A Commentary on the Proposed DSM Revision Regarding the Classification of Cognitive Disorders Peter V. Rabins, M.D., M.P.H., and Constantine G. Lyketsos, M.D., M.H.S. T he proposed changes to the fourth edition of the Diagnostic and Statistical Manual of Mental Dis- orders (DSM-4) category, currently labeled dementia, delirium, amnestic, and other cognitive disorders, at- tempts to address issues of phenomenology, sever- ity, comorbidity, and etiology while also producing a scheme that is usable for researchers, clinicians, teachers, and administrators. In this commentary we respond to the recent draft revision of the fourth edi- tion of the DSM-4 developed by the American Psychi- atric Association. Our intent is to provide construc- tive recommendations to be considered in the next it- eration as we move toward the DSM-5. The major guiding principle that we apply is that changes in the classification scheme should incorpo- rate advances in knowledge and represent the con- ditions and patients that it is intended to differenti- ate. Cognitive disorders affect one or more cognitive faculties (e.g., memory alone, language alone, several combinations), present in mild or severe form (such as day-to-day functioning is unaffected, minimally affected, or clearly affected), and are associated with a range of other psychiatric symptoms (such as de- pression, delusions, agitation). To further complicate matters, impaired cognition can be a consequence of a wide range of injuries and situations including genetic abnormalities, toxins, metabolic deranger- ments, neurodegenerative disorders (e.g., Alzheimer disease), stroke, traumatic brain injury, or primary Received May 14, 2010; accepted May 31, 2010. From the Division of Geriatric Psychiatry and Neuropsychiatry, Johns Hopkins Medicine, PVR and CGL contributed equally to his article. Send correspondence and reprint requests to Constantine Lyketsos, M.D., M.H.S., 5300 Alpha Commons Drive, Baltimore, MD 21209. e-mail: kostas@jhmi.edu c  2011 American Association for Geriatric Psychiatry DOI: 10.1097/JGP.0b013e3182051ac7 psychiatric conditions such as schizophrenia, bipo- lar disorder, and major depression (especially late life depression). The DSM-5 task force has attempted to address several of these elements in the draft proposal and they represent clear advances. First, by eliminating the requirement that memory disturbance be present in every case of dementia and by reducing emphasis on certain “cortical” abnormalities such as aphasia, apraxia, and agnosia, the definition of dementia has moved away from being Alzheimer-centric. A sec- ond advance is the addition of the requirement that cognitive decline be confirmed by objective patient assessment, as opposed to only by history, whether using standardized bedside assessment (such as the mini mental state examination and related measures) or more formal neuropsychologic assessment. A third advance is the addition and description of specific cognitive domains in which impairments are com- mon. This major improvement has the potential to help clinicians recognize specific cognitive impair- ments and to guide deficit-focused education and intervention. It also refocuses attention onto the day-to-day impairments that result from deficits in individual cognitive domains, and on identifying cognitive capacities that are relatively spared. A fourth advance is the addition of a specific cate- gory to classify the milder cognitive disorders, cur- rently referred to as “mild cognitive impairment” or Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Am J Geriatr Psychiatry 19:3, March 2011 201