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All American Career College Frontotemporal Neurocognitive Disorder Discussion

All American Career College Frontotemporal Neurocognitive Disorder Discussion

Question Description

Response 1

Neurocognitive Disorders

Neurocognitive disorders are a diagnostic class within the Diagnostic and Statistical Manual, 5th edition (DSM-5) and encompass both medical and neurological conditions that affect cognition, cause psychological disturbances and greatly limit the person’s ability to function properly.While a few are transient and can be treated effectively, such as delirium, most are progressive, and greatly reduce the quality and quantity of life.It is imperative to diagnose and treat these conditions promptly to promote and preserve as much function for as long as possible and to help clients and families adjust to the disease process (Gabbard, 2014).

Frontotemporal Neurocognitive Disorder (FTD or FTNCD)

FTD is a grouping of neurocognitive disorders that are primarily caused by atrophy and/or degeneration of the frontal and temporal lobes of the brain.FTD affects those mostly younger than 65 and is approximately four times more prominent in men than women (Pospos, Xi, Chen, Zhang, Tan, & Baskys, 2018). FTD can often be misdiagnosed as other types of dementia including Alzheimers and Parkinson’s, as well as elderly depression, atypical depression, progressive supranuclear palsy, and corticobasal degeneration. FTD has two different categories, behavioral (bv-FTD) and aphasic (SD and PNFA FTD).Behavioral is the most common type of FTD and involves a progressive change in the client’s behavior such as loss of inhibition, sexual inappropriateness, aggression, or ritualistic behavior may occur. They will also show progressive loss of executive function, insight and flexibililty (Mocellin, Scholes, Walterfang, Looi, & Velakoulis, 2015). Aphasic or language FTD has two sub-categories; semantic dementia (SD) and progressive non-fluent aphasia (PNFA).FTD-SD involves loss of meaningful speech (difficulty finding words, loss of meaning of words, causing nonsensical speech and PNFA affects the ability to produce speech (speaking haltingly, greatly slowed, or distorted by not being able to produce the words) (Mocellin, Scholes, Walterfang, Looi, & Velakoulis, 2015).There is a genetic component with 20-30% of clients with family history of early dementia.There has been a gene mutation identified in FTD in a hexamucleotide repeat disorder on chromosome 9 (C9ORF72 mutation) and is associated with the accumulation of a specific protein in the brain cells of TDP-43 protein (Mocellin, Scholes, Walterfang, Looi, & Velakoulis, 2015).

Diagnosis

Diagnosis starts with symptomology of either bv-FTD, SD-FTD, or PNFA-FTD and seen at a younger age than expected 45-65.Probable diagnosis involves symptomology, identification of the gene mutation C9ORF72, if present, and most precisely CT scan or MRI imaging showing decreased matter in the frontal and temporal lobes of the brain without another causative factor. FTD must show a progressive course to be diagnosed as well.However, definitive diagnosis is only made post-mortem by histopathological findings of FTD (Hopkins, & Chan, 2016).

Treatment

Treatment is primarily supportive.Antidepressants for depressive symptoms, antipsychotics for psychosis/agitation, and therapy for the client as well as the family and caregivers.As this is a progressive disease and especially the behavioral variant can be very disruptive and disturbing to families as it progresses.The use of SSRIs help with mood lability, impulsivity, and some repetitive behaviors and inhibition. The use of antipsychotics can be both beneficial to help reduce bizarre, psychotic behavior but there are dangers in the use of them.Antipsychotics, especially first generation have very prominent side effects that would often become permanent such as tardive dyskonesia, agranulocytosis.Whereas, second generation antipsychotics have less dystonia, TD or agranulocytosis, but do often promote metabolic syndrome and possibly induce diabetes type II, which is another life-long, severe complication, type disease if not managed well. Cholinesterase inhibitors commonly used in dementia and other neurocognitive disorders are not found to be effective in FTD and may actually worsen symptoms and are to be avoided (Mocellin, Scholes, Walterfang, Looi, & Velakoulis, 2015).As with any medication or treatment, a discussion with the client and the family/caregivers regarding the benefits and risks should always be discussed before initiating any medications or treatments and an agreement between all parties should be strived for.

Response 2

Neurocognitive Disorders

Most of the time cognitive disorders are thought to be for older adults, even though most common in this population. The cognitive disorder can actually occur at any age but more prevalent in older adults. In the general population, including very young or very old people, cognitive disorder comes with multiple health needs. For a better diagnosis, the PMHNP must conduct a multi-system assessment. For this discussion, I was assigned to discuss Dementia with Lewy Body Disease (DLB).

Explain the diagnostic criteria for your assigned neurocognitive disorder.

Dementia with Lewy Bodies (DLB) is the second most common type of degenerative dementia following Alzheimer’s disease (AD). DLB accounts for around 4.2% of all dementia diagnosed in the community, and 7.5% of those under secondary care. According to the American Psychiatric Association (APA, 2013), DLB diagnosis includes a progressive cognitive impairment with early changes in complex attention and executive function rather than learning and memory, in addition to the recurrent complex of visual hallucinations, concurrent symptoms of rapid eye movement (REM). REM is a sleep behavior disorder that can be accounted for an early manifestation of the DLB, as well as hallucinations in other sensory modalities, depression, and delusions. The symptoms fluctuate in a pattern that can look at as delirium, but no adequate underlying cause can be found.

Another core feature is spontaneous Parkinsonism, which usually starts after the onset of cognitive decline; by convention, major cognitive deficits are observed at least 1 year prior to the motor symptoms. It also important to distinguish the Parkinsonism symptoms from the neuroleptic-induced extrapyramidal signs. It is important to accurately diagnose this patient for a safe treatment planning, as up to 50% of individuals with DLB have severe sensitivity to neuroleptic drugs and these medications should be used with extreme caution in managing the psychotic manifestations (Gabbard, 2014).

There are also some supportive clinical features that could be present on individuals with DLB, and that includes frequent repeated falls and syncope, transient episodes of unexplained loss of consciousness. Autonomic dysfunction, such as orthostatic hypotension and urinary incontinence could be present. Auditory and other nonvisual hallucinations are common, as are systematized delusions, delusional misidentification, and depression (Sadock, Sadock & Ruiz, 2014).

Explain the evidenced-based psychotherapy and psychopharmacologic treatment for your assigned neurocognitive disorder.

When developing a treatment plan for individuals with DLB, it is important to

individualize care by having the patient or caregiver rank the cognitive, emotional, and motor

difficulties by the level of subjective distress. This focuses on the initial treatment and goals of

subjective discomfort. The recommended initial treatment for cognitive symptoms related to DLB is with cholinesterase inhibitors (CEIs). The medications are effective with many symptoms including fluctuating cognition, hallucinations, and mood disorders (Sadock, Sadock & Ruiz, 2014).

The use of dopaminergic medications such as carbidopa/levodopa, often used for motor disorders, can precipitate psychotic type symptoms such as visual hallucinations. It is then recommended to start with a low dose and titrating up slowly for optimum benefit and minimize side effects. Carbidopa/ levodopa (25/100 mg), one-half tablet 3 times daily, is the suggested medication titrating slowly over several weeks while monitoring the response. Care must be taken when exacerbation of motor symptoms, such as dyskinesia and dysphagia, which could lead to aspiration (APA, 2013).

The addition of memantine has been approved as an adjunct treatment for DLB. Neuroleptic or antipsychotic agents to reduce mood swings and hallucinations have shown an increased risk of death for individuals with DLB. If necessary, benzodiazepines, especially clonazepam (at extremely low doses), may be used for mood changes with extreme caution because of an increased risk for falls and confusion (APA, 2013).

Although the use of neuroleptics is discouraged, second-generation or atypical antipsychotics, such as quetiapine, are effective and safer than clonazepam in individuals with DLB. Because of the sensitivity with these classes of medications, it is important to document the DLB diagnosis, and the pharmacy needs to be aware of the diagnosis to reduce inadvertent prescribing of these medications from a provider. (Sadock, Sadock & Ruiz, 2014).

In addition to medications, there are a number of other treatment options that have proven to be effective for dementia with Lewy bodies. They include the following:

Cognitive-Behavioral Psychotherapy – Both the individual and his or her family members can benefit from psychotherapy to manage emotional and behavioral symptoms. It can also be useful as people accept the reality of living with a cognitive disorder and develop plans for the future with a brain disease.

Physical, occupational, and speech therapies: All of these therapies help maintain function and independence. They can also reduce anxiety, improve mood, and help with overall wellbeing.

Supportive care: Care that is designed to provide emotional support while providing engaging, stimulating memory care is ideal for people who have been diagnosed with dementia with Lewy bodies (Aarsland, Ballard, Walker, Bostrom, Alves, Kossakowskin & Londos, 2009).

Identify the risks of different types of therapy and explain how the benefits of the therapy that might be achieved might outweigh the risks.

The therapies designed for DLB, are all of the beneficial outcomes. For all the patients suffering from the neurocognitive disorder whether major or mild.

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