With many women in perimenopause experiencing a subjective sense of change in cognitive function, understanding normal cognitive function in perimenopause is important for clinicians in day-to-day practice. This chapter aims to equip mental health professionals with the knowledge and confidence to appropriately explore cognitive concerns arising during the perimenopause. The chapter outlines normal cognitive function in perimenopause, exploring symptoms and how they may present, as well as aiming to identify who may be at greater risk from cognitive change. It then offers suggestions on how to support women to reduce symptoms of cognitive dysfunction as far as is practicable. The chapter later explores the role of hormone replacement therapy (HRT) on both cognition in perimenopause and beyond into postmenopause, as well as considering the impact HRT has on the brain and risk of dementia in later life. With up to 45% of dementia now felt to be preventable, the chapter discusses the role of the healthcare professional in identifying risks presenting around the time of perimenopause, allowing clinicians to then offer intervention and promote good brain health in mid-life leading into later-life.

Schizophrenia is a highly heterogenous disorder with substantial interindividual variationin how the illness is experienced and how it presents clinically. The disorder is composed of primary symptom clusters—positive symptoms, negative symptoms, disorganization, neurocognitive deficits, and social cognitive impairments. These, along with duration, severity, and excluding other possible etiologies, comprise the diagnostic criteria for the disorder outlined in the two commonly used diagnostic classification systems—the Diagnostic Statistical Manual of Mental Disorders, Fifth Edition, Text Revision and the International Classification of Diseases, 11th Revision. These primary symptoms as well as accessory symptoms (mood disturbances, anxiety, violence) and comorbidities (substance use, suicidality) bear upon each other to varying degrees and impact functionaloutcomes. The following review presents two patient cases illustrating the clinical heterogeneity of schizophrenia, the natural history of the illness and diagnosis, followed by the current understanding of the primary symptom clusters, accessory symptoms, and comorbidities. In addition to noting symptom prevalence, onset, and change over time, attention is paid to the impact of symptoms on functional outcome.

What is the next step in treating a primary psychotic illness with aggression when high-dose/high-level clozapine treatment only provides a partial response?

Cognitive impairment in the ICU can have long-term, life-altering impacts well beyond the ICU and hospital stay. Cognitive impairment can be hard to identify in the complex medical setting of the ICU, but the systematic use of standardized screens and assessments can alert the write as healthcare team to cognitive impairment. Patients with disorders of consciousness benefit from cognitive stimulation interventions. For patients awake and alert, cognitive intervention strategies include cognitive training (e.g., word search, memory match) and cognitive rehabilitation (e.g., ADL and IADL performance). Early engagement in activity in the ICU can help improve overall performance. One component of rehabilitation is functional cognition, defined as the process of utilizing and integrating thinking and processing skills to accomplish everyday activities. Assistive technology is another tool that can help patients with tasks from communication to complex problem solving and executive functioning. Cognitive stimulation, training, and rehabilitation all work toward decreasing the impact of cognitive impairments and improving overall function and quality of life. Examining patients’ performance through real-life functional tasks help to generalize these skills.

Survivors of critical illness are at increased risk for the development of functional impairments, including difficulties performing activities of daily living and instrumental activities of daily living. This chapter explores the role of occupational therapy (OT) in the rehabilitation of patients impacted by post intensive care syndrome (PICS). Specific evaluation tools used by occupational therapists that can be assess PICS patients to identify their impairments in the key areas of physical, cognitive, and mental health are described. Thereafter, interventions used by occupational therapists to remediate identified impairments and maximize independence are described, derived from a combination of evidence-informed practice in similar patient populations and current empirical evidence for PICS rehabilitation.

Delirium, which is an important risk factor for post-intensive care syndrome (PICS), is common during critical illness, affecting between 20% and 80% of patients. It is associated with numerous adverse outcomes, including longer time on mechanical ventilation, longer time in the intensive care unit (ICU) and hospital, death, and long-term cognitive impairment. Delirium in the ICU can be reliably detected using multiple tools, including the Confusion Assessment Method in the ICU (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC). The exact cause of delirium, however, remains elusive even though there are many purported mechanisms, including neuroinflammation, metabolic insufficiency, neuronal dysfunction, and neurotransmitter disturbances. Due to knowledge gaps regarding the mechanism(s) of delirium, effective medical treatments for delirium also remains elusive. Current practice involves the prevention of delirium through the recognition and management of modifiable risk factors. The well-studied ABCDEF bundle is one such strategy, which is primarily non-pharmacologic, to prevent or mitigate delirium and thus limit its adverse outcomes. Unfortunately, delirium still occurs at a high rate, and the work to understand the underlying mechanism and its varied manifestations and to develop an effective treatment continues.

More than five million individuals in North America experience an episode of critical illness annually, and among those who survive, as many as a third experience substantial cognitive impairment, which often lasts long after discharge and can be permanent. While cognitive impairment after critical illness has been widely studied for two decades, much remains unknown, and the insights that have been generated by research often fail to inform clinical care. Key issues germane to understanding and optimally treating ICU survivors with cognitive deficits include: improving methods of early detection and screening, honing and implementing cognitive rehabilitation strategies, and better understanding the trajectories of impairments observed in patients. Prioritizing the brain health of individuals after critical care both through prevention and thoughtful interventional efforts remains a key public health goal and one that can only be accomplished through careful and deliberate interdisciplinary efforts.

Music is associated with reduced pain, anxiety, and sedative requirements in ICU patients. Slow-tempo music (60 to 80 beats per minute) in particular has been associated with a neuromodulatory effect. The minimum duration of music listening associated with decreased pain may be as brief as 20 to 30 minutes, resulting in a nearly 2-point decrease in self-reported pain scores (on a 0-10 scale). Longer duration of music listening (i.e., more than 45 minutes) is associated with improved sleep quality and less depressive symptoms after critical illness. Through its interaction with various cortical areas, music may also offer beneficial effects on cognition. Neurocognitive processing of music invokes brain centers related to emotion, perception, cognition, and the autonomic nervous system. In EEG and functional MRI studies, music increased communication between the functional neural networks typically disrupted in delirium and dementia. Whether music listening in ICU patients with delirium can improve long-term cognitive function is not clearly understood but is being evaluated in randomized controlled trials. Ongoing clinical and scientific work will lay the groundwork to identify the neuroprotective mechanisms by which music may reduce the risk of ICU delirium and long-term cognitive impairments.

Lewy body disease (LBD) can present as a dementia-predominant syndrome with parkinsonism (dementia with Lewy bodies or DLB), a motor-predominant syndrome with subsequent dementia ( Parkinson’s disease with dementia or PDD), or an autonomic-predominant syndrome (multiple system atrophy or MSA); this chapter focuses on treatment/management of the many complex manifestations of DLB. Education and support are important in managing DLB. Currently, there is no therapy that significantly alters the underlying pathophysiology of DLB. This chapter covers the management of cognitive impairment, neuropsychiatric features, motor dysfunction, sleep disorders, and autonomic dysfunction. Acetylcholinesterase inhibitors (AChEI) can improve cognition. Memantine may provide modest benefit. Medications such as clozapine or quetiapine can help manage visual hallucinations and delusions. Carbidopa/levodopa and dopamine agonists can improve motor symptoms, but caution is needed. Clonazepam, melatonin, and psychostimulants can address sleep issues. Orthostatic hypotension can be managed with lifestyle changes and medications.

Normal pressure hydrocephalus (NPH) is divided into idiopathic (iNPH) and secondary causes such as tumors, infections, trauma, or intracranial hemorrhage. More people are now overweight, and BMI correlates with CSF pressure so many patients have higher CSF pressure making the “normal” in NPH a partial misnomer. The dominant symptom is gait impairment often accompanied by cognitive and urinary difficulty. NPH requiring treatment is relatively rare but potentially underdiagnosed. A clinical approach to NPH should start with a differential diagnosis of the gait difficulty, as in early stages, patients may not have the full symptom triad. Those with anomia may have Alzheimer’s dementia or primary progressive aphasia, and there can be additional patients with concomitant NPH and other disorders such as Alzheimer’s, Parkinson’s, and cervical myelopathy that may require treatment of both pathologies. The most useful diagnostic tests in the workup of NPH include magnetic resonance imaging (MRI) of the brain and a CSF drainage trial, with either high volume lumbar puncture or lumbar drain trial, with the videotaping of the gait before and after the CSF removal. The primary treatment remains a CSF diversion procedure with placement of a shunt, and several shunt surgical advances have resulted in less mortality and morbidity.

This chapter discusses the diagnostic evaluation, physical examination, initial diagnostic formulation, investigations, and management of individuals with cognitive and/or behavioral changes. It emphasizes the importance of obtaining a comprehensive history from the patient and an informant, as well as conducting a thorough physical examination. The chapter also provides sample questions for assessing different cognitive domains and lists clues that suggest a non-Alzheimer’s disease etiology of cognitive/behavioral changes. It suggests various diagnostic studies and consultations that may be necessary for each patient. The document highlights the principles of management, including treating reversible causes, minimizing psychoactive medications, promoting regular sleep and exercise, and providing caregiver support. It also discusses the availability of pharmacologic therapies and the importance of providing information and support to families facing dementia-related issues.