Vascular Neurocognitive Disorder
Vascular Neurocognitive disorder (VCD) is a form of dementia that is common and is diagnosed in about 15-30% of all those who are diagnosed with dementia. The disease is also known as vascular cognitive impairment, vascular dementia and multi-infarct. The condition is caused by a disruption or a blockage of the flow of blood in the brain and the areas that receive less blood gets less oxygen and nutrients. Conditions that contribute to the disorder include Ischemia, Cerebral Vascular Accident, Transient Ischemic Attacks and Aneurysms.
Diagnostic Criteria for Vascular Neurocognitive Disorder
The symptoms of the disorder depend on the area that has is receiving reduced blood flow. Some individuals have a few symptoms like problems with forgetfulness, difficulties with attention and weakness in one side of the body. Others have symptoms in other distinct areas known as patchy presentation since different parts are affected and at various levels. Diagnosis relies on cognitive testing constituting of at least four cognitive domains to include language, memory, executive/attention and visuospatial functions. The patient has difficulty with several stimuli, difficulty retaining new information, they are not able to do mental calculations, and regular tasks take longer (Sachdev et al., 2015).
Concerning memory, they repeat themselves in conversations and relies mostly on list making. They also have difficulties with word finding and expressive language. The patients also find it cumbersome to perform activities that were previously familiar, and their behaviour is out of acceptable social range. There should be a decline in cognitive function and performance deficiency in at least two domains that are severe enough to have daily impact activities of life and independence and are not due to delirium or other mental disorder.
For an accurate diagnosis, there should also be an image showing evidence of cerebrovascular disease and a temporal relationship that is clear between a vascular event such as stroke and beginning of deficiency in cognition or an association of the severity and cognitive impairment pattern and the prescence of diffuse subcortical vascular pathology. There should also not be a history of a gradual cognitive deficit, suggesting prescence of neurodegeneration (Frances, Sandra & Ugbomah, 2016). Besides, there should be a piece of evidence that cerebrovascular disease is present from physical assessment, history and neuroimaging that is deemed sufficient enough to account for the deficits in neurocognition.
Psychotherapy and psychopharmacologic treatment for Vascular Neurocognitive Disorder
Management of risk factors that are preventable and symptomatic pharmacotherapy are the main approaches in the treatment of VCD since there are no Food and Drug Administration treatments that have been approved. The strategies in treatment attempt to control cognitive dysfunction progression. One class of drugs used are Statins which are cholesterol-lowering drugs that reverse depression, anxiety decline in cognitive abilities (Smith et al., 2017). Memantine is also another medication that has been found to have good efficacy and improve cognition with no decline in behaviour and global functioning
Another drug that has shown effectiveness is Donepezil which is a reversible acetylcholinesterase inhibitor which improves global functioning and cognition in patients. Rivastigmine has also shown benefit in the treatment of VCD. Cell-based therapy like transplantation of endothelial progenitor cells is also used and has been found to induce neurogenesis, angiogenesis and reduce cognitive decline Kumral & Ozgoren, 2017). Other risk factors of the disease such as cerebrovascular accident should be treated. Depression has also been found to occur together with the disease, and the patient who displays symptoms of depression should be put on antidepressants.
Risks of different types of Therapies
Memantine has been found to bring about restlessness and dizziness, but these effects are mild and dose-related and cannot prevent the use of the drug. These effects are too mild, and the benefits of the drug, therefore, outweigh the risks. The other therapies have minor side effects, and their use is consequently beneficial than the risks associated (Frances, Sandra & Ugbomah, 2016).
Schizophrenia spectrum and other Psychotic Disorder
Schizophrenia spectrum and other psychotic disorders constitute of schizophrenia, other psychotic disorders and schizotypal or personality disorder. They cause abnormalities in one or more of domains of hallucinations, delusions, grossly disorganised or abnormal motor behaviour to include catatonia, disorganized thinking and negative symptoms. These symptoms cause significant occupational and social distress and impairment (Pagsberg, 2013). The symptoms of schizophrenia are classified as positive or negative. Positive symptoms are disorders of commission, meaning they are things that the patient does or thinks such as delusions, hallucinations and disorganized behaviour, while negative symptoms are disorders of omission meaning the patient does not do them such as flat affect, lack of speech and asociality.
A client whom I previously met with this disorder was a 19-year-old lady called Jessy who had been brought to the clinic by her auntie who complained that her behaviour had become challenging to manage. She claimed of having imaginary friends, some of who were a half dog and half human. The aunt reported that she was also getting poor grades in campus as compared to previous semesters. It was also reported that she had become socially withdrawn and only kept a few friends. During the interview with the PMHNP, she is pleasant but looks distant and is appropriately dressed for the weather.
She has no tics, mannerisms or gestures, she is alert and oriented to time place and person, her speech is clear, coherent, spontaneous and goal oriented. She reports being in a good mood, but her affect appears to be constricted. Her eye contact is minimal, and she seems to be preoccupied at times. She denies any suicidal or homicidal ideation, and she is not paranoid.
Antipsychotics are the preferred drugs in the treatment of schizophrenia. A good example that is suitable for this client is Haloperidol 5 mg orally daily. Haloperidol has shown effectiveness in the treatment of schizophrenia and has good efficacy in the management of various domains of symptoms. The drug is also safe and has no adverse effects that are serious associated with it. A dosage of 15 mg is suitable for this client as high doses are likely to cause more extrapyramidal side effects. The drug is also useful in a reduction of both the positive and negative symptoms that are associated with Schizophrenia and also has good psychopathological scores (Smith et al., 2017). The drug is also a single dose medication, and therefore there is a likelihood of drug compliance.
I would recommend individual psychotherapy for Jessy which is both a psychological and psychosocial form of treatment. The reason for supporting this therapy is because she is not out of touch with reality, and psychotherapy focuses on the social functioning of individuals, which has been affected in her life, and she is therefore likely to benefit. The sessions will focus on both her past and current experiences, problems, feelings, thoughts, and relationships.
When she interacts with a mental health professional during the sessions, she will be in a position to understand her condition and problems more and will also learn to distinguish real from the unreal (Hamm et al., 2013).
Psychotherapy will also help in improving the self-esteem of Carrie, and this will help her interact with more people, which will help improve her social life and will view matters as real. Family therapy may also be beneficial to Jessy and her family so that the family members can be in a position to understand and tolerate her behaviour as she takes her drugs.
Medical management and Primary Care needs
The medical management needs are the use of antipsychotics, which can be given and changed later depending on the response of the patient. The patient also needs to be treated for any other comorbidity that she may have. Another medical management is having supervised the administration of antipsychotic drugs which can easily be carried out by the primary caregiver. According to Bhatia and Saha, 2017, the primary care needs include coming up with community-based programmes to manage the client and also integrate mental health services with the general services in health provided at the fundamental healthcare level. This approach of integration will help reduce the mental health gap existing in the community and thus help reduce the chances of getting more cases of schizophrenia.
Plan for follow-up intensity and collaboration with other Providers
If the client has atypical symptomatology, inadequate response to medications or gets complications, she can be referred to a specialist. The referral will assist in reducing the time and financial cost that is spent on travelling to tertiary centres of care. Other healthcare providers such as counsellors and the social worker can go for home visits to the client’s home to ensure she is adherent to medications (Pagsberg, 2013). The general healthcare practitioners can also be incorporated in home visiting the client and provide necessary psychoeducation sessions for the client as well as the caregivers. The sessions can also be done as group sessions for the family focusing or emphasizing on education about the nature of the disorder, prognosis, the course, the outcome and the significance of adherence to treatment and rehabilitation services. Most significantly, the general awareness regarding psychotic disorders in the community requires to be improved. Non-governmental organizations also ought to be incorporated in the creation of awareness and reduction of the stigma that is associated with mental illnesses, in particular, schizophrenia (Bhatia & Saha, 2017).
In conclusion, it cannot be denied that Schizophrenia has devastating consequences for both the patient and the family. Some of the consequences include disability which can be attributed to reasons like early onset, limited mental health resources, chronic course and social stigma. The limited resources lead to prolonged duration of untreated psychosis which causes a poorer outcome in schizophrenia. Such result include more significant disability, violation of human rights, social isolation and increased mortality.
Frances A., Sandra O., & Ugbomah L., (2016).Vascular cognitive impairment, a cardiovascular complication. World J Psychiatry. 2016 Jun 22; 6(2): 199–207. Published online 2016 Jun 22. doi: 10.5498/wjp.v6.i2.199
Hamm J. A., et al., (2013). Individual psychotherapy for schizophrenia: trends and developments in the wake of the recovery movement. Psychol Res Behav Manag. 2013; 6: 45–54. Published online 2013 Aug 6. doi: 10.2147/PRBM.S47891
Kumral E. & Ozgoren O., (2017). Major Vascular Neurocognitive Disorder: A Reappraisal to Vascular Dementia. DO I:10.4274/tnd.98250Turk J Neurol 2017;23:1-8
Sachdev P. et al., (2015). Diagnostic criteria for vascular cognitive disorders: a VASCOG statement. Alzheimer Dis Assoc Disord. Author manuscript; available in PMC 2015 Jul 1.Published in final edited form as Alzheimer Dis Assoc Disord. 2014 Jul-Sep; 28(3): 206–218. doi: 10.1097/WAD.0000000000000034
Smith E. E. et al., (2017). Therapeutic Strategies and Drug Development for Vascular Cognitive Impairment. J Am Heart Assoc. 2017 May; 6(5): e005568.Published online 2017 May 5. doi: 10.1161/JAHA.117.005568