deficits are sufficiently limited in scope that the patient is still able to function independently in everyday activities. “If they're not, I'm moving from [mild] to major,” said Dr. Grossberg, professor of psychiatry, neurobiology, and internal medicine at Saint Louis University. Also, if neuropsychologic testing focusing on memory is performed, Dr. Grossberg wants to see at least one standard deviation below the expected age- and education-adjusted norms before calling it “substantial” impaired cognition rising to the level of major neurocognitive disorder. For a condition to qualify as major neuro­cognitive disorder from Alzheimer's disease under the DSM-5, the impairment in cognition must be insidious in onset and gradual in progression. The patient must either have a causative Alzheimer's disease mutation or meet three criteria: a decline in memory and learning, plus at least one additional cognitive domain; a steady decline without extended plateaus; and no evidence of mixed etiology involving cardiovascular disease or other disorders. “There's no requirement that memory impairment be the first affected domain. That's a bit of a change,” the psychiatrist noted. The office-based assessment of neuro­cognitive disorders as recommended in the DSM-5 includes a careful history and an objective measure of cognitive function such as the Montreal Cognitive Assessment, the Saint Louis University Mental Status Evaluation, or the Mini-Mental State Examination. The patient's ability to perform activities of daily living should be objectively evaluated, as by the Katz Index of Activities of Daily Living scale or the Barthel Index. A screening neurologic exam should be part of the workup; this can be performed by a primary care physician or a neurologist. Since major neurocognitive disorder is a syndrome, the DSM-5 does not require imaging via MRI or CT, although both Dr. McCall and Dr. Grossberg recommend baseline ­neuroimaging in order to rule out a tumor, old stroke, or fronto­temporal atrophy. Laboratory tests deemed essential parts of the work-up are a complete metabolic profile, thyroid stimulating hormone, a complete blood count, urinalysis, and folate. In addition, Dr. Grossberg said, many memory clinics now routinely include measurements of vitamin D level, homocysteine, and C-reactive protein in the work-up. “More and more research shows that [vitamin D] deficiency may be related to depression and may also have an effect on cognition. It's something that's easily remediable.” Dr. Grossman said. Elevated homocysteine and C-reactive protein levels are implicated in cardiovascular disease and also increasingly under scrutiny in Alzheimer's disease. High homocysteine levels can readily be lowered with folate, and 81 mg/day of aspirin may be sufficient to reduce C-reactive protein, he added. “Delirium” is the one neurocognitive disorder that's essentially unchanged from the DSM-IV, according to Dr. McCall and Dr. Grossberg. This condition is characterized by rapid onset and fluctuations in severity during the day and must be linked to the physiologic consequences of a medical condition. Dr. McCall reported receiving research grants from the National Institute of Mental Health and Merck. Dr. Grossberg serves as a consultant to Forest Laboratories, Lundbeck, Novartis, Otsuka, and Takeda.