case study 2 for neurocognitive disorders alice

Module 14: Neurocognitive Disorders

Case studies: neurocognitive disorders, learning objectives.

• Identify neurological disorders in case studies

Case Study: Sarah

Sarah is a 78-year-old female and is very outspoken. Sarah has been an actor in off Broadway shows as well as working as a consultant in the education industry for 30 years prior to retirement. Sarah and her family members over the past year have noticed that she is not remembering things as well. Sarah even admitted to her husband that she is more and more having forgetful moments over the past two years. Sarah’s mother and aunt were diagnosed with a neurocognitive disorder several years before they passed away. Sarah agreed to go to the doctor and was a bit worried about the biological impact of her mother’s disorder, but kept an open mind. Sarah went to the doctor and discussed what was going on, and the doctor referred Sarah to specialists who focus on memory. Sarah was asked if she partook in any substances, which she said she occasionally has wine to drink to unwind some evenings, but nothing problematic. Sarah was administered several memory tasks and the doctor said the results were OK, as she remembered two out of four items and said that he wanted to see her again in three months.

Sarah went back in three months and there was no change, but at six months she was only able to remember one out of four items on a memory task and he suggested starting treatment. Sarah was administered an acetylcholine agent that could help limit memory loss for a period of time. Over the next three years, Sarah remained with mild cognitive loss, but after three years on the medication, the effectiveness was not showing, unfortunately. Sarah was then told that she needed permanent care as her memory was progressing at a negative rate. Sarah was at home for another three years, but then was unable take care of herself and was put in a nursing home facility.

Figure 1 . Gina has seen a decline in her desire to participate in her usual activities alongside a decline in cognitive abilities.

Case Study: Gina

Gina is 76 years old and went to her doctor for a regular physical as she did each year. Gina told the physician that she recently has socially isolated herself and has not felt comfortable visiting and spending time with family. Gina also was having hallucinations and found that she had symptoms that were consistent with Parkinson’s disease, but was not sure. Gina also told the physician that she seems to forget things a great deal more than she used to and wanted to find out why. Gina also discussed with her doctor that her alertness and attention varied quite heavily. Gina said her family members have said that they noticed a 20–25% decrease in her cognition over the past six months. Gina discussed as well that she is not as active as she was six months ago, and sometimes she does not have the energy to go outside and go for a walk as she has done in the past. Gina took part of a memory task at the physician and was only unable to recall one out of four items that the doctor presented to remember. Gina’s doctor suggested that she receive an opinion from a specialist and referred her to them.

Think it Over

What are the treatment options that could be part of the process in helping Gina and why? Also, if you were the physician, which specialist or specialists would you refer Gina to and why? What tests/exams should Gina have in relation to further diagnosis?

Also, in Sarah’s case, do you feel going to the doctor helped her cause in relation to memory loss and if so why? What treatment would you focus on for Sarah and why?

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Case Report Volume 6 Issue 3

Major Neurocognitive Disorder and Academic Achievement: A Case Report

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1 Major General Hugh G Robinson Center for Neuropsychiatry, USA 2 University of Colorado, Colorado Springs, CO, USA 3 Department of Neurology, Columbia College of Physicians and Surgeons, USA

Correspondence: Tony Brown, Columbia University, USA

Received: March 27, 2016 | Published: July 7, 2016

Citation: Bergquist NA, Weidner BA, Finley D, Brown T (2016) Major Neurocognitive Disorder and Academic Achievement: A Case Report. J Psychol Clin Psychiatry 6(3): 00353. DOI: 10.15406/jpcpy.2016.06.00353

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Neurocognitive disorders are identified by a significant decline in relation to prior levels of cognitive functioning. This case report highlights a 47 year-old Caucasian female who has a history of sub-occipital craniotomy for the removal of a grade II brain stem astrocytoma at age 17 and a difficult childhood. Of interest is this patient’s ability to overcome Major Neurocognitive Disorder while achieving advanced academic success. Recent neuropsychological evaluation and specific deficit findings are discussed in regards to this patient continually achieving academic success during cognition deficits. Common factors of neurocognitive decline are well documented but consistent integration of these factors such as age, gender, education, diagnostics, treatment, and therapy options are lacking in literature. This case highlights the importance of identifying all factors involved in neurocognitive decline and, as importantly, those factors involved in overcoming the issues related to this diagnosis. Concluded was that timely and accurate diagnosis, location of tumor, which treatment options are utilized, and post treatment monitoring can each have an effect on patient outcome.

Keywords: Neurocognitive disorder; Astrocytoma; Neurosurgery; Academia; Brain

Introduction

Compared with brain tumors in adults, a much higher percentage of pediatric brain tumors arise in the posterior fossa, which includes the brain stem and cerebellum. While astrocytoma’s can be found elsewhere in the brain, the majority are found in the posterior fossa. These infratentorial astrocytoma tumors comprise as many as two thirds of all pediatric brain tumors [1]. An astrocytoma is typically a childhood tumor and is of glial cell origin. These glioma tumors start in the brain or spinal cord tissue and do not spread beyond these defining margins or tend to affect other organs. While signs and symptoms of a brain tumor can vary depending on tumor location, generally, headaches, seizures, memory loss, and behavioral changes make up the most common signs and symptoms in the presence of an astrocytoma. Most symptomatic children have endured several visits to a physician before the correct diagnosis has been made, and often they are misdiagnosed with gastrointestinal disorders. Once an astrocytoma has been identified, initial treatment is usually neurosurgical resection. Of interest is this patient’s ability to overcome Major Neurocognitive Disorder (MND) while achieving advanced level academic success.

Astroycytoma in Major Neurocognitive Disorder

Case presentation.

Patient history included a difficult upbringing with personal alcohol abuse starting at age ten years, and ending ten years ago. She related that her mother had told her she had received psychotherapy between the ages of ten to twelve years, but she does not recall the therapy. She attended group therapy for alcohol addiction for ten years until recently when she quit participation due to new educational demands. Medical history includes bilateral polyps requiring surgery over several years, bilateral deafness requiring corrective surgery over several years, a cochlear implant that did improve her hearing, and a failed surgery to improve her vision. She had a turbulent relationship with her mother who had a history of bipolar disorder that was a dual diagnosis with her alcohol and prescription medication abuse. The patient’s mother recently died of a drug overdose and had been non-adherent with her breast cancer treatment regimen. This patient related that a good relationship existed with her father, until his death from a myocardial infarction when she was 18 years of age. She is currently divorced and related unstable intimate relationships since her divorce. She related no academic problems during her elementary years, but reported conduct problems during her middle school years.

After undergoing neurosurgical resection of her brain tumor, she dropped out of high school and ultimately earned her GED. She went on to earn a Bachelor of Science degree in biology, and subsequently graduated and became licensed as a Doctor of Chiropractic. Her current educational endeavor is also clinically focused, a Doctor of Medicine. She related that she has pushed hard and was able to struggle through her various and progressive educational programs, and that she had to work hard for her academic achievements. Recent neuropsychological evaluation results revealed compromised attention/concentration abilities under time constraints, as well as learning and memory with immediate and delayed memory recall deficiencies. This patient also encountered difficulty with organization, item misplacement, daydreaming, difficulty with sustained attention, and difficulty staying alert in situations where she felt bored, as well as shallow and fleeting relationships. She was noted to have a strong sense of self-worth and a positive self-evaluation. She has typically been intolerant of inactivity and relays a possible penchant for momentary excitement, fleeting adventures, and shortsighted hedonism. She also related an insatiable search for stimulation, affection, and a rejection of traditional gender roles.

Exacerbating Factors of MND

Factors in this case such as her female gender, length of time since her surgery, long-term alcohol abuse, chaotic childhood, challenges with bilateral deafness, and multiple surgeries for other issues each, and collectively have contributed to neurocognitive decline. Alcohol use has been well documented to affect the brain and result in impaired memory recall, slowed reaction times, and speech difficulties [6]. Long-term alcohol abuse has been generally recognized as a causative factor in brain atrophy from neuronal death. This patent abused alcohol for 27 years, and begins the abuse during her developmental years, at age 10. Other sequelae of long -term alcohol abuse include permanent memory loss, as noted in Korsakoff dementia, liver disease and cancer, nutritional deficiencies, and ataxia. Certain medications are known to affect cognition, as well. This patient’s current respiratory medications (Symbicort, Pulmicort, and Proventil), though, have not been associated with neurocognitive decline. IQ testing is a common method used to document neurocognitive decline. While testing was indicated given this patient’s history, no IQ testing was ever performed. “The rate of IQ decline is associated with several risk factors, including younger age at time of treatment, longer time since treatment, female sex, as well as clinical variables such as hydrocephalus, use of radiotherapy and radiotherapy dose, and the volume of the brain that received treatment.” [4] Regarding additional factors, the authors stated, “Chaotic and dysfunctional family environments have a substantial adverse effect on neurocognitive recovery from traumatic brain injury in school-age children.” [4] A proper diagnosis of MND’s must include impairment in one or more of the following cognitive domains: Learning and memory, complex attention, social cognition, executive ability, language, or perceptual motor abilities [7]. Recent neuropsychological evaluation findings suggested this patient has Major Neurocognitive Disorder due to a medical condition (brainstem astrocytoma with neurosurgical resection). Results from this recent evaluation revealed impairment across several cognitive domains. There was quantifiable outcome assessment to compare these results to, although perhaps, the patient’s lack of recall regarding academic problems in elementary school could be utilized as a historical comparison. Quantitative literature analysis regarding the magnitude of neurocognitive deficits specifically in pediatric brain stem tumor survivors was recently conducted. Late effects of neurocognitive decline were noted to be moderate to severe across broad neurocognitive domains, for survivors of posterior fossa tumors [8], as was also the case for this patient. Her academic success, though, are contradictory to the statement that “Disruptions in cognitive development are among the most frequently observed late effects in this group of survivors, and include possible long-term disruptions in brain development, cognitive function, and later school and work performance” [8].

Study Strategies for MND Patients

Methods of improving neurocognitive function are fairly well documented in the literature, but offer little insight as to the reasons behind this patient’s significant academic success despite her ongoing cognition issues. Cognitive remediation treatment has historically involved several forms of therapy, such as cognitive behavioral therapy and memory improvement techniques. Evidence is lacking in regard to known academic success improvement strategies. One study noted that while training with a memory notebook helped increase memory, correlated was only a slightly increased academic success [9]. For the current patient, she reported utilization of the following:

• One-on-one tutoring for five hours per week.
• Remote webinar instruction. Nine hours per week of new material. She repeated each 90-minute session twice during the week for a total of 27 hours of additional instruction per week.
• Medical Student Review Course. This coursework helps the learner effectively integrate basic science concepts in preparation for medical board examinations.

Along with the methods that this patient utilized, other suggestions to improve academic success in patients with MND include:

• Study group participation to aid in the retention of novel material.
• Verbal and visual imagery mnemonic aids to help retain information. Today there are many online sources available in many fields of study that animate, rather than condense, material for greater visual and auditory effects on memory.
• Repetitive use of practice question banks, class-specific learning videos, and flash cards to aid in creating long term memory.
• The use of memory aids in daily life such as a planner, calendar, to-do list, and pocket recorder.
• Avoidance of cluttered workspaces and background noise that reduce visual and auditory stress.
• Online cognitive training programs that improve speed of recognition and recall.

Although she did not take advantage of them, this patient was deemed eligible for academic accommodations based on her diagnosed impairment and MND. Diagnosed patients should consider the benefits of receiving these testing accommodations:

• Extra allotted time to complete tests.
• A quiet room in order to minimize distractions related to her decreased processing speed and attentional challenges.
• Seating placement at the front of the class to help with attention and concentration.

Difficulty in qualifying neurocognitive decline in this case arises from an absence of prior comparative testing. Even if pre-surgical testing had been performed, testing while experiencing deficits from a diagnosed brain tumor that also presents with functional impairment would likely have been abnormal, and thus, would not have been indicative of any truly normal function that the patient had enjoyed prior to any neurological insults. If pre-surgical testing is performed on these patients and compared to each one’s own post-surgical testing, the variables of abnormal pre-surgical data compared to post-surgical data poses a problem in attaining accurate comparisons. Lack of any pre- or post-surgical testing until years after surgery, as in this case, also poses a problem in qualifying the neurocognitive results. Regular post-surgical testing is recommended for pediatric brain tumor patients. In the case of this patient no testing had been performed in prior 30 years that had passed since her surgery.

A myriad of contributing factors related to the neurocognitive decline and the lack of comparative and objective data in this case has created difficulty in the accurate assignment of blame regarding her deficits. Recent neuropsychological testing attributed her deficits to her brain tumor and subsequent tumor resection, despite the lack of prior testing with which to make a comparison. Greater understanding of the clinical presentation of these tumors and judicious use of modern neuro imaging techniques may lead to more efficacious therapies and the potential for less post-treatment deficits. This patient had a strong drive to avoid female gender roles, which may have contributed to her educational pursuits in previously male dominated professions. Due to a strong sense of self, she has been able to navigate challenges until she has succeeded in her educational goals. No comprehensive data exists that has an explanation for this patient’s neurocognitive decline with concurrent advanced academic achievements.

Increased interest exists in the reduction of neurocognitive effects in brain tumor patients through improved treatment options. The establishment of baseline neurocognitive testing at an early age should become mainstream, in order to identify early cognitive deficits and to later provide a comparative point if the need arises. Understanding the multiple factors that contribute to neurocognitive decline as well as the factors that contribute to improvement are important for overall patient success. Social and societal implications exist regarding the well-being of neurocognitive disorder patients. Further research is needed to understand the impact of strong personal factors such as self-will and self-esteem, contribute to the ability to achieve advanced academic success, while the patient still experiences many factors that contribute to neurocognitive decline.

Authors’ Contributions

• Tabatabaei SM (2012) Posterior Fossa Tumor in Children. Iranian Journal of Child Neurology 6(2): 19-24.
• Fehling MG, Craciunas SC (2010) Editorial: High-grade intramedullary astrocytomas: What is the best surgical option? J Neurosurg Spine 12(2): 141-142.
• Gehrke AK, Baisley MC, Sonck AL, Wronski SL, Feuerstein M (2013) Neurocognitive deficits following primary brain tumor treatment: Systematic review of a decade of comparative studies. J Neurooncol 115(2): 135-142.
• Mulher RK, Merchant TE, Gajjar A, Reddick WE, Kun LE (2004) Late neurocognitive sequelae in survivors of brain tumours in childhood. Lancet Oncology 5(7): 399-408.
• Di Rocco C (2010) Preoperative and postoperative neurological, neuropsychological and behavioral impairment in children with posterior cranial fossa astrocytomas and medulloblastomas: The role of the tumor and the impact of the surgical treatment. Childs Nerv Syst 26(9): 1173-1188.
• National Institute on Alcohol Abuse and Alcoholism. Alcohol’s Damaging Effects on the Brain (2004) National Institute on Alcohol Abuse and Alcoholism.
• Schnyer DM (2016) Major and Mild Neurocognitive Disroders. SMSherman (Author), Encyclopedia of Mental Health ( 2nd Edn) Elsevier, p. 33-38.
• Robinson KE, Fraley CE, Pearson MM, Kuttesch, John F, et al. (2013) Neurocognitive late effects of pediatric brain tumors of the posterior fossa: A quantitative review. J Int Neuropsychol Soc 19(1): 44-53.
• Kerns KA, Thomson J (1998) Case study: implementation of a compensatory memory system in a school age child with severe memory impairment. Pediatr Rehabil 2(2): 77-87.

©2016 Bergquist, et al. This is an open access article distributed under the terms of the, Creative Commons Attribution License ,--> which permits unrestricted use, distribution, and build upon your work non-commercially.

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ORIGINAL RESEARCH article

Assessment of major neurocognitive disorders in primary health care: predictors of individual risk factors.

• 1 Abel Salazar Institute of Biomedical Sciences – University of Porto (ICBAS.UP), Porto, Portugal
• 2 Center for Health Technology and Services Research (CINTESIS.ICBAS), Porto, Portugal
• 3 Office on Ageing Issues 50 + (CA50 + ), Porto, Portugal

Major Neurocognitive Disorders describe the symptoms of a large group of diseases causing a progressive decline in individual’s functioning. It is an umbrella term describing a decline in memory, intellectual ability, reasoning, and social skills, as well as changes in normal emotional reactions. The general practitioner is instrumental in the early diagnosis of Major Neurocognitive Disorder. Individual risk factors act as contributing variables affecting the probability of someone developing a Major Neurocognitive Disorder and may be considered predictive factors. This study aimed (i) to show the utility of using the Global Deterioration Scale in primary health care settings as a measure to assess the stage of cognitive function for individuals identified with Major Neurocognitive Disorders and (ii) to identify predictors of severe Major Neurocognitive Disorders. Potential predictors of Major Neurocognitive Disorders considered in this study were: sex, age, years of education, social isolation, hearing impairment, cardiovascular disease, hypertension, diabetes, smoking habits, alcohol consumption, physical activity, hand strength, and nutritional status. The sample comprised 250 adults, 30.4% were classified as having probable Major Neurocognitive Disorder. The variables significantly associated with probable Major Neurocognitive Disorder were age, years of education, hearing impairment, cardiovascular disease, hand strength, nutritional status, and physical activity. In the multivariable model, only age, education, physical activity and hand strength remained significant predictors of probable Major Neurocognitive Disorder. The Global Deterioration Scale seems to be a usefull instrument in primary healthcare settings, as it guides the general practitioner in observing the patients’ cognitive functioning. Advanced age, lower education, lower hand strength and absence of physical activities should be taken into account as they increase the chance of severe Major Neurocognitive Disorders. Primary health care providers, including general practitioners are very important in the diagnosis and follow up of Major Neurocognitive Disorder. The general practitioner is in most cases the patients’ first and for many patients the only contact, thus having a critical role in evaluating with caution what is part of normal or pathological aging, and the individual factors that can increase the likelihood of developing Major Neurocognitive Disorder to further support patients in the course of the disease.

Introduction

Major Neurocognitive Disorder (MND) – previously called dementia – is a syndrome that progresses with significant deterioration of cognitive domains as compared to previous levels of cognitive performance in memory, speech, reasoning, intellectual function, and/or spatiotemporal perception, and may also be associated with changes in emotional behavior and difficulties at the functional level. The decline is initially noticed by the individual, the family, or the General Practitioner (GP) who is usually responsible for the early diagnosis ( American Psychiatric Association [APA], 2014 ).

MND may result from brain disorders, classified as primary (degenerative), or consequence of other conditions (secondary) ( Emre, 2009 ). The most common types of MND are: Alzheimer’s disease, Vascular dementia, Lewy body dementia and Frontotemporal dementia. In secondary MND (e.g., alcoholic dementia, infectious diseases) the symptoms may be treated and/or prevented. Therefore, a correct diagnosis is crucial. This is supported by a detailed collection of the person’s clinical history, neurological and neuropsychological examination and the comprehensive use of laboratory and imaging tests. In primary MND, early diagnosis is equally crucial either to delay the progression of cognitive symptoms and to control/stabilize psychiatric manifestations ( Ribeira et al., 2004 ).

Some symptoms of MND might be confused with typical changes occurring in healthy aging. The first signs of MND are very subtle and vague, and can be difficult to detect. Those signs are also very diverse and, as such, we must do a staging of Dementia, which is not only centered on aspects of the cognitive forum ( Fernández-Ballesteros et al., 2012 ).

The GP is instrumental in the detection of the first signals of MND. Additionally, the GP supports the persons with MND and their caregivers in organizing and planning interventions at an early stage of the disease and care provision as the disease progresses ( Sequeira, 2010 ). To confirm any suspicion on the decline in cognitive functioning of a patient, the GP needs to use a screening instrument that should be easy and quick to apply. The most common practice is the use of the Mini Mental State Examination (MMSE) ( Folstein et al., 1975 ) that has been used to detect and monitor the evolution of cognitive impairment ( Valle et al., 2009 ). The disadvantage of using MMSE, however, is the fact that it does not allow to establish stages of cognitive function or detect early stages of cognitive decline.

The Global Deterioration Scale (GDS), developed by Barry Reisberg (1988), provides an overview of the stages of cognitive function for those living with a primary degenerative dementia. This instrument is easy to use and facilitate the assessment of subjective cognitive complaints ( Custodio et al., 2017 ). GDS stages are associated with cognitive function but also with basic and instrumental activities of daily living (ADL; e.g., dressing, eating, and bathing) and instrumental activities of daily living (IADL; e.g., handling finances, medication management ( Paul et al., 2002 ). GDS is not a diagnostic scale and was developed as a qualitative severity rating only ( Hartmaier et al., 1994 ; Brooke and Bullock, 1999 ; Petersen et al., 1999 ). According to Custodio et al. some studies validate the GDS as an assessment tool to detect mild cognitive impairment.

The GDS includes seven stages: Stage 1 (no cognitive decline) – No subjective or objective memory deficits. Stage 2 (Very Mild Cognitive Decline) – Subjective complaints of memory deficit, but no objective measurements of memory deficit. Stage 3 (Mild Cognitive Decline) – The individual now meets criteria for mild cognitive impairment. Stage 4 (Moderate Cognitive Decline) – The individual is now classified as being mildly demented. This could manifest as a clear deficit on concentration, handling finances, orientation, and recognition of time and place. Symptoms such as flattening of affect and anxiety start to occur. Stage 5 (Moderately Severe Cognitive Decline) – The individual now meets criteria for moderate dementia and can no longer function without some assistance but can toilet and eat on their own. Stage 6 (Severe Cognitive Decline) – The individual meets criteria for moderately severe dementia. The individual is entirely dependent on someone else for survival and are generally unaware of their surroundings, year, season, etc. Personality and emotional changes occur. Stage 7 (Very Severe Cognitive Decline) – The individual is now severely demented. The individual has lost all verbal abilities and is incontinent, as well as basic psychomotor skills ( Hardcastle et al., 2019 ).

Predictive Factors of MND

MND is likely to develop in a continuous process ( Brooks and Loewenstein, 2010 ). Individual factors affect the likelihood of developing MND. Those factors predicting the development of the disease should be known, and preventive interventions must build on this knowledge.

Previous studies have identified predictive factors of MND, which can be grouped into sociodemographic (e.g., sex, age, and years spent in education and social isolation), health factors (e.g., hearing loss, cardiovascular diseases, hypertension, diabetes, handgrip strength, and nutritional status) and bio-behavioral factors (e.g., smoke, alcohol, and physical activity) ( Helzner et al., 2009 ; Nagai et al., 2010 ; Polidori et al., 2012 ; Baumgart et al., 2015 ; Santana et al., 2015 ; Schwarzinger et al., 2018 ). Given that most of these factors are potentially modifiable (e.g., diabetes, cholesterol, depression, or malnutrition; Chen et al., 2017 ), the individual can play an active role in the development of the disease, allowing for more efficient intervention. Primary prevention in the primary health care context is very important for the course of MND, and should focus on the identification of situations that increase the likelihood of occurrence or worsening of symptoms. However, few studies identify predictive factors associated with severe stage of MND ( Eshkoor et al., 2016 ).

The objectives of this paper are: (i) to show the utility of using the GDS in primary health care settings as a measure to assess the stage of cognitive function for individuals identified with MND (ii) to identify predictors of severe MND.

Materials and Methods

Participants.

This study is an observational cross-sectional study that is part of a larger project aiming at “Needs of Care for People with Dementia.”

The inclusion criteria defined in the largest project, also used in this study, are: (i) to be a user of a primary care unit in the area of Portuguese North Regional Health Authority (ARS Norte); (ii) age 65 years or plus; (iii) living in the community; (iv) presence of mental health concerns. The exclusion criteria were as follows: (i) patient not using a primary health-care unit covered by the ARS North; (ii) age less than 65 years old; (iii) living in nursing home, hospital or psychiatric institution; and (iv) absence of memory concerns (patients classified in stage 1 of the GDS).

Instruments

The study protocol was based on the “Community Assessment of Risk and Treatment Strategies (CARTS) Program” developed in the University College Cork, Ireland ( Caoimh et al., 2012 ). The protocol is divided in three different sections: The purpose of the first part (Part A) was to assess the patient with probable dementia referred by the health professional (GP or nurse); the second part (Part B) was used to assess the patient with probable dementia by the GP; the final part (Part C) focus the evaluation of the informal caregiver of the patient with probable dementia (if available).

In this study, information provided in Part A and B of the assessment protocol was used. Data were collected by resorting to the following instruments:

Sociodemographic questionnaire: It allows to collect data about the patient with probable dementia, including sex (M/F), age, years spent in education, and social isolation (living with someone/living alone).

Cognition: Global Deterioration Scale (GDS) ( Reisberg et al., 1982 , portuguese version; Leitão et al., 2007 ). This instrument allows to qualitatively classify the individuals according to the stage of primary degenerative dementia. This scale has been validated with behavioral, neuroanatomic, and neurophysiological measures in patients with primary degenerative dementia. GDS includes seven different stages of patient classification (see section “Introduction”). An overall description of the symptoms and clinical characteristics expected for each stage of dementia is provided in the instrument, and such descriptions are considered for deciding on the most appropriate global level (stage) of cognition and function.

Health: Older Americans Resources and Services (OARS) ( Fillenbaum and Smyer, 1981 , portuguese version; Rodrigues, 2008 ) is a program of resources and services for old people. The OARS methodology was developed to assess functional capacity in five key areas for older adults’ quality of life: social resources, economic resources, mental health, physical health, and activities of daily living. It also measures the use and perceived need for various types of services, enabling the evaluation of intervention programs and informed decision-making on the impact of resources and services. This instrument contains a list of the most common problems in older people and this study considered cardiovascular problems, hypertension, diabetes, hearing loss, and dementia; Handgrip strength was assessed using a dynamometer considering four attempts, two on each hand. The final score corresponds to the average of the highest values for each hand ( Wearing et al., 2018 ; Zammit et al., 2019 ).

Bio-behavioral aspects: Frequency of physical activity [(1) more than once a week; (2) once a week; (3) 1–3 times per month; (4) almost never or never]; Alcohol and tobacco consumption [(1) no; (2) yes, but stopped; (3) yes]; Short-Term Nutritional Assessment (MNA-SF) ( Rubenstein et al., 2001 ) is a nutritional screening and assessment tool aimed at identifying malnourished patients. It consists in six questions and the total score ranges from 0 to 14. A score of 11 or above indicates possible malnutrition.

The Risk Instrument for Screening in the Community ( Caoimh et al., 2012 ) was first used as a screening tool to identify potential participants, i.e., patients with mental health concerns. Based on these results, and considering strata by age group, sex, and region, 572 participants with mental health concerns were randomly selected. Of these, 504 agreed to participate and 436 were eligible to participate. The final sample of this study included 250 individuals with mental health concerns and with the evaluation provided by the GP (Part B of the study protocol).

The data collection lasted 27 months (from January 2014 to April 2016). The Part A of the study protocol was administered to potential participants by trained interviewers and took on average 45 min to complete. Most interviews were carried in health-care centers, and, when participants were not able to meet the interviewers at the health centers, interviews were completed at patients’ home.

After the first interview, the GP completed the Part B of the evaluation protocol using mainly the existing clinical registries of the patient. To complete the checklist of diagnoses (OARS), the GP used the International Classification of Diseases 9th Revision Clinical Modification (ICD-9-CM). This classification was adopted in Portugal in 1989 for the purposes of clinical coding. In the specific case of the diagnosis of dementia, the coding F03-dementias (not specified) was considered.

The study was submitted to the Ethics Committee of the ARS-Norte and was approved unanimously on January 7, 2014 (Reference No. 6/2014). All participants signed the informed consent form complying with the Declaration of Helsinki.

The detailed methodological aspects are reported and can be consulted elsewhere ( Teixeira et al., 2017 ).

Statistical Analysis

First, a receiver operating characteristic (ROC) analysis was performed to determine the optimal GDS cutoff point to identify stages of MND, considering the GP diagnosis as gold standard [coding F03-dementias (not specified) in the diagnosis’ checklist]. The area under the curve (AUC) was calculated as well as the sensitivity and specificity values. The Youden Index (Sensitivity + Specificity-1) was used to obtain the optimal cutoff point.

Then, based on the optimal cutoff point obtained, two groups were considered: patients with non-severe MND vs. patients with severe MND.

Descriptive analysis of the data was performed in order to describe the sociodemographic and health profile of the study sample. Differences between groups with and without non-severe MND across sociodemographic, health, and bio-behavioral variables were assessed using the Student t -test (for continuous variables) and the Chi-Square test (for categorical variables). To identify potential predictors of severe MND, a multivariable binary logistic regression model was used.

All analyses were performed using IBM SPSS Statistics 24. A significance level of 0.05 was considered.

In order to identify stages of MND through the optimal GDS cutoff point, we use a ROC curve analysis. The area under the ROC curve [AUC = 0.777, 95% CI = (0.700; 0.854)] shows that GDS can predict about 77.7% of the events (severe MND). Given the estimates for sensitivity and specificity (0.615 and 0.860, respectively) and based on the Youden index, the optimal cutoff was 3.5, i.e., individuals with a score equal or greater than four were classified as severe MND ( Figure 1 ).

Figure 1. ROC curve.

With this cutoff point we classified and grouped the individuals in the sample as “with non-severe MND” or “with severe MND.”

More than half of the sample ( N = 250) is female, and the average age 76 years old. The participants spent, on average, 2.5 years in formal education and only a small percentage live alone. About 1/3 of the participants have hearing impairment and more than 40% have diabetes, cardiovascular problems or hypertension. The average handgrip strength and nutritional status score is below 20%. Regarding the bio-behavioral aspects, more than 50% of the sample do not smoke, report to exercise more than once a week and less than 50% do not drink alcohol ( Table 1 ).

Table 1. Characteristics of the total sample and according groups.

The potential predictors of severe MND considered in this study were: gender, age, years of education, social isolation, hearing loss, cardiovascular disorders, hypertension, diabetes, smoking, alcohol consumption, physical activity, hand strength, and nutritional status.

Of the referred factors, there was a significant association with severe MND for age ( p < 0.001), years of education ( p = 0.006), hearing loss ( p = 0.002), cardiovascular disorders ( p < 0.001), hand strength ( p < 0.001), nutritional status ( p < 0.001), and physical activity ( p < 0.001).

Individuals with severe MND had a higher mean age and lower years of education compared to individuals with non-severe MND. Additionally, the percentage of individuals with severe MND was higher in individuals with hearing and cardiovascular problems. Individuals with severe MND had a lower mean of Hand Strength and a lower mean of MNA score. Finally, individuals who exercise more than once a week have a lower percentage of severe MND than individuals who never exercise.

In order to identify independent predictors of severe MND, we used a multivariable binary logistic regression model, considering results obtained from the bivariate analysis ( Table 1 ). Only age, years of education, physical activity and hand strength have shown to be significant predictors of severe MND (see Table 2 ).

Table 2. Multivariable logistic regression model.

Older patients had more chances to had severe MND ( OR = 1.090; 95% CI 1.017–1.167). Additionally, the more years of education the participants had, the lower the chance of having been classified with severe MND ( OR = 0.696; 95% CI 0.550–0.882). Similar results were found for hand strength, with higher hand strength related with a decreased risk of severe MND ( OR = 0.919; 95% CI 0.856–0.986). Finally, regarding physical activity, those who almost never or never practice physical exercise had a higher chance of being classified as having severe MND than those who never practice physical exercise ( OR = 4.121; 95% CI 1.635–10.390).

The first objective of this study related to the need of identification of MND stages of MND by GPs, to facilitate an early referral of patients to specific and beneficial interventions. This would enable to timely implement appropriate interventions targeted at these patients and their caregivers and aimed at monitored more effectively the disease from its outset and during its course. There is no specific protocol to make the diagnosis of MND in Primary Health Care settings. GPs tend to use various tests and complementary exams, whenever available, to determine whether symptoms meet diagnosis criteria of MND and to exclude other possible causes for observed symptoms.

Although there are other scales widely used, such as the “Clinical Dementia Rating scale (CDR)” and the “Clinical Dementia Score” ( Morris, 1991 ) we have selected the GDS accounting for the fact that this is a friendly tool that allows the GP to go further with the diagnosis and classify the state of the MND, through observational interviewing and recording of the patients’ symptoms. In addition to the usefulness of this instrument to appraise the stage of MND, thus focusing mainly on cognition, it is one of the simplest scales, helping to understand the patients’ actual and future condition, and proved to be very suitable. We determined the optimal cutoff point for the GDS in the early diagnosis of probable MND, considering the medical diagnosis as gold standard. We have determined that individuals with a GDS score equal or greater than four are considered as having severe MND.

Having as a health priority the early diagnosis of MND and the classification of the stage of the disease in primary health care settings, the second aim of this study was to investigate the predictors of MND, with the ultimate goal of preventing/intervening in some risks that may be circumventable. It was possible to identify four predictors of MND: age, years spent in education, physical activity and hand strength. Physical activity, hand strength and education play a protective role (“the more the better”). On the other hand and as expected, while age increases, the risk of MND also increases.

The findings from this study on the risk factors for MND are in line with available literature on the topic. Regarding physical activity, other studies have suggested Weuve et al. (2004) that regular physical activity reduces vascular risk factors and may directly increase the production of neurotrophic factors in the brain physical exercise as a protective function of neurons. Regarding the role of education, some studies ( Amieva et al., 2014 ) report that the mechanism through which more educated individuals are at lower risk of developing MND is the greater ability of more educated individuals to cope with symptoms.

The older the person, the greater the risk of having MND. Age is the main risk factor for MND. After the age of 65, the risk of MND increases every 5 years. The same is true for hand strength: the lower the strength, the higher the risk of MND. Among older adults, this association is often cited for its relation to the concept of frailty and implications on the person’s functional status ( Abizanda et al., 2012 ). Several studies ( Jang and Kim, 2015 ) have found a significant association of cognitive decline with worse hand strength among older adults values in the elderly. Hand strength may represent an age-related change in physical function and frailty, contributing to cognitive decline and increasing the risk of MND. Thus, we can formulate the hypothesis that cognitive changes may influence the motor skills of older adults, which would justify the worse performance in the hand strength test in older persons with cognitive deficit. Another justification would be that that low hand strength is a consequence of inactivity, which can contribute to cognitive decline. In any case, hand strength losses arean alert sign to the development of MND.

Although significant contribution of sex was not found in this study, the literature has been suggesting that female are at greater risk of developing MND than male. Worldwide, most people with MND or at risk of developing MND are women, according to Alzheimer’s Disease International (2015) . However, other studies suggest that, up to the age of 90, there is no sex differences in the incidence of MND, above this age men appear to be at lower risk than women ( Ruitenberg et al., 2001 ).

In future studies, other variables should be taken into account and investigated about their association with the development of MND. Sleep hygiene, for instance, is an important variable. Some studies suggest that sleep changes often occur in people with MND, and can aggravate with the progression of MND. In addition to normal sleep changes as a result of aging, changes that occur in the brain increase sleep disorders in older adults with MND ( Rose and Lorenz, 2012 ). Changes in the pattern of sleep modify the homeostatic balance, with repercussions on psychological function, immune system, performance, behavioral response, mood and ability to adapt ( Ebersole and Hess, 2001 ).

The main limitations of this study are related to its cross-sectional design, not allowing the observation of the disease progression as classified by GDS. Moreover, the GDS may not be very sensitive to cognitive changes over time. Also, while the coding system for the diagnosis of dementia is unique both at national and international levels, the GPs follow different protocols to assess patients and stablish the diagnosis that was used as a golden standard in this study. Other concerns are the dimension of the sample and the heterogeneity of this population (in terms of age, education, access to health services and even life style) making it difficult to generalize the results. However, this study is innovative because it is based in a Portuguese representative sample of users of the health care centers in the north of the country, and reports on current MND diagnosis by GPs. These findings have clinical relevance and implications for case management in dementia in the context of primary health care.

Primary health care settings are very important in the identification of MND. The GP is in most cases the patients’ first and only contact and for this professional the differentiation between normal or pathological aging should be clear and the individual factors that can contribute to MND must be known. The recognition of the stage of MND supports a more accurate understanding of the patient, family conditions and needs during the progression of the disease and should lead to an adequate customization of available health and social support services. An early diagnosis of MND, together with the use of GDS to acknowledge the stage of the disease in which the patient is, and the identification of predictors of probable MND will consubstantiate very relevant aspects of clinical practice. These aspects are the foundation of the design of more targeted interventions for each individual, which at should emphasize physical and lifelong learning throughout life.

Data Availability Statement

The datasets for this article are not publicly available because: this study is part of a larger study. Requests to access the datasets should be directed to CP, [email protected] .

Ethics Statement

The studies involving human participants were reviewed and approved by the Ethics Committee of the ARS-Norte on January 7, 2014 (Reference No. 6/2014). The patients/participants provided their written informed consent to participate in this study.

Author Contributions

SS wrote the manuscript and conducted the data analysis. LT and CP reviewed the manuscript. All authors contributed to the manuscript and approved the submitted version.

This work was supported by the National Funds through the General Health Directorate of the Portuguese Ministry of Health.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Keywords : major neurocognitive disorders, predictors, primary health care, older people, health

Citation: Sousa S, Teixeira L and Paúl C (2020) Assessment of Major Neurocognitive Disorders in Primary Health Care: Predictors of Individual Risk Factors. Front. Psychol. 11:1413. doi: 10.3389/fpsyg.2020.01413

Received: 27 November 2019; Accepted: 26 May 2020; Published: 17 June 2020.

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*Correspondence: Susana Sousa, [email protected]

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