Neurocognitive Disorder Comprehensive Psychiatric Evaluation Example: Major NCD Due to Alzheimer’s Disease, Differentials and Reflection

Assignment: Assessing neurocognitive and neurodevelopmental disorders (Comprehensive Psychiatric Evaluation)

Neurodevelopmental disorders begin in the developmental period of childhood and may continue through adulthood. They may range from the very specific to a general or global impairment, and often co-occur (APA, 2022). They include specific learning and language disorders, attention deficit hyperactivity disorder (ADHD), autism spectrum disorders, and intellectual disabilities. Neurocognitive disorders, on the other hand, represent a decline in one or more areas of prior mental function that is significant enough to impact independent functioning. They may occur at any time in life and be caused by factors such as brain injury; diseases such as Alzheimer’s, Parkinson’s, or Huntington’s; infection; or stroke, among others.

For this Assignment, you will assess a patient in a case study who presents with a neurocognitive or neurodevelopmental disorder. Select a video case study, review the Case History Reports, consider what history to collect and what interview questions to ask, and identify at least three possible differential diagnoses. Complete the Comprehensive Psychiatric Evaluation template:

• Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
• Objective: What observations did you make during the psychiatric assessment?
• Assessment: Discuss the mental status examination results. Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest to lowest priority. Compare the DSM-5-TR diagnostic criteria for each and explain what criteria rule out each differential. Explain the critical-thinking process that led to your primary diagnosis. Include pertinent positives and negatives.
• Reflection notes: What would you do differently? Discuss legal/ethical considerations (beyond confidentiality and consent), health promotion and disease prevention considering patient factors (age, ethnic group, etc.), PMH and other risk factors (socioeconomic, cultural background, etc.).

Original example for study purposes.

Week 10: Assessing and Diagnosing Patients With Neurocognitive and Neurodevelopmental Disorders
Student Name • College of Nursing-PMHNP • NRNP 6635: Psychopathology and Diagnostic Reasoning • Faculty Name • Due Date

Subjective

CC: “My daughter says I keep forgetting things. I think I’m just getting older.” Daughter: “Mom got lost driving to church last month.”

HPI: L. G. is a 76-year-old African American woman, a retired elementary school teacher, referred by her primary care provider for evaluation of memory decline. She is accompanied by her daughter, who provides collateral history with the patient’s permission. The daughter reports a gradual, steadily worsening decline over about two years. Early changes included repeating questions and stories and misplacing items. Over the last eight months, the patient has missed several bill payments, received a utility shut-off notice, taken her blood pressure medication twice on some days and missed it on others and burned two pots on the stove. Last month, she became lost driving a familiar route and called her daughter from a gas station. She has stopped hosting family dinners because cooking “gets confusing.” The patient minimizes the problems, saying, “I’ve always been a little scatterbrained.” She remains independent in bathing, dressing, eating and toileting but now needs help with finances, medications, meal preparation and transportation. The daughter notes less interest in her church choir over the past year, which the patient attributes to “trouble keeping up with the new songs.” The patient denies persistent sadness and hopelessness, and sleep and appetite are stable. There is no history of sudden onset, stepwise decline, fluctuation in alertness, visual hallucinations, falls or recent illness. She denies suicidal and homicidal ideation.

Past psychiatric history:

• General statement: no prior psychiatric diagnosis.
• Caregivers: daughter, who lives 15 minutes away, visits daily.
• Hospitalizations: denies psychiatric hospitalizations.
• Medication trials: none.
• Psychotherapy or previous psychiatric diagnosis: grief counseling through her church after her husband’s death four years ago.

Substance current use and history: denies alcohol use for 20 years (previously social drinking); never smoked; denies illicit drugs; one cup of coffee daily.

Family psychiatric/substance use history: mother had “senility” in her 80s and lived with family until death; brother has depression; no known substance use disorders or suicides.

Psychosocial history: born in Alabama, moved to Ohio as a young adult; master’s degree in education; taught for 34 years; widowed four years; lives alone in her own home; two adult children; active Baptist church member. Medicare and a teacher pension; no reported financial hardship, although the daughter recently found a $600 payment to a telephone “prize” caller. No legal history. Strengths: strong faith community, involved daughter, high educational attainment.

Medical history: hypertension (15 years), type 2 diabetes (8 years, last A1c 7.4%), hyperlipidemia and bilateral hearing loss without hearing aids. No history of stroke, head injury or seizures.

• Current medications: lisinopril 20 mg daily, metformin 1,000 mg twice daily, atorvastatin 40 mg daily, over-the-counter diphenhydramine 25 mg at bedtime “for sleep” for one year.
• Allergies: no known drug allergies.
• Reproductive history: postmenopausal; two pregnancies, two live births.

ROS:

• General: no weight change, fever or fatigue.
• HEENT: decreased hearing bilaterally; wears glasses; no headaches.
• Skin: no rashes.
• Cardiovascular: no chest pain or palpitations.
• Respiratory: no shortness of breath.
• Gastrointestinal: no constipation or abdominal pain.
• Genitourinary: no dysuria; occasional urgency.
• Neurological: memory problems as above; no weakness, numbness, tremor or gait change.
• Musculoskeletal: mild knee arthritis.
• Hematologic and lymphatics: no easy bruising or swollen nodes.
• Endocrinologic: no heat or cold intolerance; no polyuria.

Objective

Vital signs: BP 148/86, HR 74, RR 16, temperature 98.2°F, BMI 29.

Physical exam: alert; normal gait; no focal neurological deficits; no tremor or rigidity; decreased hearing to whispered voice bilaterally.

Diagnostic results: Montreal Cognitive Assessment (MoCA) 17/30 (adjusted for education), with 0/5 on delayed recall that did not improve with cues, 4/6 on orientation (missed date and day) and errors on clock drawing and trail making (Nasreddine et al., 2005). PHQ-9 score of 5. Labs from PCP within the last month: CBC, CMP, TSH, vitamin B12 and folate within normal limits; RPR nonreactive; urinalysis negative. MRI of the brain: bilateral hippocampal and mild generalized atrophy, mild age-related white matter changes, no infarcts or masses.

Assessment

Mental status examination: 76-year-old woman who appears her stated age, well groomed and appropriately dressed. Pleasant and cooperative; frequently turns to her daughter to answer questions (head-turning sign). Speech normal in rate and volume, with occasional word-finding pauses. Mood “fine”; affect euthymic and mildly constricted. Thought process mostly linear, with some circumstantiality. Thought content without delusions, obsessions or suicidal or homicidal ideation. Denies auditory and visual hallucinations; not responding to internal stimuli. Alert and oriented to person and place but not to date. Immediate recall 3/3; delayed recall 0/3. Attention mildly reduced (unable to complete serial sevens beyond two steps). Insight poor, as she minimizes deficits; judgment impaired, as shown by unsafe driving and the scam payment.

Differential diagnoses:

1. Major neurocognitive disorder due to probable Alzheimer’s disease, mild, without behavioral disturbance (G30.9, F02.A0). Pertinent positives: significant decline from a previously high level of functioning reported by the patient’s daughter and confirmed by testing (DSM-5-TR Criterion A); impaired memory and learning plus executive function and visuospatial deficits; insidious onset with steady progression over two years; dependence on others for complex instrumental activities such as finances and medications (Criterion B); MRI showing hippocampal atrophy; family history of late-life dementia. Pertinent negatives: alert with no fluctuating attention (not delirium, Criterion C); no stepwise decline or infarcts; no parkinsonism, hallucinations or REM sleep behavior; no major depressive episode (Criterion D). DSM-5-TR criteria for probable Alzheimer’s disease are met because there is clear decline in memory and at least one other domain, steadily progressive decline without extended plateaus and no evidence of mixed etiology (American Psychiatric Association [APA], 2022). Mild severity is specified because she has difficulty with instrumental activities but remains independent in basic ADLs.
2. Major vascular neurocognitive disorder. Supporting evidence: hypertension, diabetes, hyperlipidemia and mild white matter changes are vascular risk factors. Ruled out (lower priority): DSM-5-TR requires clinical features consistent with a vascular etiology, such as onset temporally related to cerebrovascular events or prominent decline in complex attention and frontal-executive function, along with evidence of cerebrovascular disease considered sufficient to account for the deficits (APA, 2022). L. G. has no history of stroke, her decline is gradual rather than stepwise, memory impairment is the most prominent deficit and the MRI shows no infarcts. Vascular disease may contribute, and repeat imaging would be reconsidered if new focal signs appeared.
3. Major depressive disorder with cognitive symptoms (sometimes called “pseudodementia”). Supporting evidence: reduced interest in choir, history of bereavement and a brother with depression. Ruled out: she does not meet Criterion A for a major depressive episode because she denies depressed mood, and anhedonia is limited; sleep, appetite and energy are unchanged; PHQ-9 is 5 (minimal); and depressed patients often say “I don’t know” and complain of memory loss, whereas she minimizes deficits and fails delayed recall even with cues, a pattern typical of Alzheimer’s disease. Withdrawal from choir is better explained by cognitive difficulty.
4. Delirium (considered and ruled out). Diphenhydramine, an anticholinergic medication, can worsen cognition in older adults, and urinary urgency raised the question of infection. However, the course is two years rather than hours to days, attention and alertness do not fluctuate and the urinalysis is negative, so Criteria A and B for delirium are not met.

Critical-thinking process: I first ruled out acute and reversible causes, including delirium, medication effects, vitamin B12 deficiency, hypothyroidism, syphilis and depression, because these require different and urgent treatment. I then used functional history from a reliable informant to distinguish major from mild NCD; the need for help with finances and medications indicates major NCD. Finally, I determined the most likely etiology by comparing the pattern and course: amnestic deficits with an insidious, steady progression and hippocampal atrophy point to Alzheimer’s disease rather than vascular, Lewy body or frontotemporal causes. Hearing loss and anticholinergic use may worsen her performance and should be addressed, and testing should be repeated after the diphenhydramine is stopped.

Reflection notes

What I would do differently: I would interview the daughter separately as well as together, because the patient may minimize deficits and the daughter may hesitate to describe them in front of her mother. I would make sure the patient had hearing amplification during testing, because uncorrected hearing loss can lower MoCA scores, and I would use a functional scale such as the Functional Activities Questionnaire to document IADLs objectively. I would also screen for caregiver strain.

Legal and ethical considerations: Beyond confidentiality and consent, this case raises several issues. Decision-making capacity must be assessed for specific decisions, such as managing money or agreeing to treatment, rather than assumed to be absent because of the diagnosis. Advance care planning is time sensitive; while she still has capacity, she should be encouraged to complete a durable power of attorney for finances and health care and to state her wishes. Driving safety is an ethical tension between autonomy and public safety; getting lost on a familiar route warrants a formal driving evaluation, and providers should know their state’s reporting rules. The $600 scam payment raises concern for financial exploitation, and most states require or permit reporting suspected elder abuse to Adult Protective Services. Truth-telling about the diagnosis respects her autonomy. Finally, if she asks about anti-amyloid therapies, informed consent must include eligibility testing, infusion and MRI monitoring demands and the risk of amyloid-related imaging abnormalities.

Health promotion and disease prevention: About 7.4 million Americans aged 65 and older live with Alzheimer’s disease, and older Black Americans are about twice as likely as older White Americans to have Alzheimer’s or other dementias (Alzheimer’s Association, 2026). Disparities in vascular risk factors, education quality, income and access to care contribute to this gap. The Lancet Commission estimates that nearly half of dementia cases may be linked to 14 modifiable risk factors, including hypertension, diabetes, high LDL cholesterol, hearing loss, physical inactivity, social isolation and depression (Livingston et al., 2024). For L. G., priorities are controlling blood pressure, glucose and cholesterol; obtaining hearing aids; stopping diphenhydramine and using sleep hygiene; regular physical activity such as a church walking group; staying socially engaged in choir with support; fall prevention; and vaccinations. Although the U.S. Preventive Services Task Force (2020) found insufficient evidence to recommend routine cognitive screening of asymptomatic older adults, evaluation is appropriate when patients or families notice decline, as in this case. Her daughter should be connected with caregiver education, the Alzheimer’s Association helpline and respite resources, and culturally responsive care should include her faith community as a source of support.

References

Alzheimer’s Association. (2026). 2026 Alzheimer’s disease facts and figures. https://www.alz.org/alzheimers-dementia/facts-figures

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

Livingston, G., Huntley, J., Liu, K. Y., Costafreda, S. G., Selbæk, G., Alladi, S., Ames, D., Banerjee, S., Burns, A., Brayne, C., Fox, N. C., Ferri, C. P., Gitlin, L. N., Howard, R., Kales, H. C., Kivimäki, M., Larson, E. B., Nakasujja, N., Rockwood, K., . . . Mukadam, N. (2024). Dementia prevention, intervention, and care: 2024 report of the Lancet standing Commission. The Lancet, 404(10452), 572–628. https://doi.org/10.1016/S0140-6736(24)01296-0

Nasreddine, Z. S., Phillips, N. A., Bédirian, V., Charbonneau, S., Whitehead, V., Collin, I., Cummings, J. L., & Chertkow, H. (2005). The Montreal Cognitive Assessment, MoCA: A brief screening tool for mild cognitive impairment. Journal of the American Geriatrics Society, 53(4), 695–699. https://doi.org/10.1111/j.1532-5415.2005.53221.x

U.S. Preventive Services Task Force. (2020). Screening for cognitive impairment in older adults: US Preventive Services Task Force recommendation statement. JAMA, 323(8), 757–763. https://doi.org/10.1001/jama.2020.0435

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