NRNP 6635 Week 10: Assessing and Diagnosing Patients With Neurocognitive and Neurodevelopmental Disorders

NRNP 6635 Week 10: Assessing and Diagnosing Patients With Neurocognitive and Neurodevelopmental Disorders

Neurodevelopmental disorders usually show up in childhood and make it hard to learn, pay attention, and get along with other people. They may last into adulthood. Conversely, neurocognitive diseases entail a deterioration from a previously achieved level of functioning and typically manifest later in life. This paper provides a thorough psychiatric assessment of Harold Brown, a 60-year-old adult facing attention-related challenges. The assessment will encompass subjective and objective findings, differential diagnoses, mental status evaluation, and a critical analysis of diagnostic reasoning.

Subjective:

CC (chief complaint): “I am having trouble focusing and making silly mistakes.”

HPI: Harold Brown is a 60-year-old Caucasian male with a bachelor’s degree in engineering, seeking psychiatric treatment owing to persistent challenges with attention and concentration, particularly in high-pressure job environments. He recounts committing substantial architectural blunders, including the improper placement of windows and the erroneous routing of air ducts. His difficulties escalate with more stringent deadlines, and he indicates a tendency to disengage during meetings and lectures. Attention difficulties have persisted throughout childhood, characterized by challenges in studying or concentrating, frequently diverted by outside stimuli. He additionally delineates disorganization, inadequate time management, difficulties in work completion, and a history of procrastination, especially with bill payments. The symptoms have continued and intensified in his high-stress work environment, hindering job performance and amplifying self-doubt.

Past Psychiatric History:

• General Statement: The patient has never had an official mental health diagnosis or treatment.
• Caregivers (if applicable): Not currently applicable.
• Hospitalizations: denies ever being admitted to a mental health facility.
• Medication trials: No prior use of psychotropic drugs.
• Psychotherapy or Previous Psychiatric Diagnosis: Never had a mental diagnosis or therapy before.

Substance Current Use and History: denies using illegal drugs. On weekends, he smokes a cigar and occasionally drinks one scotch—no history of withdrawal or abuse.

Family Psychiatric/Substance Use History: There was no documented family history of substance use issues or mental disease.

Psychosocial History: They were born and brought up with a younger sibling in the US. He has never been married, lives alone, and has no kids. He continues to work for a primary architecture business. Has an engineering bachelor’s degree. He describes himself as a casual dater and socially active person. Despite his enjoyment of his employment, he reports significant levels of stress at work because of the heightened expectations. Denies any legal problems. He claims to have a healthy appetite and to get enough sleep. Hobbies are not mentioned. No history of violence or trauma has been noted.

Medical History: The patient states that he has a history of benign prostatic hyperplasia, hypertension, angina, and hypertriglyceridemia.

• Current Medications: The patient is currently prescribed Cozaar 50 mg daily for hypertension, ASA 81 mg daily for cardiac health, Valsartan 160 mg daily for blood pressure, Fenofibrate 145 mg daily for lipid management, and Tamsulosin 0.4 mg nightly for benign prostatic hyperplasia. No over-the-counter medications or supplements.
• Allergies: Dilaudid induces nausea. No sensitivities to food or the environment.
• Reproductive Hx: Not applicable.

ROS:

• GENERAL: Reports a steady appetite and enough sleep. Denies experiencing chills, fever, exhaustion, or recent weight fluctuations.
• HEENT: denies dental problems, headaches, sore throats, nasal congestion, visual changes, and hearing loss.
• SKIN: Free of itching, bruises, sores, or rashes.
• CARDIOVASCULAR: Angina and hypertension history. Denies edema, palpitations, or chest pain.
• RESPIRATORY: rejects hemoptysis, coughing, wheezing, or shortness of breath.
• GASTROINTESTINAL: denies constipation, diarrhea, vomiting, nausea, or pain in the abdomen.
• GENITOURINARY: Benign prostatic hyperplasia in the past. Denies frequency, hematuria, or dysuria.
• NEUROLOGICAL: rejects tremors, weakness, numbness, disorientation, and convulsions.
• MUSCULOSKELETAL: denies muscle weakness, stiffness, edema, or joint pain.
• HEMATOLOGIC: Disavows anemia, bleeding tendencies, and bruises.
• LYMPHATICS: denies swelling or lymphadenopathy.
• ENDOCRINOLOGICAL: denies thyroid problems, polyuria, polydipsia, and heat/cold intolerance.

Objective:

• Vital Signs: Temperature: 98.8°F; Pulse: 74 bpm; Respiratory Rate: 18 breaths/min; Blood Pressure: 134/70 mmHg; Height: 5’10”; Weight: 170 lbs.; BMI: 24.4 (normal range).
• Physical Exam – General: The patient is attentive, oriented, and suitably groomed. The individual presents as their reported age and demonstrates cooperation during the assessment, exhibiting everyday speech and conduct.

Diagnostic Results: A MOCA score of 28/30 signifies mild challenges with attention and delayed memory. A score of 21/24 on the ASRS-5 strongly indicates ADHD, predominantly inattentive type—no anomalies observed throughout the comprehensive physical checkup.

Assessment:

Mental Status Examination: Mr. Harold Brown is a 60-year-old Caucasian individual who exhibits his stated age and appears in a cooperative and respectful demeanor. He is well-groomed, seasonally attired, and shows typical posture plus psychomotor activity. No atypical motions or tics were noted. His speech is articulate, coherent, and impromptu, exhibiting a typical tempo, rhythm, and volume. His mood is characterized as “adequate,” plus his affect is little constrained yet coherent with his mood. His cognitive processes are rational, sequential, and purpose-driven, exhibiting no signs of disorganized associations, rapid ideation, or thinking obstruction. The thought content exhibits no delusions, paranoia, obsessions, or preoccupations. He refutes any suicidal or homicidal thoughts, both past and current. No evidence of hallucinations, illusions, or perceptual abnormalities is present. He is awake and oriented to person and place, but slightly inaccurate regarding time, consistent with stated attentional difficulties. Cognitive assessment indicates mild short-term memory impairment and diminished focus. His insight, alongside judgment, is sound; he recognizes his challenges and seeks assistance, yet occasionally underestimates their significance.

Differential Diagnoses:

1. Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Presentation (ADHD-PI): Harold’s ASRS-5 score (21/24) signifies intense inattentive symptoms, encompassing distractibility, lack of memory, disorganization, and challenges in task completion—symptoms that have persisted from childhood. The DSM-5-TR mandates that symptom onset occurs before age 12, manifests in two or more contexts, and results in impairment of function, all of which Harold affirms (Sasaki et al., 2022). The persistent lifelong symptoms substantiate ADHD-PI as the principal diagnosis.
2. Mild Neurocognitive Disorder: Harold reports recent cognitive difficulties and slight memory lapses. The MOCA score of 28/30 indicates only minor abnormalities that do not substantially impede independence, aligning with DSM-5-TR criteria for Mild Neurocognitive Disorder (Swinnen et al., 2021). Nonetheless, the symptoms are chronic rather than progressing or newly manifested, rendering this diagnosis a lesser priority.
3. Generalized Anxiety Disorder (GAD): Occupational stress and pressure may lead to difficulties in concentration. Nonetheless, Harold does not exhibit excessive concern, sleep disturbances, irritability, or somatic complaints that fulfill the DSM-5-TR criteria for Generalized Anxiety Disorder (Landreville et al., 2021). The lack of widespread anxiety and emphasis on attentional symptoms excludes this diagnosis.

Reflections: Should I have the opportunity to do this session anew, I would investigate Harold’s academic and social history more thoroughly to elucidate early-onset symptoms and exclude other potential contributing variables, such as undiagnosed learning impairments or mood dysregulation (Wu et al., 2023). I would additionally get input from his employer (with consent) regarding functional impairment. It is essential to consider his age and professional consequences when diagnosing ADHD in adulthood, particularly for employment accommodations and non-discrimination safeguards under the ADA (Dobrosavljevic et al., 2023). From a health promotion perspective, it is essential to address lifestyle issues such as stress management, cardiovascular health, and sleep hygiene, considering his medical history (hypertension, angina, benign prostatic hyperplasia) (Levine et al., 2023). It is imperative to engage in educational discussions regarding stimulant versus non-stimulant therapy, given his cardiovascular risk. Harold’s reluctance to pursue previous mental health care may indicate generational or cultural stigma; psychoeducation can facilitate the normalization of treatment and bolster behavioral techniques.

Conclusion

Harold Brown’s presentation, persistent attentional difficulties, and elevated ASRS-5 score substantiate a diagnosis of ADHD, Predominantly Inattentive Presentation. Although a minor neurocognitive disorder was contemplated, the persistence and context of symptoms were more consistent with a neurodevelopmental issue rather than a degenerative one. Recognizing ADHD in adulthood facilitates specific interventions that can enhance occupational performance, minimize mistakes, and improve overall quality of life. Continuous education, therapy formulation, and monitoring are essential to meet his psychological and medical requirements.

References

Dobrosavljevic, M., Larsson, H., & Cortese, S. (2023). The diagnosis and treatment of attention-deficit hyperactivity disorder (ADHD) in older adults. Expert Review of Neurotherapeutics, 23(10), 883–893. https://doi.org/10.1080/14737175.2023.2250913

Landreville, P., Gosselin, P., Grenier, S., & Carmichael, P. (2021). Self-help guided by trained lay providers for generalized anxiety disorder in older adults: study protocol for a randomized controlled trial. BMC Geriatrics, 21(1). https://doi.org/10.1186/s12877-021-02221-x

Levine, S. Z., Rotstein, A., Kodesh, A., Sandin, S., Lee, B. K., Weinstein, G., Beeri, M. S., & Reichenberg, A. (2023). Adult Attention-Deficit/Hyperactivity Disorder and the risk of dementia. JAMA Network Open, 6(10), e2338088. https://doi.org/10.1001/jamanetworkopen.2023.38088

Sasaki, H., Jono, T., Fukuhara, R., Honda, K., Ishikawa, T., Boku, S., & Takebayashi, M. (2022). Late-manifestation of attention-deficit/hyperactivity disorder in older adults: an observational study. BMC Psychiatry, 22(1). https://doi.org/10.1186/s12888-022-03978-0

Swinnen, N., Vandenbulcke, M., De Bruin, E. D., Akkerman, R., Stubbs, B., Firth, J., & Vancampfort, D. (2021). The efficacy of exergaming in people with major neurocognitive disorder residing in long-term care facilities: a pilot randomized controlled trial. Alzheimer S Research & Therapy, 13(1). https://doi.org/10.1186/s13195-021-00806-7

Wu, Z., Wang, P., Liu, J., Liu, L., Cao, X., Sun, L., Yang, L., Cao, Q., Wang, Y., & Yang, B. (2023). The clinical, neuropsychological, and brain functional characteristics of the ADHD restrictive inattentive presentation. Frontiers in Psychiatry, 14. https://doi.org/10.3389/fpsyt.2023.1099882

CLICK HERE TO ORDER A PLAGIARISM-FREE PAPER