Dementia: Update for the Practitioner

Any patient who comes to a clinician with memory complaints, with or without functional impairment, should be evaluated for cognitive problems and dementia. Anyone who has cognitive complaints and is depressed and anxious should also be evaluated.

The standard evaluation consists of getting a history from the patient and, ideally and importantly, from an informant. The tempo of decline in the history is important; if the illness has come on acutely over days to weeks, you should consider whether the cause is a metabolic problem, toxic problem, stroke, or infection. If illness has occurred subacutely, over weeks to months, you should think about causes such as normal-pressure hydrocephalus or a mass lesion as the cause of the illness.

A typical history includes an assessment of cognitive symptoms and noncognitive symptoms. In addition to memory loss, there can be disorientation, poor attention span, and language impairment. There must be a decline in the activity of daily living, and possibly also impaired perception and personality changes. Behavioral symptoms include delusions, aggression, agitation, anger, wandering, hallucinations, and sleep disturbance.


	Symptoms Indicating Cognitive Impairment or Alzheimer's Disease

	History

	Cognitive symptoms Memory loss Disorientation Decreased attention Language impairment Decreased attention Personality changes (apathy,withdrawal) Impaired ADLs Impaired perception	Noncognitive symptoms Suspiciousness, paranoia Delusions Anger, aggression Restlessness, agitation Wandering Sundowning Sleep disturbance Hallucinations, illusions

	A number of cognitive symptoms and noncognitive symptoms in a patient history may indicate Alzheimer's disease. Courtesy of Dr. Karen Bell

The neurological exam is generally normal in patients with dementia; cranial nerves, the motor exam, and the sensory exam should be intact. There may be some frontal release signs, such as snout, grasp, and glabellar on the examination. Rigidity or increased tone can be seen in up to 15 percent of those with mild to moderate Alzheimer's disease. Typically myoclonus is not part of Alzheimer's disease, but may be seen late in the disease progression.

The clinician's examination should include a structured mental-status examination. In the doctor's office, we typically use the Mini Mental State Exam (MMSE), a thirty-item test that looks at orientation, registration, calculations and attention, recall, language, and visual-spatial function.


	Mini Mental State Exam
		Orientation
	(5)	What is the year, season, date, month?
	(5)	Where are we: state, country, town or city, hospital, floor?
		Registration
	(3)	Repeat the following: apple, table, penny.
		Attention and Calculation
	(5)	Serial 7s: 93, 86, 79, 72, 65 or spell world backwards.
		Recall
	(3)	What were the three objects: apple, table, penny?
		Language
	(2)	Name a pencil and watch.
	(1)	Repeat the following: No ifs, ands, or buts
	(3)	Three-step command: Take this piece of paper in your right hand, fold it in half, and put it on the floor.
	(1)	Read and obey: Close your eyes.
	(1)	Write a sentence.
	(1)	Copy the design:
	(30)

	Mini Mental State Exam (MMSE) tests orientation, registration, calculations and attention, recall, language, and visual-spatial function. Courtesy of Dr. Karen Bell

Laboratory tests are also necessary. The American Academy of Neurology revised its practice parameters in 2001 using an evidence-based medicine approach and now recommends routine tests include blood count, serum B-12, thyroid screening, liver function tests, and basic electrolytes, glucose and renal function tests. Structural imaging by standard CT or MRI is generally recommended. Typically a non-contrast head CT scan suffices, but MRI is preferred for those who have hypertension or diabetes, who are at risk for cerebral vascular disease. Depression screening is also recommended.


	Alzheimer's Disease: Structural Changes in MRI


	Structural imaging by standard CT or MRI, as shown here, is generally recommended in evaluating for Alzheimer's disease. Courtesy of Dr. Karen Bell

Optional tests include Rapid Plasma Reagin (RPR) to test for syphilis, formerly a standard part of the clinical work-up. It is considered optional except for those living in a high-risk area, such as the South or the Midwest. Lumbar puncture was also once a standard part of the work-up but is now only indicated if there is suspected CNS infection, positive syphilis serology, recent history of cancer, possible vasculitis, or age below 55.

There are a number of tests that are not recommended and a number for which there is not enough evidence to recommend or not recommend. Tests that are not recommended include volumetric neuroimaging, functional imaging such as SPECT, and apo-E testing for Alzheimer's disease. There is not enough evidence to support or refute using genetic-marker tests or testing CSF biomarkers for Alzheimer's disease, in which you see decreased A-beta-42 levels and increased levels of the microtubule-associated protein Tau.

Certainly, many illnesses cause dementia other than Alzheimer's disease, and you will learn more about those shortly. The standard work-up will rule out thyroid disease, B-12 deficiency, paraneoplastic illnesses, and collagen-vascular diseases.


	Disease Progression

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