How the UK describes functional memory symptoms

Perspectives on the diagnosis and management of functional cognitive disorder: An international Delphi study

BACKGROUND

Current proposed criteria for functional cognitive disorder (FCD) have not been externally validated. We sought to analyse the current perspectives of cognitive specialists in the diagnosis and management of FCD in comparison with neurodegenerative conditions.

METHODS

International experts in cognitive disorders were invited to assess seven illustrative clinical vignettes containing history and bedside characteristics alone. Participants assigned a probable diagnosis and selected the appropriate investigation and treatment. Qualitative, quantitative and inter-rater agreement analyses were undertaken.

RESULTS

Eighteen diagnostic terminologies were assigned by 45 cognitive experts from 12 countries with a median of 13 years of experience, across the seven scenarios. Accurate discrimination between FCD and neurodegeneration was observed, independently of background and years of experience: 100% of the neurodegenerative vignettes were correctly classified and 75%-88% of the FCD diagnoses were attributed to non-neurodegenerative causes. There was <50% agreement in the terminology used for FCD, in comparison with 87%-92% agreement for neurodegenerative syndromes. Blood tests and neuropsychological evaluation were the leading diagnostic modalities for FCD. Diagnostic communication, psychotherapy and psychiatry referral were the main suggested management strategies in FCD.

CONCLUSIONS

Our study demonstrates the feasibility of distinguishing between FCD and neurodegeneration based on relevant patient characteristics and history details. These characteristics need further validation and operationalisation. Heterogeneous labelling and framing pose clinical and research challenges reflecting a lack of agreement in the field. Careful consideration of FCD diagnosis is advised, particularly in the presence of comorbidities. This study informs future research on diagnostic tools and evidence-based interventions.

Functional Cognitive Disorder: Diagnosis, Treatment, and Differentiation from Secondary Causes of Cognitive Difficulties

Functional cognitive disorder is an increasingly common cause of referral to the memory clinic. As a substantial source of disability, clinicians involved in the management of patients with cognitive complaints need to familiarize themselves with this important differential diagnosis. Our approach focuses on the identification of positive features of internal inconsistency (historical and clinical clues alongside patterns of performance) instead of an exclusionary approach. Although effective treatments are desperately needed, promising therapies include metacognitive retraining and cognitive-behavioral therapy modalities. Future research should focus on a better understanding of disease trajectories and outcomes as well as the development of evidence-based interventions.

Clinical signs in functional cognitive disorders: A systematic review and diagnostic meta-analysis

OBJECTIVE

Functional cognitive disorder (FCD) accounts for around a third of patients attending specialized memory clinics. It is also overrepresented in patients with other functional and somatic diagnoses. So far, no long-term diagnostic validity studies were conducted, and a positive diagnostic profile is yet to be identified. We aimed to review the literature on diagnostic signs and symptoms that allow for a discrimination between FCD and neurodegeneration.

METHODS

Systematic review of Ovid-Medline®, Embase and PsycINFO databases. Relevant clinical features were extracted including demographics, symptom history, comorbidities, language and interaction profiles and cognitive assessments. Studies with quantifiable diagnostic accuracy data were included in a diagnostic meta-analysis.

RESULTS

Thirty studies (N = 8602) were included. FCD patients were younger, more educated, and more likely to have a family history of older onset dementia, abrupt symptom onset, and higher rates of anxiety, depression and sleep disturbance. Promising language profiles include longer duration of spoken answer, elaborated examples of memory failures, ability to answer compound and personal questions, and demonstration of working memory during interaction. The pooled analysis of clinical accuracy of different signs revealed that attending alone and bringing a handwritten list of problems particularly increase the odds of a FCD diagnosis. Current evidence from neuropsychometric studies in FCD is scarce.

CONCLUSIONS

Our systematic review reinforces that positive signs contribute for an early differentiation between FCD and neurodegeneration in patients presenting with memory complaints. It is the first to attain quantitative value to clinical observations. These results will inform future diagnostic decision tools and intervention testing.

Feasibility randomised controlled trial of online group Acceptance and Commitment Therapy for Functional Cognitive Disorder (ACT4FCD)

INTRODUCTION

Functional cognitive disorder (FCD) is seen increasingly in clinics commissioned to assess cognitive disorders. Patients report frequent cognitive, especially memory, failures. The diagnosis can be made clinically, and unnecessary investigations avoided. While there is some evidence that psychological treatments can be helpful, they are not routinely available. Therefore, we have developed a brief psychological intervention using the principles of acceptance and commitment therapy (ACT) that can be delivered in groups and online. We are conducting a feasibility study to assess whether the intervention can be delivered within a randomised controlled trial. We aim to study the feasibility of recruitment, willingness to be randomised to intervention or control condition, adherence to the intervention, completion of outcome measures and acceptability of treatment.

METHODS AND ANALYSIS

We aim to recruit 48 participants randomised 50:50 to either the ACT intervention and treatment as usual (TAU), or TAU alone. ACT will be provided to participants in the treatment arm following completion of baseline outcome measures. Completion of these outcome measures will be repeated at 8, 16 and 26 weeks. The measures will assess several domains including psychological flexibility, subjective cognitive symptoms, mood and anxiety, health-related quality of life and functioning, healthcare utilisation, and satisfaction with care and participant-rated improvement. Fifteen participants will be selected for in-depth qualitative interviews about their experiences of living with FCD and of the ACT intervention.

ETHICS AND DISSEMINATION

The study received a favourable opinion from the South East Scotland Research Ethics Committee 02 on 30 September 2022 (REC reference: 22/SS/0059). HRA approval was received on 1 November 2022 (IRAS 313730). The results will be published in full in an open-access journal.

TRIAL REGISTRATION NUMBER

ISRCTN12939037.

Functional Cognitive Disorders (FCD): How Is Metacognition Involved?

Functional cognitive disorders (FCD) have become a subject of increasing clinical interest in recent years, in part because of their high prevalence amongst patients attending dedicated memory clinics. Empirical understanding of FCD based on observational studies is growing, suggesting a relationship to other functional neurological disorders (FND) based on shared phenomenology. However, understanding of FCD at the theoretical level has been lacking. One suggestion has been that FCD are disorders of metacognition, most usually of metamemory. In this article, a brief overview of these constructs is presented along with existing evidence for their impairment in FCD. Previous adaptations of theoretical models of FND to accommodate FCD are reviewed. A novel application to FCD of Nelson and Narens’ monitoring and control model of metamemory is then attempted, positing an improper setting of the monitoring function, with examples of ecological relevance. Formulation of FCD in light of a metacognitive model of anosognosia is also considered. Although lacking mechanistic and neuroanatomical sophistication, this metacognitive formulation of FCD may give pointers for future hypothesis-driven research and a pragmatic basis for management strategies.

Functional cognitive disorder: dementia's blind spot

An increasing proportion of cognitive difficulties are recognized to have a functional cause, the chief clinical indicator of which is internal inconsistency. When these symptoms are impairing or distressing, and not better explained by other disorders, this can be conceptualized as a cognitive variant of functional neurological disorder, termed functional cognitive disorder (FCD). FCD is likely very common in clinical practice but may be under-diagnosed. Clinicians in many settings make liberal use of the descriptive term mild cognitive impairment (MCI) for those with cognitive difficulties not impairing enough to qualify as dementia. However, MCI is an aetiology-neutral description, which therefore includes patients with a wide range of underlying causes. Consequently, a proportion of MCI cases are due to non-neurodegenerative processes, including FCD. Indeed, significant numbers of patients diagnosed with MCI do not 'convert' to dementia. The lack of diagnostic specificity for MCI 'non-progressors' is a weakness inherent in framing MCI primarily within a deterministic neurodegenerative pathway. It is recognized that depression, anxiety and behavioural changes can represent a prodrome to neurodegeneration; empirical data are required to explore whether the same might hold for subsets of individuals with FCD. Clinicians and researchers can improve study efficacy and patient outcomes by viewing MCI as a descriptive term with a wide differential diagnosis, including potentially reversible components such as FCD. We present a preliminary definition of functional neurological disorder-cognitive subtype, explain its position in relation to other cognitive diagnoses and emerging biomarkers, highlight clinical features that can lead to positive diagnosis (as opposed to a diagnosis of exclusion), and red flags that should prompt consideration of alternative diagnoses. In the research setting, positive identifiers of FCD will enhance our recognition of individuals who are not in a neurodegenerative prodrome, while greater use of this diagnosis in clinical practice will facilitate personalized interventions.

Functional cognitive disorders: update on diagnostic status

Many patients referred to cognitive disorders clinics are not found to have evidence of any neurological disorder(s) to account for their symptoms. Many demonstrate incongruence between their subjective cognitive symptoms and preserved social and occupational functions. The term ‘functional cognitive disorders’ (FCD) has been used to denote this diagnostic category. This article aims to review the current state of knowledge regarding FCD. Studies of FCD are in their infancy, but available evidence suggests positive diagnosis may be made based on typical clinical profiles, including language discourse and simple clinical signs. Concurrent mood disorder and sleep disturbance are common, as well as other functional disorders. Pathogenesis is yet to be determined, but a disorder of metamemory has been suggested.

Functional cognitive disorders: identification and management

We review the various functional cognitive disorders (FCDs) – complaints about memory function or another cognitive process in the absence of relevant neuropathology. These are increasingly coming to the attention of psychiatrists and neurologists and FCD encompasses some newly recognised conditions in addition to classic types such as pseudodementia and psychogenic amnesia. The clinical features, neuropsychological findings and treatment are presented and discussed.

LEARNING OBJECTIVES

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Functional cognitive disorders: demographic and clinical features contribute to a positive diagnosis

Aim: To examine features associated with functional cognitive disorders (FCDs) compared with neurological cognitive disorders (dementia, mild cognitive impairment, transient amnesias) in consecutive patients referred to a secondary care cognitive disorders clinic. Methods: Patients diagnosed with either neurological cognitive disorder or FCD were compared by demographic (age, gender, handedness, referral source) and clinical features (family history of dementia, clinical signs, Likert screening measure of subjective memory complaint, mini-Addenbrooke's Cognitive Examination). Results: Patients diagnosed with FCD were younger than those with neurological cognitive disorders, and more likely to attend alone, have a family history of dementia and be categorized as positive for subjective memory complaint. Conclusion: These data suggest features which may be helpful in making a positive diagnosis of FCD and differentiating from neurological cognitive disorders.

Identifying patterns of communication in patients attending memory clinics: a systematic review of observations and signs with potential diagnostic utility

BACKGROUND

Subjective cognitive complaints are commonly encountered in primary care and often result in memory clinic referral. However, meta-analyses have shown that such concerns do not consistently correspond to objective memory impairment or predict future dementia. Memory clinic referrals are increasing, with greater proportions of patients attending who do not have dementia. Studies of interaction during memory clinic assessments have identified conversational profiles that can differentiate between dementia and functional disorders of memory. To date, studies exploring communication patterns for the purpose of diagnosis have not been reviewed. Such profiles could reduce unnecessary investigations in patients without dementia.

AIM

To identify and collate signs and observable features of communication, which could clinically differentiate between dementia and functional disorders of memory.

DESIGN AND SETTING

This was a systematic review and synthesis of evidence from studies with heterogeneous methodologies.

METHOD

A qualitative, narrative description and typical memory clinic assessment were employed as a framework.

RESULTS

Sixteen studies met the criteria for selection. Two overarching themes emerged: 1) observable clues to incapacity and cognitive impairment during routine assessment and interaction, and 2) strategies and accounts for loss of abilities in people with dementia.

CONCLUSION

Whether the patient attends with a companion, how they participate, give autobiographical history, demonstrate working memory, and make qualitative observations during routine cognitive testing are all useful in building a diagnostic picture. Future studies should explore these phenomena in larger populations, over longer periods, include dementia subtypes, and develop robust definitions of functional memory disorders to facilitate comparison.