Neurocognitive Case Study

Part 1: Neurocognitive Disorder

Neurocognitive disorders are a range of conditions that affect cognitive function, leading to deficits in memory, attention, language, and executive function. According to the American Psychiatric Association (2022), one such disorder is the major neurocognitive disorder due to vascular disease, or vascular dementia, characterized by a progressive cognitive decline that compromises a person’s ability to carry out daily activities: Neurocognitive Case Study.

For Robert Thompson, a 78-year-old male, impairments in memory, disorientation, and difficulty in organizing thoughts indicate a neurocognitive disorder, most likely with vascular etiology in light of his history of transient ischemic attacks. He has reportedly worsened following such attacks, and concern has been raised for cerebrovascular factors in his cognitive decline.

Neuroanatomy of Major Neurocognitive Disorder Due to Vascular Disease

The neuroanatomy of major neurocognitive disorder due to vascular disease primarily involves structural and functional deterioration in brain regions responsible for cognition and memory. Vascular neurocognitive disorder, as in Robert’s condition, is marked by damage to frontal and subcortical areas from ischemic events. Damage to the hippocampus, which is responsible for consolidating memory, can lead to progressive amnesia. White matter lesions and cortical thinning are classic imaging findings, indicating compromised neuronal connectivity.

Physical and Mental Status Examination

The physiological findings in major neurocognitive disorders due to vascular disease include alterations in cerebral blood flow, neuroinflammation, and neurotransmitter imbalances. Robert has a history of transient ischemic attacks, which are characterized by episodes of reduced blood flow to the brain, which may have caused neuronal damage.

His key symptoms include high blood pressure, thus the diagnosis of vascular neurocognitive disorder because hypertension leads to arterial rigidity and diseases of cerebral circulation (Santisteban et al., 2022). Arteriovenous nicking and cotton wool spots noticed during his funduscopic examination support his compromised vascular status. These physiological findings support his cognitive symptoms, thus confirming that the etiology is vascular.

The evaluation of mental state examination (MSE) results offers crucial information to answer the case questions regarding Robert’s mental state. Due to his current performance, his recent memory may be considered as being affected because, in five minutes, he could not recall three words. He presents with bradyphrenia and deranged cognitive ability, hence fulfilling the criteria for dementia.

His anxious mood and affect are appropriately congruent to demonstrate signs of emotional stress, which can be due to his deteriorating health. Moreover, he speaks slowly, uses inappropriate words, and repeats words and phrases, indicating a language disorder. However, his knowledge and reasoning ability are good, and he can be affected by the disease, but such changes can be observed with the disorder’s progression.

Cultural, Spiritual, and Biopsychosocial Factors

Cultural, spiritual, and biopsychosocial dimensions influence the diagnosis and management of Robert. Robert’s Hispanic origin may affect his attitude towards illness and seeking treatment. He stated that there are no issues regarding cultural sensitivity, but family support is critical because Hispanic cultures encourage the sharing of caregiving responsibilities among relatives (Office of Minority Health, 2024).

Further, his catholic religion can help him with coping strategies. From the biopsychosocial point of view, he observed poor engagement in activities in the community, hence a deteriorating quality of life. These aspects should be taken into consideration to enhance culturally sensitive healthcare delivery.

Diagnostic Examinations

Imaging studies and other tests are needed to establish the diagnosis of major neurocognitive disorders due to vascular disease and find out the causes. According to Sharma et al. (2021), imaging studies like magnetic resonance imaging (MRI) and computer tomography (CT) scans can help identify pathological white matter lesions or infarcts that show signs of vascular involvement.

According to Wang et al. (2022), Montreal Cognitive Assessment and the mini-mental state examination are crucial in the diagnosis of cognitive impairment and its deterioration. Determining metabolic risk factors regarding cognitive decline thus requires screening the blood glucose and lipid profile disposition. Furthermore, the neuropsychological test can help check other cognitive domains that may be affected by the disorder.

Primary Diagnosis and Differential Diagnoses

The primary diagnosis, in this case, being Major neurocognitive disorder due to vascular disease, is supported by symptoms since Robert is known to have suffered a history of two transient ischemic attacks, complains of memory loss, and inability to perform complex activities. As a consequence of cerebrovascular events, the gradual worsening of this cognitive function indicates a vascular process. In addition, he has hypertension and hyperlipidemia that could contribute to cerebrovascular pathology.

There are two possibilities for differential diagnoses: Alzheimer’s disease and mild cognitive impairment (MCI). Alzheimer’s disease and major neurocognitive disorder due to vascular disease share some resemblance, but they differ in terms of neuroanatomy and the course. Neuroanatomical evident changes in Alzheimer’s disease are cortical atrophy, predominantly in the temporal and parietal lobes with amyloid plaques and neurofibrillary tangles (Kumar et al., 2024).

In contrast, major neurocognitive disorders due to vascular disease affect subcortical white matter and especially the frontal lobe because of ischemic damage. While physiologically, Alzheimer’s is accompanied by neuronal loss and diminished levels of neurotransmitters such as acetylcholine, the major neurocognitive disorder due to vascular disease is characterized by ischemic or hemorrhagic cerebrovascular accidents resulting in a progressive cognitive decline.

Psychiatric assessment is also different. According to Scheltens (2021), Alzheimer’s disease shows apathy, agitation, and severe memory loss, but significant neurocognitive disorders due to vascular disease reveal mood changes and executive dysfunction. Culturally, Alzheimer’s disease is well-known, and this shapes caregiving approaches, while major neurocognitive disorders due to vascular disease might be poorly understood in some cultures. According to Britt et al. (2022), both can be spiritually disturbing, but coping mechanisms may differ from the religion held by the patient.

In biopsychosocial aspects, Alzheimer’s disease leads to progressive cognitive dysfunction and social seclusion. In contrast, major neurocognitive disorders due to vascular disease may cause a loss of social functioning at advanced stages. Prognosis varies, as Alzheimer’s disease tends to deteriorate over time, whereas major neurocognitive disorder due to vascular disease course is determined by stroke prevention and cardiovascular disease.

MCI represents a transitional stage between normal aging and major neurocognitive disorder due to vascular disease, involving memory deficits without significant functional impairment. Neuroanatomically, MCI has mild hippocampal atrophy. On the other hand, a major neurocognitive disorder due to vascular disease has diffuse white matter lesions and sub-cortical injury.

MCI does not show any severe ischemic changes in the brain, but abnormal slight deficits in synaptic transmission are evident (Anand & Schoo, 2024). Under the psychiatric assessment, MCI patients are more likely to have mild memory complaints and retain functional independence as compared to major neurocognitive disorders due to vascular disease, which significantly impairs activities of daily living.

Culturally, MCI may be seen as normal aging, and early treatment is not likely to be sought. From a spiritual point of view, MCI patients may be anxious about cognitive impairment and, therefore, require support. Biopsychosocial MCI patients maintain social functioning while, in major neurocognitive disorder due to vascular disease, cognitive impairment causes social isolation.

The prognosis of MCI is not very clear. However, there is possible progression to dementia, while that of major neurocognitive disorder due to vascular disease is worse with recurrent strokes or non-optimal vascular management.

Prognosis

The severity of cerebrovascular damage and management of vascular risks determines the treatment for major neurocognitive disorders due to vascular disease. According to Robert’s history of transient ischemic attacks, his condition will deteriorate unless vascular risks are kept in control. Lifestyle modification, antihypertensive, and cognitive therapy can slow disease progression. Multidisciplinary management with medical, psychological, and social interventions is required to optimize his quality and functional autonomy for as long as possible.

Part 2: Management of Major Neurocognitive Disorder due to Vascular Disease

Major neurocognitive disorder due to vascular disease is treated with an integrated approach that involves many disciplines. It is a condition that originates from pathological changes in the cerebral vasculature, which in turn causes an alteration of the thought process (American Psychiatric Association, 2022). The pharmacological approach treats the vascular risk factors underlying the cognitive manifestations. On the other hand, the non-pharmacological treatment options involve a transition to lifestyle modification, cognitive exercises, and other forms of support.

Pharmacological Management

Controlling Vascular Risk Factors

Pharmacological management of major neurocognitive disorders due to vascular disease aims to limit cerebrovascular risk factors. Cutrell et al. (2023) show that blood pressure management using antihypertensive agents such as ACE inhibitors (Lisinopril) and calcium channel blockers inhibits subsequent ischemic damage.

Inhibiting blood clotting using antiplatelet regimens such as aspirin and clopidogrel prevents the recurrence of strokes. Statins such as pravastatin reduce cholesterol levels, which reduces the risk of atherosclerosis and vascular complications. Vascular control can halt the disease’s progression and optimize brain function.

Cognitive Enhancing Medications

Cognitive-enhancing drugs may be prescribed at times, although their utility in major neurocognitive disorders due to vascular disease is variable. Donepezil and rivastigmine, which are cholinesterase inhibitors in Alzheimer’s disease, can result in mild improvement in cognition (Stahl, 2021). Memantine, an N-methyl-D-aspartate receptor antagonist, can be administered for moderate to severe cognitive impairment (Kuns et al., 2024).

The disease cannot be reversed with these medications, although the symptoms can be alleviated, and the ability to perform daily activities can be enhanced. Treatment response and side effects should be checked regularly when deciding whether to continue with medication.

Non-Pharmacological Management

Lifestyle Modifications

Non-pharmacological management is an integral component of the treatment for major neurocognitive disorders due to vascular disease. A dietary pattern with a heart-healthy nature, exercise, and smoking abstinence significantly prevents subsequent vascular damage (Ghodeshwar et al., 2023). A Mediterranean diet with high intakes of fruit, vegetables, whole grains, and lean protein sources is associated with beneficial cognitive outcomes. Physical exercise, including aerobic exercises such as walking and swimming, enhances cerebral blood flow and neuroplasticity, which retards the progression of cognitive impairment.

Cognitive Rehabilitation

Cognitive preservation through systematic mental exercises can maintain cognitive capacity. Cognitive stimulation therapy (CST) involves formal group exercises for improving memory, problem-solving, and communication. Puzzles, reading, and reminiscence therapy stimulate the brain while improving cognitive resilience (Hallford et al., 2022). Tailored cognitive training programs for the patient’s capacity can increase attention and executive functions, decelerating impairment progress.

Psychosocial Support

Psychosocial care and regular routines are beneficial to patients and caregivers. Having daily routines creates clarity and reduces anxiety, allowing patients to orient themselves in the environment better. Both patient and caregiver support groups offer emotional support and education, which enhances coping mechanisms and social interaction (Dinapoli et al., 2021).

Care quality improves with the education of caregivers regarding the progression of dementia and communication strategies, while the patient benefits in overall well-being. Social interaction through supervised group activities can minimize isolation and depression.

Behavioral and Psychological Symptom Management Targeted interventions should be provided for behavioral and psychological symptoms of major neurocognitive disorders due to vascular disease. The patient may be treated with non-pharmacological interventions, including music therapy, art therapy, and pet therapy for agitation, apathy, or depression. These therapies relax the patient and provide emotional expression, which reduces stress and behavioral disturbances. In the case of severe behavioral symptoms, low-dose selective serotonin reuptake inhibitors, including sertraline, may be administered for the treatment of anxiety and depression.

Management of Differential Diagnoses

Major Neurocognitive Disorder due to Vascular Disease and  Alzheimer’s Disease

Major neurocognitive disorders due to vascular disease may be treated with cholinesterase inhibitors such as rivastigmine and donepezil, though their benefit is more clearly defined in Alzheimer’s disease. Memantine is applied in moderate to severe Alzheimer’s disease but may have minimal therapeutic benefit in major neurocognitive disorders due to vascular disease (Knorz & Quante, 2021). The primary pharmacological treatment in major neurocognitive disorders due to vascular disease is the management of the risk factors for cerebrovascular disease, including antiplatelet agents, antihypertensives, and statins.

Non-pharmacological interventions differ in their emphasis. While cognitive rehabilitation is required for both conditions, treatment for major neurocognitive disorders due to vascular disease emphasizes physical exercise, dietary modifications, and vascular optimization. On the other hand, treatment for Alzheimer’s includes training in memory, adaptation to the environment, and regular routines to compensate for the gradual loss of memory.

Major Neurocognitive Disorder due to Vascular Disease versus Mild Cognitive Impairment

Mild cognitive impairment (MCI) does not typically require pharmacological treatment unless there is progression to neurocognitive disorder. Major neurocognitive disorders due to vascular disease, in contrast, require intensive management of vascular risk factors in an attempt to slow progression. According to Parsons et al. (2021), cholinesterase inhibitors and memantine are generally not used in MCI but may be used if symptoms worsen.

Non-pharmacological management of  MCI majors on cognitive training, lifestyle changes, and regular monitoring. Unlike major neurocognitive disorders due to vascular disease, which try to slow cognitive impairment, treatment for MCI focuses on delaying the onset of dementia through mental stimulation, social engagement, and risk factor control.

Special Considerations in Prescribing for the Elderly

Prescription of medication in elderly patients with major neurocognitive disorders due to vascular disease requires special caution due to the physiological changes of aging. Drug metabolism is influenced by reduced hepatic and renal functions, which increases the risk of drug accumulation and side effects (Vondracek et al., 2021). Cautionary dose adjustment with monitoring of the renal functions is necessary to prevent toxicity.

Polypharmacy is especially problematic, as Robert is using multiple medications for comorbidities such as hypertension, diabetes, and hyperlipidemia. Drug interactions must be carefully examined, with special attention to the anticoagulants, the antihypertensives, and the psychotropic agents. The best benefit-risk ratio medications should be used by physicians, with non-essential medications discontinued when possible.

Consistently, the risks of falls, sedation, and cognitive impairment should be balanced when psychotropic medication is prescribed. The use of benzodiazepines and antipsychotics should be avoided or used with caution since they can cause confusion and increase the risk of falls (Capiau et al., 2022). Selective serotonin reuptake inhibitors replace tricyclic antidepressants for treating depression due to their safer cardiovascular and cognitive profiles.

In addition, cognitive impairment in the elderly often undermines medication compliance. Simplifying dosing regimens, using pill organizers, and the help of caregivers can enhance compliance and ensure effective treatment. Notably, regular medication reviews should be carried out to assess efficacy, side effects, and the requirement for continuation of treatment.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.).

Anand, S., & Schoo, C. (2024, January 11). Mild Cognitive Impairment. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK599514/

Britt, K. C., Kwak, J., Acton, G., Richards, K. C., Hamilton, J., & Radhakrishnan, K. (2022). Measures of religion and spirituality in dementia: An integrative review. Alzheimer’s & Dementia: Translational Research & Clinical Interventions, 8(1). https://doi.org/10.1002/trc2.12352

Capiau, A., Huys, L., van Poelgeest, E., van der Velde, N., Petrovic, M., & Somers, A. (2022). Therapeutic dilemmas with benzodiazepines and Z-drugs: insomnia and anxiety disorders versus increased fall risk: a clinical review. European Geriatric Medicine, 14. https://doi.org/10.1007/s41999-022-00731-4

Cutrell, S., Alhomoud, I. S., Mehta, A., Azita Hajhossein Talasaz, Van, B. W., & Dixon, D. L. (2023). ACE-Inhibitors in Hypertension: A Historical Perspective and Current Insights. Springer Link, 25. https://doi.org/10.1007/s11906-023-01248-2

Dinapoli, L., Colloca, G., Di Capua, B., & Valentini, V. (2021). Psychological Aspects to Consider in Breast Cancer Diagnosis and Treatment. Current Oncology Reports, 23(3). https://doi.org/10.1007/s11912-021-01049-3

Ghodeshwar, G. K., Dube, A., & Khobragade, D. (2023). Impact of lifestyle modifications on cardiovascular health: A narrative review. Cureus, 15(7). https://doi.org/10.7759/cureus.42616

Hallford, D. J., Hardgrove, S., Sanam, M., Oliveira, S., Pilon, M., & Duran, T. (2022). Remembering for resilience: Brief cognitive‐reminiscence therapy improves young adults’ psychological resources and mental well‐being. Applied Psychology: Health and Well-Being. https://doi.org/10.1111/aphw.12364

Knorz, A. L., & Quante, A. (2021). Alzheimer’s Disease: Efficacy of Mono- and Combination Therapy. A Systematic Review. Journal of Geriatric Psychiatry and Neurology, 35(4), 089198872110447. https://doi.org/10.1177/08919887211044746

Kumar, A., Tsao, J. W., Sidhu, J., & Goyal, A. (2024, February 12). Alzheimer Disease. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499922/

Kuns, B., Rosani, A., & Varghese, D. (2024, January 31). Memantine. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK500025/

Office of Minority Health. (2024, November 8). Hispanic/Latino Health | Office of Minority Health. Minorityhealth.hhs.gov. https://minorityhealth.hhs.gov/hispaniclatino-health

Parsons, C., Lim, W. Y., Loy, C., McGuinness, B., Passmore, P., Ward, S. A., & Hughes, C. (2021). Withdrawal or continuation of cholinesterase inhibitors or memantine or both in people with dementia. Cochrane Database of Systematic Reviews, 2. https://doi.org/10.1002/14651858.cd009081.pub2

Santisteban, M. M., Iadecola, C., & Carnevale, D. (2022). Hypertension, Neurovascular Dysfunction, and Cognitive Impairment. Hypertension. https://doi.org/10.1161/hypertensionaha.122.18085

Scheltens, P. (2021). Alzheimer’s disease. The Lancet, 397(10284), 1577–1590. https://doi.org/10.1016/S0140-6736(20)32205-4

Sharma, R., Sekhon, S., & Cascella, M. (2021). White Matter Lesions. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK562167/

Stahl, S. M. (2021). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (5th ed.). Cambridge University Press

Vondracek, S. F., Teitelbaum, I., & Kiser, T. H. (2021). Principles of Kidney Pharmacotherapy for the Nephrologist: Core Curriculum 2021. American Journal of Kidney Diseases, 78(3). https://doi.org/10.1053/j.ajkd.2021.02.342

Wang, G., Estrella, A., Hakim, O., Milazzo, P., Patel, S., Pintagro, C., Li, D., Zhao, R., Vance, D. E., & Li, W. (2022). Mini-Mental State Examination and Montreal Cognitive Assessment as Tools for Following Cognitive Changes in Alzheimer’s Disease Neuroimaging Initiative Participants. Journal of Alzheimer’s Disease, 90(1), 263–270. https://doi.org/10.3233/jad-220397

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Part Two

• The entire paper is completed on the case study assigned to the student at the beginning of the course.
• Part two of the paper should be three to five pages long (not including title/reference pages), using the current APA formatting requirements with appropriate grammar and spelling. The paper requires at least four peer-reviewed resources, one of which may be Stahl’s Essentials of Psychopharmacology. All peer-reviewed resources used in the paper should be less than five years old.
• Part Two of the paper builds on part one and must include:
  • Part one of the paper with the title page
  • Evidence-based non-pharmacological treatment recommendations for the primary diagnosis
  • Evidence-based pharmacological treatment recommendations for the primary diagnosis
  • Comparison of treatment recommendations for the primary diagnosis compared to the two differential diagnoses
    • When comparing and contrasting your differential diagnoses, make sure to address the following components for each:
      • • pharmacological treatment recommendations
        • non-pharmacological treatment recommendations
  • Special considerations in prescribing for your older adult client
  • Complete the reference page with all references used in the entire paper in APA format
    

    Neurocognitive Case Study

Criteria

Part One Present

All of part one is included in the part 2 submission.

Non-pharmacological Treatment

Evidence-based non-pharmacological treatment recommendations for the primary diagnosis are thoroughly discussed.

Pharmacological Treatment

Evidence-based pharmacological treatment recommendations for the primary diagnosis are thoroughly discussed.

Comparison

Comparison of the differential diagnoses to the primary diagnosis, make sure to address the following components for each of the two differential diagnoses:

-pharmacological treatment recommendations

-non-pharmacological treatment recommendations

Special Considerations

Special considerations in prescribing for the older adult client is thoroughly examined.

APA Format & Grammer/Spelling

The paper must contain a title and reference page. The paper must include in-text citations. APA format is required. Appropriate grammar and spelling are required. Four peer-reviewed resources are provided which are each published within the last five years. Paper length is three to five pages.

Resources: 

• Stahl, S. M. Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications(cite & reference)
• DSM-5-TR  text