Rebecca Puchkors; Jeanne Saunders; David Sharp

Learning Objectives

By the end of this section, you will be able to:

Outline the issues involved in diagnosing mild neurocognitive disorders
Describe the care planning for and the role of the nurse in treating clients with mild neurocognitive disorders

A group of disorders known as neurocognitive disorders (NCD) affects an individual’s cognition with a gradual decline in at least one of the following domains of cognition: “executive function, complex attention, language, learning, memory, perceptual-motor or social cognition” (Emmady et al., 2022, para 1). For information on neurodevelopmental disorders that occur in younger clients, see Chapter 23 Children and Adolescents. According to the Alzheimer’s Society (2023b), 5 to 20 percent of people sixty-five and older are living with mild cognitive impairment. Mild cognitive impairment (MCI) happens when normal changes in brain cognition that occur with aging begin to gradually increase and negatively impact daily living. People with MCI have more problems with memory and thinking than other people their age. Because the symptoms are not as severe as in some of the major neurocognitive disorders, such as Alzheimer disease or other dementias, people with MCI generally are able to continue to care for themselves and carry out their normal daily activities. Signs and symptoms include being unable to follow a conversation or difficulty making decisions, getting lost in a known place, missing appointments, and forgetting things more often (Mayo Clinic, 2023). Many people remain in this stage for years, while others will progress to more severe cognitive decline and dementia. The DSM-5 now uses the term mild neurocognitive disorder (MiND), which requires the presence of one or more measurable cognitive disabilities for diagnosis (Ellison, 2021).

Diagnosing Mild Neurocognitive Disorders

A mild neurocognitive disorder (MiND) causes a gradual decline in a person’s cognition, beyond that of normal aging, negatively impacting daily living, but the individual is still able to function independently (Mount Sinai, 2023). There is no single test that a provider can do to diagnose MCI. Instead, it takes a combination of information provided by the individual and standardized mental status testing (Mayo Clinic, 2023). Providers may also do a neurological exam to test reflexes, eye movements, and walking/balance to assess the neurological deficits. Labs can determine if the individual has a physical problem related to deficiencies in vitamin B12 or thyroid hormones (Mayo Clinic, 2023). An MRI can check for strokes, bleeding, or a brain tumor. To be diagnosed, the symptoms must be connected to a medical condition, not another mental health problem (Psychology Today, 2019).

Link to Learning

A multidisciplinary advisory group of health professionals involved in dementia care have published a summary of pragmatic approaches for nurses to help address modifiable risk factors for early Alzheimer disease and mild cognitive impairment in their clients in an article in the British Journal of Nursing.

Diagnosis for MiND, according to the DSM-5, includes the presence of one or more cognitive difficulties in the areas of complex attention, memory, executive function, expression and understanding of language in written and spoken forms, visuospatial cognition, or social cognition (Ellison, 2021). In most cases, people who do not know the individual would not notice these changes.

Psychosocial Considerations

Living with HIV and Neurocognitive Impairments

There are approximately thirty-eight million people who have HIV, and 55 percent of those people live in southern and eastern Africa (Tareke et al., 2022). Sixty-eight percent of people with HIV have a neurocognitive impairment related to the infection and the medications used to treat it. HIV-associated neurocognitive disorder (HAND) decreases quality of life and, along with the stigma of living with HIV, these individuals also face stigma related to having a neurological illness. Lack of social support in individuals with HIV can cause a 31 percent higher chance of developing anxiety and depression as compared with the general population. Further, people who feel that they have poor social support are less likely to have good outcomes or follow their treatment protocol. A recommendation based on the study by Tareke et al. was screening all individuals who get treatment at antiretroviral therapy (ART) clinics (Tareke et al., 2022).

Causes of Mild Neurocognitive Disorders

There are both nonreversible and reversible causes of neurocognitive disorders. Nonreversible causes will be discussed in 14.3 Dementia. Reversible causes include hypoxia, low oxygen level in the brain; hypercapnia, high carbon dioxide levels in the body; infections; reactions to medications; poisoning; thyroid problems; vitamin deficiencies, such as low B1, B6, or B12; subdural hematoma; and tumors (Baptist Health, 2023; Mount Sinai, 2023). As with any other mental health consideration, providers should rule out medical causes first.

Risk factors for developing a neurocognitive disorder include being over sixty-five years of age, smoking, excessive alcohol, Down syndrome, a family history, cardiovascular disease, depression, diabetes, or sleep apnea (Baptist Health, 2023). The primary risk factor is age. Women are more likely to be diagnosed with a neurocognitive disorder, but this could be because they tend to live longer than men (Psychology Today, 2019).

Symptoms of Mild Neurocognitive Disorders

All neurocognitive disorders, whether mild or major, share the following symptoms, with differences in their severity depending upon the person’s diagnosis: difficulty planning and making decisions, difficulty focusing and remembering the names of objects or people, difficulty performing daily tasks, and speaking or acting in ways that are not socially correct (Psychology Today, 2019). Individuals may take longer to perform some of the activities of daily living, including grocery shopping, finding their keys, being able to drive or use a telephone, managing their medications, and handling their finances (National Institute on Aging and National Institutes of Health, 2024).

The decline usually occurs gradually over time. In cases of mild neurocognitive disorders, only close family and friends may notice the differences in an individual, where strangers do not see a decline.

Nursing Treatment of Mild Neurocognitive Disorders

There is no cure for true mild cognitive disorders, but there are treatments that can help decrease symptoms. A provider may prescribe an antidepressant or a medication specifically for memory loss (Psychology Today, 2019). Psychotherapy can be very helpful for dealing with the stress of cognitive decline. This therapy can include family members so that they have a better understanding of the disease and the amount of support needed by the individual. There are certain things that an individual can do to reduce the risk of their cognitive decline becoming more severe. Things like getting regular exercise; eating healthy food; limiting alcohol, smoking, and sugar intake; having good sleep hygiene; and staying connected to social supports all work together toward better overall health (Psychology Today, 2019).

Clinical Judgment Measurement Model

Treatment and Help for MiND: Take Action

After assessing the client and gathering data, the nurse prepares a care plan that is written in easy-to-understand language. This care plan should include the specific symptoms that the client is experiencing, how the team proposes to manage those symptoms, information about any comorbid medical conditions, and caregiver support needs. The nurse then discusses the care plan with the client and their family and gives them a copy. Referrals to consult specialists must be made. While there is no cure for MiND, some daily interventions can be helpful, such as maintaining a routine, providing memory aids like calendars and clocks, eating and drinking well, and getting enough sleep.

(Alzheimer’s Association, 2023a)

Planning Nursing Care for a Client with Mild Neurocognitive Disorders

Nurses need to be supportive of the person who is noticing a decline in their cognitive abilities. Person-centered care involves treating the client with empathy, respect, and looking at situations from their point of view, including their history, cultural preferences, and basic likes and dislikes. It entails assisting them to enjoy their relationships with others, despite a decline in some of their cognitive abilities (Alzheimer’s Society, 2023b). One important step in the nursing assessment process is to ask the person to describe their own perceptions of problems they are encountering. It may be helpful to have the family involved while gathering the health history, because they may have a better grasp of the cognitive decline they have witnessed in their loved one (Lin et al., 2012). Because early detection is beneficial in managing MiND, nurses should routinely educate older clients and their families about the signs and symptoms of mild neurocognitive disorders (Lin et al., 2012).

Nurses can make a difference by incorporating interventions that address modifiable risk factors (MRFs). MRFs are separated into four areas that evidence has shown may delay cognitive decline (Hope, 2020). These areas are medical, nutrition, psychosocial, and lifestyle. Examples of interventions in these areas are listed in (Table 14.1).

Category	Examples
Medical	Checking blood pressure routinely to ensure that blood pressure remains within a healthy range. This could include the purchase of an at-home electronic blood pressure cuff for an individual who already has some cardiovascular concerns. Checking that cholesterol and blood glucose levels are within normal ranges—hypercholesterolemia and diabetes are known to increase the risk for dementia.
Nutrition	Teaching individuals about the importance of eating a nutritious diet to maintain a healthy weight/BMI.
Psychosocial	Encouraging the individual to remain socially active. Encouraging the individual to pursue treatment for depression and anxiety. Encouraging the individual to do daily activities that will work the brain—crossword puzzles, playing cards, and learning something new.
Lifestyle	Advising the reduction/cessation of smoking or drinking alcohol. Encouraging the individual to remain physically active.

Table 14.1 Interventions That May Delay Cognitive Decline (Hope, 2020)

There are several challenges nurses may face caring for a person with MiND. First, an individual may have noticed some decline but not be fully aware of how far their deficits extend. Second, a nurse may see an individual who they suspect has a cognitive decline but has not yet been diagnosed. In this case, the nurse could perform a screening assessment such as the Mini-Cog (see 14.3 Dementia). Third, the nurse needs to be sure to include the individual’s beliefs and cultural values in the conversations they have about the disease process (Lin et al., 2012) because there are different belief systems about the signs and symptoms as well as the illness itself. Additionally, some people think of cognitive declines as a normal part of aging and do not consider that these declines may be due to something else.

Life-Stage Context

The Use of Standardized Screening Tools

The use of standardized screening tools to test for cognitive impairment and dementia provides information about the client’s strengths and weaknesses. The psychologist must choose the tool that uses normative data that is the most appropriate for their client’s age, culture, gender, language, and educational background. Brief mental status exams are frequently used to determine if a client is experiencing cognitive decline or dementia. Health-care providers must be aware that this tool is more sensitive to dementia than to MCI. There has been an increase in the number of screening tests available for clients in the older age ranges and for particular demographics, such as particular cultures. Providers must continue to educate themselves on the screening tools available for particular population groups (American Psychological Association, 2021).

Supporting Caregivers

Cognitive impairment is stressful for the individual and their family members. Talking about the responsibilities that often fall on family caregivers when cognitive impairment worsens may be the first step to take in preparing the family for the road ahead. A family meeting can help the family members learn more about MiND and what they can do to support their loved one. Encouraging the family to think about how they might divide or design tasks allows each person to have a sense of autonomy and connection to one another. Even family members who live far away can be involved in such things as checking in regularly (via phone, e-mail, texting, or FaceTime) with the individual and the primary caregiver, taking over things that can be handled online, such as bill paying or doing research to locate in-home services should that need arise (National Institute on Aging, 2023).

Encourage family members to be honest about how much they feel they can realistically do and to share any concerns they may have about how these added responsibilities might affect their own jobs, immediate family, or personal wellness. Pay particular attention to what is referred to as the “sandwich generation” caregivers. These are the family members who are caring for their parents while also caring for their children (National Institute on Aging, 2023). These caregivers account for one in four people who are caring for an aging parent. They are at an increased risk for additional stress and fatigue due to caring for both their parents and their children.

Offering resources, such as support groups that are available in the community, will help family members connect with other people caring for older parents. Respite care services are another helpful resource for family caregivers if the individual’s cognitive impairment has progressed beyond basic assistance. One such resource is the ARCH National Respite Locator Service which has a searchable function for finding care.