Neurocognitive Disorder (NCD): Comprehensive Psychiatric Evaluation

There are several forms of neurocognitive disorder (NCD) in that diagnostic category in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders or DSM-5. They include NCD due to Alzheimer’s Disease, NCD due to HIV, NCD with Lewy bodies (dementia with Lewy bodies), and frontotemporal NCD amongst others (APA, 2013). In terms of diagnosis, this group of psychiatric conditions is marked by significant cognitive decline that impairs the patient in terms of social, self-care, and occupational functioning. The areas of cognition affected are usually memory, speech/ language, learning, and problem-solving. The purpose of this paper is to evaluate a psychiatric patient comprehensively with regard to their diagnosis of a neurocognitive disorder.    Assessing and Diagnosing Patients with Neurocognitive and Neurodevelopmental Disorders

Comprehensive Psychiatric Evaluation

CC (chief complaint): The chief complaint that the patient presented with was being forgetful about where he placed things as well as finding it difficult to concentrate on tasks or conversations.

HPI: The client is a 60 year-old African American male presenting with loss of memory that is getting worse as days go by. He has had the symptoms for more than one month now but denies having a previous history of the same. These clinical manifestations are constant in duration and characterized by persistence. Aggravating factors include being at work with colleagues (and not being able to perform) and relieving factors include being at home with family. The timing of the symptoms is all day. He scores the severity of his symptoms at 7/10 on a scale of 1-10.

Past Psychiatric History:

• General Statement: The patient is still in formal employment and began getting the symptoms he has at his place of work. He has been a good employee until recently when he started losing concentration in his work. His memory started getting impaired also with him forgetting mundane details of where he put things and what he is supposed to do.
• Caregivers (if applicable): this patient will soon require the assistance of caregivers if his symptoms progress at the pace with which they are now. Since he forgets almost everything, he will soon need help with activities of daily living (ADLs) such as remembering to bathe and to eat.
• Hospitalizations: The patient does not have a hospitalization history for psychiatric illness. He has however been hospitalized before for asthma and hypertension.
• Medication trials: He has not been involved in medication trials of any nature. He has also never been prescribed any psychotropic medications.
• Psychotherapy or Previous Psychiatric Diagnosis: Since he does not have a psychiatric history, he has never gone through any psychotherapy sessions.

Substance Current Use and History: The client drinks alcohol infrequently and socially. He however admits to occasional binge drinking when with friends. He denies smoking neither cigarettes nor marijuana. He also has not used cocaine or other substances of abuse.  Assessing and Diagnosing Patients with Neurocognitive and Neurodevelopmental Disorders

Family Psychiatric/Substance Use History: The only significant psychiatric history in the family is his grandfather who was in and out of involuntary commitment all his adult life for suicidality due to bipolar disorder. His parents occasionally drank wine but nobody else in the family has a history of etoh, smoking, or abusing other substances and hard drugs.

Psychosocial History: He lives with his wife and youngest son who is still in high school. The other two sons are grown but live within the state and frequently visit home. His family is supportive. As a matter of fact, he admits that his symptoms get better when he is with family members. The home environment for him has no obvious mental health risks. In her words, there are no obvious mental health disease triggers in his home surroundings.

Medical History: He has a history of asthma and hypertension. He has been previously admitted in 2005 for asthma exacerbation and in 2010 for a hypertensive crisis.

• Current Medications:

1. Metoprolol 50 mg to be taken orally twice a day (prescription medicine)
2. Albuterol inhaler 2 puffs (inhalations) PRN (prescription medication)

• Allergies: He has a history of allergy to dust, pollen, and hay. He however does not have allergy to foods and food products.  

• Reproductive Hx: He states that he is heterosexual. He has a wife and they have three sons together.

ROS:

• GENERAL: Denies any fever, loss of weight, fatigue, malaise, or weakness.
• HEENT: Denies any headache. Negative for diplopia, photophobia, or strabismus. Last seen by the eye specialist one year ago. Denies otorrhea, tinnitus, or loss of hearing. Negative for the use of hearing aids. Denies rhinorrhea, sneezing, epistaxis, or loss of smell. Negative for dysphagia and sore throat.
• SKIN: Negative for itching and rashes.
• CARDIOVASCULAR: Negative for palpitations, chest tightness or discomfort, and chest pain.
• RESPIRATORY: Negative for difficulty in breathing, coughing, and wheezing. Denies pedal edema.
• GASTROINTESTINAL: Negative for nausea, diarrhea, or vomiting. He also denies any abdominal discomfort and changes in his bowel habit. His latest bowel movement had been on the morning of coming to the clinic.
• GENITOURINARY: Negative for frequency of micturition, urgency, and dribbling. Negative for loss of bladder control.
• NEUROLOGICAL: He admits to forgetting very mundane things such as where he put his phone, jacket, and wallet. He also states that he cannot concentrate on tasks. He however denies ever fainting, dizziness, or seizures.
• MUSCULOSKELETAL: Negative for muscle pain and joint pain. Denies joint stiffness, back pain, or a history of trauma/ fractures.
• HEMATOLOGIC: Negative for blood and clotting disorders such as immune thrombocytopenic purpura or ITP.
• LYMPHATICS: Negative for lymphadenopathy and previous splenectomy.
• ENDOCRINOLOGIC: Negative for excessive thirst and excessive intake of water. Also negative for heat or cold intolerance as well as excessive diaphoresis. He denies ever receiving hormonal therapy.

Physical exam:

CONSTITUTIONAL: The patient is alert and oriented in person, place, tome, and event. However, his speech is clear but neither coherent nor goal-directed. He is appropriately dressed for the time of the day and the weather.

HEENT: His head is atraumatic and normocephalic. Both of his pupils are equal, round, and reactive to both light and accommodation. The extraoccular muscles appear intact. Negative for inflammation of the nasal turbinates with no rhinorrhea. Bilaterally, the pinna and tragus appear symmetrical and are non-tender. There is no otorrhea and the tympanic membranes demonstrate adequate light reflex. There is no evidence of ulceration or bleeding gums in the oral cavity. A few cavities can be seen. There is no throat exudate.

CARDIOVASCULAR: S1 and S2 audible with regular rate and rhythm. Negative for murmurs, gallop, bruit, or rub. The patient has no overt pedal edema.

RESPIRATORY: Clear lungs that are negative for wheezing, rhonchi, crepitations, crackles, and rales.

NEUROLOGICAL: Negative for facial palsy, hemiplegia, and hemiparesis. Has a GCS score of 14/15 and is alert.

PSYCHIATRIC: Speech is confused, incoherent, and not goal-directed. He is unable to make complete meaningful sentences.

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Diagnostic results:

1. Radiologic: Normal MRI findings
2. Laboratory: (i) WBC 8.3 x 10³ /mcL (normal WBC and differentials) (ii) HIV seropositive.

Vitals: T 98.7°F; BP 130/80 mmHg, normal cuff and sitting; RR 17 and non-labored; PR 75 and regular.

Assessment

Mental Status Examination (MSE)

The patient is a 60 year-old African American male who is alert and oriented in person, place, time, and event. His speech is clear but neither coherent nor goal-directed. There was no evidence of any tics, mannerisms, or gestures. His self-reported mood was “anxious”. The observed affect was euthymic and this was incongruent with the stated mood. He displayed no delusions or hallucinations and had no suicidal or homicidal ideation. Insight and judgment were both poor. The diagnosis is mild NCD due to HIV.

Differential Diagnoses

1. Mild NCD due to HIV – 331.83 (G31.84)

The patient in this case has met the diagnostic criteria for mild NCD in terms of the symptomatology. According to the DSM-5, he has met the following criteria for the diagnosis of mild NCD due to HIV (APA, 2013):

• There is clear evidence that he is undergoing a decline in cognitive functioning when compared to a previous period in which he was still doing well in the past. Particularly, his memory and attention are affected as he cannot remember where he has placed everyday things such as his keys and jacket. All this was observed based on the concerns of his supervisor who then set up the clinic appointment for psychiatric evaluation.
• This impairment in cognitive function does not yet interfere with his ability to carry out his duties at his workplace and even to pay his bills. He however requires putting in greater effort to achieve this than before, and the colleagues and his supervisor must now accommodate this to allow him to function.
• These deficits in cognition displayed by the patient are not occurring exclusively in the context of a delirium.
• The deficit in cognition displayed by this patient is also not attributable to another psychiatric illness such as schizophrenia.
• He has a documented infection with HIV that has also been confirmed with a laboratory result for HIV that is seropositive.
• His NCD cannot be better explained by other infections that are not HIV such as meningitis.
• Lastly, this cognitive decline in this patient cannot be attributed to another medical or mental condition.      Assessing and Diagnosing Patients with Neurocognitive and Neurodevelopmental Disorders

2. Mild NCD with Lewy Bodies (NCDLB) – 331.83 (G31.84)

This is a possible differential diagnosis for thus patient even though this condition usually affects those that are 75 years old and above. According to the DSM-5, the diagnostic criteria to be fulfilled before this diagnosis can be made must include the following:

• Criteria for mild NCD must have been met as a prerequisite (as above with HIV).
• As core diagnostic features, there must be fluctuation in cognition and variation in attentiveness and alertness. He must also have repetitive visual hallucinations that are extensive in detail. Features of Parkinsonism also should appear after the cognitive decline has set in.
• He may also meet some suggestive diagnostic criteria such as severe neuroleptic sensitivity and REM sleep behavior disorder.
• Lastly, the cognitive disturbance is not better explained by other neurodegenerative diseases or cerebrovascular disease (APA, 2013; Stahl, 2013).

3. Mild Frontotemporal NCD – 331.83 (G31.84)

This is another NCD that is also fit to be a differential diagnosis for this patient. To be diagnosed with this condition according to the DSM-5, the following diagnostic criteria must be met (Sadock et al., 2015; APA, 2013):

• The diagnostic criteria for mild NCD must first be met, as with HIV above.
• It occurs insidiously and may be missed since it progresses very gradually.
• There is a behavioral variant and a language variant. For the behavioral variant the patient has to display some of the following: apathy, loss of sympathy, behavioral disinhibition, and hyperorality. There must also be a significant decline in social cognition as well as executive abilities. For the language variant, there is a marked decline in language ability, word finding, grammar, and word comprehension. It is notable that this particular patient is displaying this characteristic.
• There is relative sparing of learning and memory.
• The cognitive disturbance cannot be explained by another neurodegenerative disease, substance abuse, cerebrovascular disease, or another mental/ physical disease (Tsai & Boxer, 2014; Sadock et al., 2015; APA, 2013).

Reflections

            This comprehensive psychiatric evaluation for this 60 year-old African American male has been done according to evidence-based patient assessment protocols and techniques that are clinically relevant (Ball et al., 2019; Bickley, 2017). For this reason, I would do exactly the same if I were to be accorded another opportunity to evaluate the patient again. Ethical principles were observed including autonomy in that consent was obtained before testing for HIV (Entwistle, 2019; Motloba, 2018). On health promotion and education for the patient, he would be advised t agree to attend psychosocial therapy which would be beneficial to them.

Conclusion

The diagnostic category of neurocognitive disorders (NCDs) in the DSM-5 is an important one with regard to diagnosis of mental health conditions in senior citizens. However, diagnosis is tricky and requires thorough clinical reasoning to come up with the correct primary diagnosis and differential diagnosis. This is because the presentation of each of the NCDs is quite similar. They are only differentiated by what causes the NCD such as Lewy bodies, HIV, infection like meningitis, or traumatic brain injury. In the case evaluated in this paper, the patient has been found to be seropositive for HIV and in addition fulfils the diagnostic criteria for mild NCD. His diagnosis is therefore mild NCD due to HIV.

Introduction
The case under analysis concerns an adult by the name Harold who works in a large architectural engineering firm and complains of a decrease in his level of concentration. Although paying attention and concentrating has always been a problem to him even in his school years, he managed to get to adulthood, but recently the situation has worsened and it started after the supervisor tightened the deadlines that Harold and his colleagues are expected to deliver their assigned tasks. Since then, Harold has been having challenges concentrating due to the immense pressure placed by the deadlines and seems to have lost his level of concentration even on the small tasks that he is assigned; for instance, the case of gutters, where he designed and was required to place them, but upon reaching the work site, he notices that the tiles are Italian and are not aligned, although there were some people assigned to work on the tiles, he started to study them. The subjective and objective information suggest that Harold suffers from Attention- Deficit Hyperactivity Disorder (ADHD), although differential diagnosis assessment will be carried out to ensure that the diagnosis is correct and pave way for the treatment process.
CC: “ I just can’t concentrate. I mean, everyone else is, doesn’t have a problem with it. But, but I just, I just can’t seem to be able to do the same job they’re doing.”The patient complains of having a problem with concentration
HPI: H.H is a male and presents for psychiatric evaluation for concentration difficulty. He is not presently under any psychotropic medications prescriptions. He is referred by his supervisor for medication evaluation and treatment
The issue of concentration has been ongoing for a long time, actually, since childhood, but the client has never been diagnosed. As a child, Harold’s mother made threats that she would take him forcefully to the hospital, but never did. However, owing to his high level of hyperactivity, she opted to ensure that he never took caffeine or sugar, the argument being that if he did, then he would climb wall, which even without the consumption of the said products he was already doing. Although as an adult Harold drinks caffeine and soda once in a while, he has managed to progress and live his life without major occurrences like the ones that he is experiencing presently, where he seems to have lost his sense of concentration with his work and it is getting him into constant problems with his supervisor and colleagues. Innately, without the introduction of the tight deadlines, Harold was leading a normal level and was in a position to concentrate on his work and complete them the same way his colleagues are doing, even with the introduction of the tight deadlines as nothing has changed for them.
Past Psychiatric History:
• General Statement:The patient has never been under any psychotropic medications prescriptions
• Hospitalizations: No instances of hospitalizations related to concentration difficulty
• Medication trials: No History of psychotropic medications tried by the patient
• Psychotherapy or Previous Psychiatric Diagnosis : no previous diagnosis for the patient noted from previous treatments and other providers.
Substance Current Use and History: Although as an adult Harold drinks caffeine and soda once in a while, he has managed to progress and live his life without major occurrences like the ones that he is experiencing presently, where he seems to have lost his sense of concentration with his work and it is getting him into constant problems with his supervisor and colleagues.
Family Psychiatric/Substance Use History: No family history of psychiatric illness, substance use illnesses, and family suicides
Psychosocial History: There is no personal or social history that is provided about Harold
Medical History: Since no diagnosis has ever been done to determine the type of disease that causes the symptoms that Harold displays, he has never and is not currently on any medication
• Current Medications: not presently under any psychotropic medications
• Allergies: No known allergies
• Reproductive Hx: No reproductive history provided
ROS:
• GENERAL: No fever, chills, weakness, fatigue or weight loss
• HEENT: Eyes: visual imparement. Ears, Nose, Throat: hearing impairment, no congestion, runny nose or sore throat.
• SKIN: No itching or rash
• CARDIOVASCULAR: No form of chest discomfort. No presence of palpitations or edema.
• RESPIRATORY: No breath shortness, cough, or sputum
• GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
• GENITOURINARY: No burning on urination, odor, odd color
• NEUROLOGICAL: No headache, dizziness, paralysis, ataxia, numbness, or extremities tingling. No change control of bowel or bladder.
• MUSCULOSKELETAL: No muscle, back,or joint pain.Absence of stiffness
• HEMATOLOGIC: No bleeding ,anemia or bruising
• LYMPHATICS: No enlarged nodes. No splenectomy history
• ENDOCRINOLOGIC: No sweating, cold, or heat intolerance reports. No reports of polyuria or polydipsia.
Physical exam: physical examination involved inspections for hearing and vision impairments, neurodevelopmental immaturity in relation to fine motor functions retardation. neurological assessment indicates visual and helaring imparement.
Diagnostic results: Rating scales, intellectual screenings, Questionnaires, and sustained attention and distractibility measures are some of the diagonistics required to confirm the presence, persistence, generality, and functional complications of core symptoms, as well as establish the coexistence of emotional, behavioral, and medical disorders.  Assessing and Diagnosing Patients with Neurocognitive and Neurodevelopmental Disorders

Assessment
Mental Status Examination: The client is alert and oriented to person, place, and event. The client’s speech if coherent and adheres with the questions that he is asked. The client appears to understand that he has a problem and one that needs to be addressed, based on the reflection about his life from his childhood to date that he gives. The client’s self-reported mood is not euthymic.
Differential Diagnoses:
Attention Deficit Hyperactivity Disorder (ADHD): ADHD is a mental health illness that presents a combination of persistent issues such as impulsive behavior, hyperactivity and challenges in paying attention. ADHD symptoms can emerge from childhood and continue to adulthood and the symptoms make it difficult for the individual to function normal and carry out their daily duties. The result of this is poor relationship with others, for instance a partner or colleagues; poor academic performance among school children, lack of focus and concentration on the normal activities that an individual carries out, this includes concentrating at the workplace whereby the individual opts to focus on other issues that do not align with the duties assigned to him, trouble dealing with pressure or stress, challenges completing assigned task, being messy and lacking organization and low self-esteem (Mayo Clinic, 2019). The DSM V criteria to diagnose ADHD is the presence of at least six symtpoms of inattention and/or six symtpoms of hyperactivitity and impulsivity in a period of six months (Sadock et al., 2015).
Bipolar Disorder: Bipolar disorder is one of the mental disorders that can easily be misdiagnosed as ADHD owing to a number of symptoms that the two disorders share that include mood swings, difficulty focusing and maintaining attention and hyperactivity. Bipolar disorder is characterized by a depressive state and mania, the symptoms in these two phases may be be similar to some of the symtpoms of ADHD. For instance, the depressive state have similar symptoms such as poor or lack of concentration, memory and attention; and difficulty completing the tasks that one is assigned, which is associated with the challenge of maintaining concentration. The differentiating features of the two mental disorders include appetite and sleep disturbance; and anhedonia and enduring dysphoric mood, which are specific for major depressive disorder (Katzman, et al., 2017). Although this patients symptoms may be similar to bipolar; the differentiating symptoms of ADHD and bipolar include delusions, insomnia and euphoric mood, which are specific for bipolar disorder (Torres, et al., 2018).
Personality Disorders: Antisocial and Borderline Personality Disorders: There are a number of personality disorders that can be passed as ADHD, and which thereby demand thorough diagnosis and they include borderline personality disorder and antisocial disorder. The symptoms that are similar to those of ADHD include interpersonal difficulties, impulsivity and affective liability, for instance, the case of gutters and tilted Italian tiles, whereby although his task was to place the gutters, Harold started studying the tiles after noticing that they were titled, yet this was a duty assigned to other individuals. The distinguishing symptoms include repeated self-injuries and suicidal behavior in the case for borderline personality disorder; arrest history in the case of antisocial personality disorder and the failure to determine the impact of one’s behavior to self and others. The diagnosis and test screening utilized for the personality disorders discussed include interview for the diagnosis and severity for the antisocial personality disorder; and MacLean Screening Instrument for the for the borderline personality disorder (Sánchez-García, et al., 2020).
Generalized Anxiety Disorder: The other mental disorder that the client must be cleared for is the generalized anxiety disorder, which as well shares some similarities with ADHD such as lack and difficulties concentrating and fidgetiness. However, there are differentiating symptoms that include insomnia and syncope and exaggerated worrying and apprehension, which are very common for generalized anxiety disorder. The disorder is as well diagnosed using the generalized anxiety disorder (GAD-7) screening and the adult severity measure for the generalized anxiety disorder diagnosis (Loskutova, Callen & Lutgen, 2019).
Substance use disorders or Dependence: The substance use disorders or dependence aligns with the use of substances that are considered illegal and addictive, which include cocaine, alcohol, opiates, hallucinogens, and other psychotic stimulants. The danger with excessive use of these substances is that they disrupt the normal functioning of the individual, mood and behavior. The symptoms of substance use disorder that are similar to those of ADHD include mood swings, this is because the individual has become dependent on the substance that he abuses and challenges paying attention, loss of memory and lack of concentration. The differentiating symptoms between substance use disorder and ADHD include psychologic and physiologic symptoms such as dependence, withdrawal and tolerance; and substance use pathological patterns that have social consequences. The test screening and diagnosis for substance use disorder include interview for diagnosis and severity and NIDA Modified ASSIST Drug Use Screening tool screening (Crunelle, et al., 2018).
Mild Autism Spectrum Disorder (Asperger Syndrome): According to Mayo Clinic (2018) autism spectrum disorder is a mental disorder that can be passed for ADHD, which is associated with brain development and thus, it impacts on the individual’s ability to socialize as well as their perception. The result of this is ineffective communication, poor social interaction and challenges making decisions. The symptoms that can easily make this mental disorder be misdiagnozed for ADHD include lack of attention and concentration, interrupting others and talkativeness. However, the symptoms that differentiate Asperger syndrome with ADHD include the patient being often illogical, hyper focus on certain activities that are excluded from the normal daily life of the individual, the inability to study the social cues and the lack of interest with other people, inability to socialize. The diagnostic and test screening tests used for the disorder is Diagnostic Statistical Manual of Mental Disorder (DSM-5)- diagnosis.  Assessing and Diagnosing Patients with Neurocognitive and Neurodevelopmental Disorders

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Reflections:
The assessment of the possible mental disorder that the client suffers in line with the differential diagnosis shows that it is adult ADHD, which is a mental disorder that is characterized by a combination of inattention, impulsiveness and hyperactivity. It is estimated that 8 million adults or rather 4% of the adult population of the United States suffers from adult ADHD (ADAA, 2020). The unfortunate fact is that less than 20% of the adults with ADHD have been diagnosed and this is very clear with the case of Harold, who were it not for the tightening of deadlines at his workplace, he would not have been diagnosed with the disorder, as he had learnt to live and cope with the disease and proceed with his day-to-day activities without interference. This is even with the realization that he had concentration issues from childhood, which his mother as well recognized, but did not take the initiative to have him diagnosed. ADHD is believed to be genetic or biological and that it starts early in brain development, although in the case of Harold there is no enough information to determine whether the disorder was genetic or biological. The five symptoms that help in the diagnosis of adult ADHD include emotional instability, inattention, impulsivity, hyperactivity and disorganization (ADAA, 2020). From the analysis of the case of Harold, it is clear that he displays all of these symptoms, inattention is demonstrated by his inability to concentrate on his assigned tasks after the supervisor tightened the deadlines, which increase the pressure that was required to focus on the work. Impulsivity and disorganization are demonstrated by the gutters and Italian tiles case, where instead of working on his assigned tasks, he started studying a task that was already assigned to other individuals; Harold did not consider the feelings and emotions of the people that were already assigned the Italian tiles task. This gutters tasks caused Harold too much trouble with his supervisor and the client who had given his company the job, and it is also demonstrated the hyperactivity symptom, where the individual feels that he needs to multitask, but unfortunately this only results incomplete tasks as the attention is soon diverted to something else prior to the completion of the task at hand. The client reports that he is messy and disorganized, which is one of the symptoms of individuals with ADHD. Emotional instability is displayed by the lack of motivation of the client to his assigned tasks; while his colleagues were motivated by the tightened deadlines, Harold panic and lost his level of concentration, the result of which was lack of completion of his tasks.
The diagnosis of the client will take into account ethical considerations to ensure that the client comprehends the diagnosis process and most especially the mental disorder that he suffers. The diagnosis process demands that the client gives consent for the procedure to be carried out and on the same note is offered the guarantee that confidentiality of his medical information will be observed. Legal consideration that aligns with the diagnosis of ADHD will as well be taken into consideration, with the realization that the mental disorder displays symptoms that are very similar to other mental disorders, meaning that they can be easily passed for another mental disorder. The possible outcome of this is medical error as the client will be treated for the wrong disorder, and leading to a legal suit for the healthcare provider and the health care organization. For this reason, a differential diagnosis of the mental disorders that display similar symptoms as as ADHD will be analyzed and a proper diagnosis provided.
Conclusion
This paper sought to examine the case of a client by the name Harold, who has been having challenges focusing on his assigned tasks at the workplace after tight deadlines were introduced, leading his supervisor to make appointment for him with the healthcare provider. From the subjective and objective data, it is clear that the client suffers from ADHD. Although to be sure that it was no other mental disorder, differential diagnosis was conducted. Assessing and Diagnosing Patients with Neurocognitive and Neurodevelopmental Disorders

References
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Assessing and Diagnosing Patients with Neurocognitive and Neurodevelopmental Disorders