Psychogeriatrics

Proposed Revisions of Dementia Diagnostic Categories for DSM-5

Professor, Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Director, Division of Geriatric Psychiatry, Montefiore Medical Center

First published in Psychiatry Weekly, Volume 5, Issue 27, on November 8, 2010

Out With the Old, In With the New

Delirium, dementia, amnestic, and other cognitive disorders are subsumed in the DSM-5 under the category of “neurocognitive disorders.” Neurocognitive disorders, in contrast to neurodevelopmental disorders, are acquired and degenerative rather than inborn and apparent in childhood. The term was chosen in part to avoid the stigma associated with dementia when categorizing deficits among younger people with progressive cognitive decline associated with HIV or traumatic brain injury. Neurocognitive disorders are further divided into major and minor. The DSM-IV condition described as “age-related cognitive decline (ARCD)” appearing in “other conditions that may be a focus of clinical attention” would now appear under minor neurocognitive disorder in the DSM-5. This is a decided advance. Terms such as ARCD, cognitive impairment not dementia (CIND), mild cognitive impairment (MCI), amnestic MCI, and non-amnestic MCI—which have variable criteria but are often considered a prodrome of dementia—would now be listed as a minor neurocognitive disorder. More importantly, in contrast to those without detectable impairment, people with CIND exhibit both a greater prevalence of neuropsyschiatric symptoms such as depression as well as functional limitations. Minor neurocognitive disorder is analogous to minor depressive disorder, which appears in Appendix B of the DSM-IV, along with subsyndromal depressive condition not elsewhere classified (CNEC). Indeed, subsyndromal depressive CNEC is further divided into prodromal depression and subsyndromal, and mixed subsyndromal anxiety-depressive disorder depending on duration, severity, or associated features, respectively. Both MCI and minor depression are similar in that they predict progression to either dementia or MDD. However, many people believed to have MCI or minor depression never develop a major mental illness. The certainty with which we can distinguish a symptom or performance profile which represents a genuine prodrome from periodic variability in cognitive performance or mood remains problematic. Nonetheless, identifying minor neurocognitive disorder as a DSM diagnosis reflects a growing consensus that MCI and CIND are too often the early manifestations of dementia. Additionally, not to have a “minor” diagnostic category would leave investigators and the public with the confusing terminology that followed in the wake of the DSM-IV.

Cognitive Domains Mature

The DSM-IV identifies impairments in memory and learning plus one of the following—aphasia, apraxia, agnosia, or executive dysfunction—as criteria for dementia. Deficits must cause social disability to justify the diagnosis. The proposal for the DSM-5 includes domains for “complex attention, executive ability, learning and memory, language, visuoconstructional-perceptual ability, and social cognition.” Each item has a paragraph describing major and minor deficits as well as definitions of the domain and examples of assessment procedures. Equally important are descriptions of how impairment within the domain disrupts behavior and threatens independence. The work group remains uncertain about how to formally portray domain-specific deficits. However, it seems critical to tailor the caregiver approach and structure the environment to take advantage of capacities which are preserved and to compensate for those which are deficient. Achieving the right fit between strengths and vulnerabilities would presumably lessen the patient’s disability, reduce the caregiver’s burden, and minimize the occurrence of behavioral disturbances.

Disclosure: Dr. Kennedy reports no affiliations with, or financial interests in, any organization that may pose a conflict of interest.

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