Diagnostic Process

Key Points

• Use of clinical tools will improve the precision, efficiency, and usefulness of the clinical evaluation, as well as provide a baseline for comparison because dementia progresses over time.

• Mini-Cog is an efficient and easily interpreted tool for initial cognitive assessment.

• Demonstration of ability to perform ADLs and IADLs will provide insight into the practical problems created by dementia and allow for focused anticipatory guidance relative to patient safety and risk for exploitation.

• Initial laboratory evaluation of the dementia patient includes CBC, urinalysis, chemistry panel, TSH, B12, and perhaps a syphilis serology.

• Structural imaging is appropriate, but functional imaging is still a research tool.

A casual conversation or even a medical interview is unlikely to uncover mild dementia. Patients often maintain social skills and unconsciously develop ego-protective techniques that hide cognitive deficits. Although this observation makes routine screening for cognitive dysfunction attractive, the U.S. Preventive Services Task Force, noting insufficient evidence, does not recommend routine screening for dementia (MCI) for any age group (USPSTF, 2003).

On the other hand, multiple guidelines strongly encourage a prompt and systematic response when family members report symptoms suggestive of cognitive decline. Use of screening tools in this context is appropriate. These tools assess cognitive and functional deficits as well as mood. Screening tools provide semiquantitative and reproducible assessments that add diagnostic certainty, document change over time, and facilitate efficient communication with other professional caregivers. The 30-item Mini-Mental State Examination (MMSE) has demonstrated utility in primary care and research settings, but is criticized as being too cumbersome for use in a busy office setting. The Mini-Cog, involving only three-word recall and clock drawing, is an attractive alternative because of its brevity, ease of scoring, and usefulness in ethnolinguistically diverse populations

Table 48-1 Comparison of Presenting Characteristics of Conditions with Altered Mental Status

Presentation

Delirium

Dementia

Depression

Psychoses*

Onset

Acute

Insidious

Insidious

Variable

Duration

Short to prolonged

Prolonged, progressive

Variable or recurrent

Chronic with exacerbations

Attention

Impaired, fluctuating

Normal except late stage

Normal or impaired

Normal or impaired

Consciousness

Impaired, fluctuating

Normal except late stage

Normal

Normal

Sensory perceptions

Impaired

Agnosia, misperception

Intact

Impaired

Thought content

Disorganized

Paucity of thought

Normal or ruminating

Normal or disorganized

Orientation

Impaired, fluctuating

Impaired, mostly stable

Intact

Intact

Delusional thinking

Disorganized if present

Secondary to memory loss or misperceptions

Self-depreciating if present

Systematized

Participation in exam

Distractable or unable

Tries but fails to perform

Lacks in effort

Variable

Hallucinations

Common, visual, suggestible

Uncommon, later stages, visual or global

Not in absence of psychotic features

Common, auditory (e.g., command hallucinations), visual

*DSM-IV-R Axis I psychotic mental illnesses.

(Borson et al., 2003). The Montreal Cognitive Assessment Test (MoCA) and the St. Louis University Mental Status Test (SLUMS) are more elaborate tools that seek to detect MCI and distinguish MCI from early dementia.

Examination and assessment of function can be accomplished by evaluating ADLs (bathing, dressing, toileting, transfers, continence, eating) and instrumental ADLs (using telephone, shopping, food preparation, housekeeping, laundry, transportation, taking medicine, money management). Functional assessment provides insight into the impact of cognitive impairment on everyday life. The Geriatric Depression Scale (GDS) offers uniform assessment for coexisting depression when MMSE score is 15 or greater. The Cornell Scale for Depression in Dementia, an observer-generated scale, provides a screen for depression in more severely impaired patients. These tests should become a familiar part of the initial evaluation and continuing care provided by the family physician.

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