Major & mild neurocognitive disorders

Neurocognitive disorders (NCDs) on case exams test whether the counselor recognizes acquired cognitive decline, refers for proper workup, adapts counseling to the client's capacity, and supports caregivers and safety decisions.

Criteria at exam depth (paraphrased).

• Major NCD: significant decline from a previous level in one or more cognitive domains: complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition. Evidence comes from concern (client, informant or clinician) plus substantial impairment on standardized testing or equivalent clinical assessment. The deficits interfere with independence in everyday activities (at minimum, needing help with complex instrumental tasks such as paying bills or managing medications).
• Mild NCD: modest decline on the same evidence, but the person remains independent, though tasks may need greater effort or compensatory strategies.
• Both: not occurring exclusively during delirium, and not better explained by another mental disorder (such as major depression or schizophrenia).
• Etiological subtypes: Alzheimer's disease, frontotemporal, Lewy bodies, vascular, traumatic brain injury, substance/medication-induced, HIV, prion, Parkinson's, Huntington's, another medical condition, multiple etiologies.
• Specifiers: with or without behavioral disturbance (e.g., agitation, psychotic features, mood symptoms, apathy); for major NCD, current severity mild (instrumental tasks), moderate (basic daily activities), severe (fully dependent).

Subtype clues. Alzheimer's: insidious onset, gradual progression, early memory and learning loss. Vascular: stepwise decline linked to cerebrovascular events. Lewy bodies: fluctuating cognition, recurrent detailed visual hallucinations, parkinsonism, REM sleep behavior disorder. Frontotemporal: early personality change, disinhibition or apathy, or language decline, with memory relatively spared early.

Hinge differentials.

• Normal aging: slower recall but independence and learning preserved.
• Delirium: acute onset, fluctuating attention, medical cause.
• Depression with cognitive complaints: onset alongside mood symptoms; client emphasizes deficits.
• Intellectual disability: lifelong, not acquired decline.

On the NCMHCE. Use brief screens (MoCA, MMSE) as screens only, and refer for medical workup (reversible causes such as thyroid, B12, medication effects, infection) and neuropsychological testing. Adapt treatment: structured, behavioral and compensatory strategies rather than abstract insight work, repetition and written summaries, involvement of family. Raise safety questions (driving evaluation, wandering, medication management, firearms, elder abuse). Introduce advance care planning while decision-making capacity remains, and assess caregiver burden, which often determines whether home care is sustainable. Screen depression and suicide risk after diagnosis.

Clinical Pearl: Independence in everyday instrumental tasks is the line between mild and major NCD. Rule out delirium and depression first; screening scores alone never make the diagnosis.