Detecting Major Neurocognitive Disorder: The DSM-5’s New Term for Dementia

Major neurocognitive disorder, known previously as dementia, is a decline in mental ability severe enough to interfere with independence and daily life.

This term was introduced when the American Psychiatric Association (APA) released the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

The updated manual replaces the term “dementia” with major neurocognitive disorder and mild neurocognitive disorder. Although the DSM-5's terms are now different, they should have little effect on the person-centered, abilities-based approach to care that we promote. As such, they should also have little effect on how most Dementia Capable Care Certified Instructors deliver their training programs.

Dementia vs. Neurocognitive Disorder

The word "dementia" is related to a Latin word for "mad," or "insane." Because of this, the introduction of the term neurocognitive disorder attempts to help reduce the stigma associated with both the word dementia and the conditions that it refers to.

That said, the APA acknowledges that because the word dementia is in common use and is easily understood by everyone, it will likely remain in use. The terms major neurocognitive disorder and minor neurocognitive disorder are likely to be used only by some health care professionals and organizations. However, not all care professionals and organizations are likely to use the new term. Currently, the Alzheimer's Association, for example, uses the word dementia—not neurocognitive disorder.

Here at Dementia Care Specialists, we use the term dementia because it refers to a variety of conditions that can be caused by a number of factors. Dementia is not a disease itself, but a group of symptoms that can accompany certain diseases or conditions. It's a broad term that can be defined as a condition involving impairments in thinking, remembering, and reasoning, which affect a person's function and safety. 

Dementia causes can be reversible, or they can be irreversible and progressive. There are many factors that can cause symptoms of dementia. Potentially reversible dementia symptoms include those caused by depression, stroke, traumatic brain injury, certain medications, and even bladder infections. Irreversible and progressive dementias include Alzheimer’s disease, vascular dementia, Lewy body dementia, and frontotemporal dementia.

Focusing on Abilities—Not Disabilities

One thing that's noteworthy about the new DSM-5 terms is that they focus on a decline, rather than a deficit, in function.

This is very much in line with our philosophy. We train therapists and other health care professionals to focus not on the disabilities of people with dementia, but on the abilities of people with dementia. We help care partners create the just-right level of challenge so a person with dementia can stay engaged, remain productive, and retain feelings of self-worth.

It's essential that the family and the other caregivers of a person with dementia recognize the changes in the person's behavior and function. This helps them to simplify and adapt activities to help the person retain function, mobility, and quality of life.

At the same time, it's vital to recognize that each person with dementia has many remaining abilities. Even at Allen Cognitive Level 1, the most advanced stage of dementia, a person has the ability to have meaningful relationships and emotional experiences. Be sure to check out the video below to learn more about that!

Memory and Early Detection

The APA's diagnostic criteria for major neurocognitive disorder and minor neurocognitive disorder focus less on memory impairment than the former DSM-IV criteria for dementia did. This de-emphasis on memory impairment allows for variables associated with conditions like frontotemporal dementia (FTD), which sometimes begin with declines in speech and language usage ability, and do not necessarily affect memory immediately. This is important to keep in mind because there is more to dementia symptoms than simply changes in memory. And it is essential to recognize, diagnose, and treat all forms of dementia and all its symptoms—with the goal of helping people to function as safely, as independently, and for as long as possible.

The DSM-5 also states that individuals with major neurocognitive disorder exhibit cognitive deficits that interfere with independence, while persons with mild neurocognitive disorder may retain the ability to be independent. This is an important distinction that highlights the need for assessing individuals’ functional cognitive abilities. Is it still safe for the person to drive? To live alone? Does the person have the judgment to seek medical help for infections and injuries? Does the person have the ability to take precautions to avoid falls and spoiled food? To remain safe?

Experienced health care professionals, such as those using the Cognitive Disabilities Model and the Allen battery of cognitive assessment tools, can identify and recognize the effect of a cognitive or memory impairment on a person's daily abilities and function—and can facilitate remaining abilities and provide care, environmental supports, and assistance where needed.

A consideration about the addition of criteria for mild neurocognitive disorder is that this new term is intended to promote early detection and treatment of cognitive decline. Early detection is essential, as doctors, therapists, nurses, and other care professionals must be there with skills to guide and support individuals and their families both early on and throughout the disease process. This can help slow progression, ease suffering, and improve the quality of life for both the person with the disease and their loved ones.

Major Neurocognitive Disorder: Coding and Reimbursement Implications for Therapists

According to the APA, "the DSM-5 is completely compatible with the HIPAA-approved ICD-9-CM coding system now in use by insurance companies."

The International Classification of Diseases, Version 9 (ICD-9) outlines codes that describe conditions and complexities in order to support skilled intervention. These include:

• Dementia (290.0–290.4) 
• Alzheimer's (331.0)
• Mild cognitive impairment (331.83)
• Memory loss not specified elsewhere (780.93) 

The codes for dementia, Alzheimer's, mild cognitive impairment (MCI), and memory loss not elsewhere specified still stand. For more on ICD-9 codes for major neurocognitive disorder and minor neurocognitive disorder, please refer to the DSM-5.

Additionally, if you're a therapist, be sure to use the diagnosis code provided by the person’s doctor. Keep in mind too that your documentation of the symptoms you observe can be useful to a physician in determining the correct diagnosis of a person’s condition.

Major Neurocognitive Disorder and Skilled Memory Care

The most important thing to keep in mind about the new terms is that, regardless of names and labels, the focus of quality dementia care should always be on providing skilled, compassionate, and person-centered support. Terms matter little; compassion is essential.

Resources

If you're a health care professional and you haven't heard about our Dementia Capable Care training program, I urge you to find out how it can help you provide the support that more and more people with all types of dementia need.

• Read more about the new terms in DSM-5 Changes: Neurocognitive Disorders.
• Find out about the Alzheimer’s Association’s diagnostic criteria for Alzheimer’s disease.