682 CHAPTER 15
can have impaired attention, concentration, and memory; those with a psychotic
disorder have impaired perception and judgment; and substance abuse and depen-
dence can lead to a wide variety of cognitive impairments. The cognitive changes
associated with these disorders, however, are secondary to the other symptoms that
characterize the disorders: depressed mood, anxiety and fear, psychotic symptoms,
or behaviors related to substance abuse and dependence.
In contrast, with cognitive disorders, the changes in cognitive functioning—in
mental processes—constitute the primary set of symptoms. Patients may (or may
not) also exhibit disturbances in behavior, mood, or mental contents. Usually, the
undesired cognitive changes arise from a medical disease such as Parkinson’s dis-
ease, a medical condition such as a stroke, or the use of or withdrawal from a
psychoactive substance (which may include exposure to a toxic substance). When
substance use or withdrawal causes the cognitive symptoms, according to DSM-IV-
TR, the symptoms must be in excess of those typically experienced with intoxica-
tion or withdrawal from a substance in order to be considered a cognitive disorder
(American Psychiatric Association, 2000).
The three types of cognitive disorders discussed in this chapter are delirium, am-
nestic disorder, and dementia. Delirium involves impaired cognition and a marked
change in awareness (as occurs when someone who is drinking alcohol doesn’t rec-
ognize friends or drinks to the point of being in a stupor). Amnestic disorder involves
impaired cognition that is confi ned to memory. Dementia involves impaired memory
plus at least one other impaired cognitive function—such as perception, attention, or
language use. Cognitive disorders are almost exclusively due to neurological factors.
In most cases, these disorders affl ict older adults rather than younger adults.
So, part of the job of diagnosing these disorders is to distinguish the symptoms of
these disorders from changes that occur with normal aging. Let’s fi rst examine the
changes in cognitive functioning that arise during the normal aging process, which
will allow us to contrast these effects with those described in subsequent sections.Normal Versus Abnormal Aging
and Cognitive Functioning
The neuropsychologist assessing Mrs. B. needed to determine whether her distur-
bances in memory, mood, and behavior were normal for an 87-year-old, particularly
one with a variety of medical problems. And, if her memory, mood, and behavior
weren’t in the normal range, given her circumstances, what, specifi cally, could ac-
count for her diffi culties? The neuropsychologist initially assessed Mrs. B. using a
clinical interview (discussed in Chapter 3), observing her as well as noting her re-
sponses to questions:
“Mrs. B. arrived promptly for her appointment, accompanied by her private-duty nurse.
She was well-groomed and alert but ambulated slowly, leaning against the railing on
the wall to maintain her balance; she was also unsteady on rising and standing from a
chair. She was fl uent and willing to talk at great length about her situation, although her
speech was often repetitive and tangential. Mood was... positive during the interview.
She denied hallucinations, delusions, or suicidal ideation but admitted to some depres-
sion, which she felt had improved somewhat on antidepressant medication. She was
able to describe some aspects of her experience at the [nursing home] and gave several
examples of the types of things that annoyed her at the current board-and-care home.”
(LaRue & Watson, 1998, p. 6)
Mrs. B. was able to remember aspects of her nursing home experience that she
didn’t like, but she forgot other types of information, such as upcoming plans to
which she had agreed. In the normal course of events, however, various cognitive
functions tend to decline with advancing age. Mental health clinicians must com-
pare the individual’s current cognitive functioning both to the person’s prior abili-
ties and to the normal changes in functioning that occur with age. Even healthy
older adults have some cognitive defi cits, compared to their younger counterparts,