Mood disturbances, including depression, anxiety, and elation, may occur. Depression is common early in the course (including at the mild NCD level) of NCD due to Alzhei- mer’s disease and Parkinson’s disease, while elation may occur more commonly in fron- totemporal lobar degeneration. When a full affective syndrome meeting diagnostic criteria for a depressive or bipolar disorder is present, that diagnosis should be coded as well.
Mood symptoms are increasingly recognized to be a significant feature in the earliest stages of mild NCDs such that clinical recognition and intervention may be important.
Agitation is common in a wide variety of NCDs, particularly in major NCD of moder- ate to severe severity, and often occurs in the setting of confusion or frustration. It may arise as combative behaviors, particularly in the context of resisting caregiving duties such as bathing and dressing. Agitation is characterized as disruptive motor or vocal activity and tends to occur with advanced stages of cognitive impairment across all of the NCDs.
Individuals with NCD can present with a wide variety of behavioral symptoms that are the focus of treatment. Sleep disturbance is a common symptom that can create a need for clinical attention and may include symptoms of insomnia, hypersomnia, and circadian rhythm disturbances.
Apathy is common in mild and mild major NCD. It is observed particularly in NCD due to Alzheimer’s disease and may be a prominent feature of NCD due to frontotemporal lobar degeneration. Apathy is typically characterized by diminished motivation and re- duced goal—directed behavior accompanied by decreased emotional responsiveness.
Symptoms of apathy may manifest early in the course of NCDs when a loss of motivation to pursue daily activities or hobbies may be observed.
Other important behavioral symptoms include wandering, disinhibition, hyperpha- gia, and hoarding. Some of these symptoms are characteristic of specific disorders, as dis- cussed in the relevant sections. When more than one behavioral disturbance is observed, each type should be noted in writing with the specifier ”with behavioral symptoms.”
Major and mild NCDs exist on a spectrum of cognitive and functional impairment. Major
NCD corresponds to the condition referred to in DSM-IV as dementia, retained as an alter- native in this volume. The core feature of NCDs is acquired cognitive decline in one or part of the individual, a knowledgeable informant, or the clinician, and 2) performance on an objective assessment that falls below the expected level or that has been observed to de- cline over time. Both a concern and objective evidence are required because they are com- plementary. When there is an exclusive focus on objective testing, a disorder may go tually represents a substantial decline in abilities, or an illness may be incorrectly diag- from their own baseline or is a result of extraneous factors like test conditions or a passing illness. Alternatively, excessive focus on subjective symptoms may fail to diagnose illness in individuals with poor insight, or whose informants deny or fail to notice their symptoms, or it may be overly sensitive in the so-called worried well.
taneously. Rather, it may need to be elicited by careful questioning about specific symp- toms that commonly occur in individuals with cognitive deficits (see Table 1 in the introduction to this chapter). For example, memory concerns include difficulty remember— ing a short grocery list or keeping track of the plot of a television program; executive con- cerns include difficulty resuming a task when interrupted, organizing tax records, or planning a holiday meal. At the mild NCD level, the individual is likely to describe these tasks as being more difficult or as requiring extra time or effort or compensatory strategies.