It is also vitally important to evaluate any safety concerns that arise from the cognitive changes. In addition to further characterization of the cognitive changes, it is important to evaluate their current functional abilities and any changes in their ability to perform daily tasks. Often patients will report different awareness of the deficits than caregivers or companions will report. A detailed history should include past medical, family, medication, and substance use history, and defining observed symptoms of cognitive decline. History must be obtained from the patient and their close friends, family members or caregivers. Patients may present with symptoms of changes in behavior, getting lost in familiar neighborhoods, memory loss, mood changes, aggression, social withdrawal, self-neglect, cognitive difficulty, personality changes, difficulty performing tasks, forgetfulness, difficulty in communication, loss of independence, etc. It often takes time to distinguish the etiology and can be aided by many factors including the results of imaging studies, lab studies, genetic markers, patient comorbidities, medical and family history, and clinical findings. The etiology is further characterized by "possibly" vs "probably" assigning the degree of certainty as to the cause of the major neurocognitive disorder. Other medical conditions that can lead to dementia include progressive supranuclear palsy, corticobasal syndrome, and less commonly multiple system atrophy. A patient may have more than one etiology contributing to MND, for example, there may be a mixed picture of alzheimer disease with vascular disease in the same patient. These subtypes include alzheimer disease, vascular disease, frontotemporal lobar degeneration, lewy body disease, parkinson disease, HIV infection, huntington disease, prion disease, substance and or medication use, traumatic brain injury, another medical condition, multiple etiologies, and unspecified. The DSM-V criteria for major neurocognitive disorder further delineate 13 etiological subtypes that indicate the possible etiology of the disorder. Several conditions can cause major neurocognitive disorder with alzheimer's dementia (AD) being the most common cause accounting for about 70% of cases. In 2010, the costs of treating dementia in the United States were projected to be about $200 billion per year in the United States and $600 billion worldwide. The individual lifetime cost to care for an individual with dementia was nearly $200,000 more than an individual without dementia. Dementia is a significant public health burden and significantly increases the costs of care, both to the individual and society. Alzheimer's disease is the 5th leading cause of death for people over the age of 65 in the United States. The prevalence of dementia is expected to continue to increase along with the increasing numbers of the aging population. Currently, 47 million people in the world have dementia, and the number is expected to increase to 131 million by 2050. Currently, no cure exists for any of the causes of dementia. It is often a progressive disorder, and individuals often do not have insight into their deficits. The everyday function of a patient is often evaluated in terms of the ability to perform IADL's (Instrumental Activities of Daily Living) such as managing finances or medications, or if more severe, ADL's (Activities of Daily Living) such as grooming or feeding oneself. In addition to the cognitive decline, there must also be a decline in the patient's ability to function and perform everyday tasks. The decline represents a change from a patient's prior level of cognitive ability, is persistent and progressive over time, and not associated exclusively with an episode of delirium. Major neurocognitive disorder is characterized by a significant decline in at least one of the domains of cognition which include executive function, complex attention, language, learning and memory, perceptual-motor, or social cognition. Major neurocognitive disorder can affect younger individuals and does not always imply Alzheimer's disease as the etiology of cognitive decline. It is worth noting the limitations of using the term dementia, including its common association exclusively with the elderly, and that it is often used synonymously with Alzheimer's disease. However, due to the common use of the term dementia in society and medical literature, it will be referred to as both Dementia and Major Neurocognitive Disorder in this article. It is actually no longer termed Dementia but is now called Major Neurocognitive Disorder (MND). The definition of dementia has been updated in the DSM-V criteria.
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