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Essentials of a Diagnostic Workup
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General diagnostic principles

Widely used guidelines for diagnosis of dementia emphasize decline that:

  • Occurred from a higher level of function

  • Is severe enough to interfere with usual activities and daily life

  • Affects more than one of the following four core cognitive domains:

    1. Recent memory - ability to learn and recall new information

    2. Language - either comprehension or expression

    3. Visuospatial ability - comprehension and effective manipulation of nonverbal, graphic or geographic information

    4. Executive function - ability to plan, perform abstract reasoning, solve problems, focus despite distractions and shift focus when appropriate

Evaluating a patient for dementia involves four key elements:

  1. A thorough medical and family history

  2. Mental status testing

  3. A physical and neurological exam

  4. Appropriate laboratory tests

Medical and family history

Obtain a complete medical and family history, including psychiatric history and history of cognitive and behavioral changes. Ideally, a family member or other close informant should also provide input. Although many individuals with early-stage dementia retain some awareness of their difficulties, insight tends to diminish as the disease progresses.

  • Ask the patient and informant:

    o "Do you feel as if you’re having any trouble with your memory or with getting confused or becoming lost?"

    o "When do you think the problem started?"

    o "Has it gotten worse since you first noticed it?"

    o "Is it getting worse quickly or slowly?"
  • Recent memory and instrumental activities of daily living (those requiring extensive interaction with the environment) are extremely sensitive to cognitive change. Ask your patient and informant about increased difficulty with:

    o Recalling recent events, conversations, appointments or family occasions

    o Repeating stories, questions or anecdotes

    o Using the telephone or other devices previously used comfortably (video recorder, computer, household appliances)

    o Playing a game of skill, functioning in employment or volunteer situations

    o Following the thread of a conversation or the plot of a book or movie

    o Making unsound judgments (buying inappropriate items, committing excessive funds to telemarketers, engaging in unwise financial transactions)

    o Traveling via accustomed mode of transportation (driving, public transit)

    o Shopping for food or clothing

    o Planning and preparing meals

    o Keeping or maintaining the house

    o Paying bills, balancing the checkbook

    o Managing medications
  • A medication history is vital. Ask the patient to bring in a drug list or containers of all current drugs. Review and be alert to drugs that can impair cognition, including some analgesics, psychotropics and sedative-hypnotics.

    Anticholinergics are also an issue because they target one of the chief neurotransmission systems affected by Alzheimer’s. Antihistamines, including over-the-counter allergy and cold preparations and sleeping aids, are among the most widely used anticholinergics. A list of anticholinergic medications is posted by the Geriatrics Department at Virginia Commonwealth University: http://www.virginiageriatrics.org/consult/medications/medsList.html
  • Inquire about drinking habits. Excessive use of alcohol can impair memory and judgment, and long-term abuse can lead to Wernicke-Korsakoff syndrome.

Mental status testing

Depending on the responses of the patient and informant to medical and family history questions, a brief cognitive screening tool may be sufficient to suggest a diagnosis of dementia. One such tool is the Mini-Cog, which includes a three-word recall and a clock drawing task.

If a more thorough evaluation is required, the Mini-Mental State Examination (MMSE) should be considered. It is the most widely used mental status test in U.S. clinical practice. Some clinicians like to supplement the MMSE with the clock drawing test, which measures certain functions not well assessed by the MMSE. Many experts also recommend screening for depression. The Geriatric Depression Scale Short Form [link to below] is a widely used screening tool.

The MMSE takes 5 to 10 minutes to administer, depending on the patient’s speed and level of function. It tests orientation, short-term memory, language, attention and praxis (performance of an action). The exam’s 11 tasks yield a total score from 0 to 30. The MMSE is copyrighted. A kit with tests and instructions is available for $130 at www.minimental.com.

Montreal Cognitive Assessment Test (MOCA): A recent alternative to the MMSE is the Montreal Cognitive Assessment Test, developed under the auspices of the Canadian Institutes for Health Research and others. MOCA is distributed free for clinical or educational use. The test and instructions are available in 17 languages at www.mocatest.org.

Ruling out depression: Geriatric depression is widespread, and older adults with depression often report problems with memory. Some studies have found that a subjective sense of memory loss may be more closely linked to depression than to dementia. Many experts recommend that a standard workup for cognitive problems include screening for depression.

One widely used screening tool is the Geriatric Depression Scale Short Form. Patients answer 15 "yes or no" questions. Bolded and underlined answers are linked to depression. A score of 5 suggests depression, while a score of 10 or more is highly suggestive of depression.


 Geriatric Depression Scale Short Form

   Question

 Answer

 1. Are you basically satisfied with your life?  Yes  No
 2. Have you dropped many of your activities and interests?  Yes  No
 3. Do you feel that your life is empty?  Yes  No
 4. Do you often get bored?  Yes  No
 5. Are you in good spirits most of the time?  Yes  No
 6. Are you afraid that something bad is going to happen to you?  Yes  No
 7. Do you feel happy most of the time?  Yes  No
 8. Do you often feel helpless?  Yes  No
 9. Do you prefer to stay at home, rather than going out and doing things?  Yes  No
 10. Do you feel as if you have more problems with memory than most people?  Yes  No
 11. Do you think it is wonderful to be alive now?  Yes  No
 12. Do you feel worthless the way you are now?  Yes  No
 13. Do you feel full of energy?  Yes  No
 14. Do you feel that your situation is hopeless?  Yes  No
 15. Do you think that most people are better off than you are?  Yes  No

Sheikh JI, Yesavage JA: Geriatric Depression Scale (GDS): Recent evidence and development of a shorter version. Clinical Gerontology : A Guide to Assessment and Intervention 165-173, NY: The Haworth Press, 1986  

Printable version of the form (may be produced without permission)

Physical and neurological exam

The physical and neurological exam should focus on ruling out medical illnesses other than dementia that can cause cognitive decline. It should also identify cardiovascular risk factors that are associated Alzheimer’s and other forms of dementia.

  • Check heart sounds, pulses and blood pressure, including postural values. Postural hypotension is common in neurological diseases.

  • Ask about general nutrition and alcohol use.

  • Inquire about headaches or seizures.

  • Perform focused neurological tests to identify indications of Parkinsonism or focal neurological signs that could be due to strokes.

    o Test cranial nerves, reflexes, motor system and coordination.

    o Observe strength and gait; some clinicians favor the "get up and go" test in which a patient is asked to rise from an armless chair and walk across the room.

    o A brief sensory exam may reveal deficits or uncorrected problems with vision or hearing that can contribute to impaired function.
  • Inquire about episodes of dizziness or severe confusion.

Laboratory tests

The American Academy of Neurology recommends specific laboratory assessments for the evaluation of dementia.

 View the Laboratory Evaluation of Dementia (1 page)


 

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