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Ask the Mental Health Expert Archives 2001-2004

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Cognitive Disorder NOS

Q. I am a mental health counselor working in a medical clinic. I have a 61-year-old-woman diagnosed with cognitive disorder not otherwise specified (NOS) that I am currently working with. I am having trouble getting information on treating this disorder in therapy. Her physician is covering the medical side of the issue, however I am have difficulty proceeding with the mental health portion. Can you offer any helpful hints?

A. You have a challenge here for several reasons. First, the diagnosis "Cognitive Disorder NOS (not otherwise specified)" is a bit like hearing that your car has "engine trouble, not otherwise specified." It doesn't really tell you much about what is going on. Sometimes this label (Cognitive Disorder NOS) is more the result of diagnostic laziness than scientific evidence. Sometimes, it truly reflects the fact that the patient's disorder does not meet established (e.g., DSM-IV) criteria for any of the commonly-diagnosed cognitive disorders, such as Alzheimer's Disease or Vascular Dementia.

Indeed, some patients may have mixed forms of dementia that defy easy classification, such as Lewy Body Dementia or Cortico-basal dementia. (For descriptions of these and related disorders, see Handbook of Geriatric Psychopharmacology, edited by Dr. Sandra Jacobson and colleagues). If you are unable to pin down your patient's doctors and get a more specific diagnosis, you may be left with two options: (1) Lobbying for more extensive neuropsychiatric testing; or (2) Accepting the diagnosis as is, and identifying target symptoms for your work with this woman.

This second point is very important: your interventions, since they will not be directed at reversing the underlying problem, need to be focused on specific areas of concern. For example, does this patient experience primarily problems with short-term memory? If so, there are some cognitive rehabilitation strategies that you can use with her. Does she show evidence of a co-morbid or underlying depressive or anxiety disorder? (These are very common in some types of dementia, such as those related to basal ganglia pathology; e.g., Huntington's or Parkinson's Disease). If so, there may be some cognitive-behavioral, supportive, or even psychodynamic interventions you can consider. (Such co-morbid anxious or depressive symptoms may also respond to specific medications--an issue to discuss with the patient's primary care physician or psychiatrist).

Are the patient's problems mainly in the area of poor impulse control? Loss of social judgment? Irritability or aggression? Low self-esteem? Poor social supports? All these potential target symptoms lend themselves to psychotherapeutic strategies, including, perhaps, working with the patient's family or caregivers.

You may benefit greatly from the paper, "Nonpharmacologic interventions for inappropriate behaviors in dementia," by Dr. Jiska Cohen-Mansfield (American Journal of Geriatric Psychiatry, Fall 2001). Other papers that may be of help include: DA Koder, "Treatment of anxiety in the cognitively impaired elderly" ( Int Psychogeriatr 1998 Jun;10(2):173-82); and Mintzer & Brawman-Mintzer, "Agitation as a possible expression of generalized anxiety disorder in demented elderly patients: toward a treatment approach (J Clin Psychiatry 1996;57 Suppl 7:55-63; discussion 73-5).

So, get those target symptoms nailed down; devise a way of monitoring the patient's progress (e.g,, the GAF scale or various geriatric psychopathology scales); and good luck with this challenging case!

September 2002

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