Evaluation

The diagnosis of dementia is still made clinically, so evaluation of a patient with suspected dementia begins with a complete history and physical examination. The history should include questions regarding the time frame surrounding symptom progression. The relation to any recent vascular events such as stroke should be noted. Risk factors for vascular disease (hypertension, diabetes, hyperlipidemia, atrial fibrillation, smoking history) should be reviewed. Changes in the ability to perform ADLs should also be addressed. The patient's ability to perform dressing, eating, ambulating, toileting, and bathing tasks should be recorded as independent, requiring assistance, or dependent. The physical examination should include a thorough neurologic examination for signs of underlying vascular disease and stoke. Cognitive testing should be done, ideally with the Mini-Mental State Examination, which allows for quantification of cognitive impairment over time (Table 42-4). A score less than 24 is considered abnormal, but because of educational bias, highly educated patients may have inflated scores and those with limited education artificially low scores (Tombaugh, 1992).

When considering which tests to perform as part of the evaluation of a patient with dementia, physicians have traditionally been taught to search for reversible causes of dementia. It is now recognized that reversible dementia rarely occurs (Sloane, 1998). Current recommendations for laboratory testing generally recommend that all patients be evaluated with a CBC, thyroid-stimulating hormone (TSH), serum calcium, electrolytes, and fasting glucose, as well as a serum B12 level. Selective testing based on the presenting medical history, physical examination, and cognitive testing may include a red blood cell (RBC) folate level, RPR for syphilis screening, and HIV antibodies. Testing for

Table 42-4 Mini-Mental Status Examination

Max Score*

Task

5

Orientation: Year, season, date, day, and month.

5

Orientation: State, county, town, building, and floor (as applicable)

3

Registration: Name three objects. Record the number of trials required to learn.

5

Attention and calculation: Serial 7 subtraction: Subtract from 100 by 7 (stop after 5 answers) or Spell the word "world" backward (score number of correct letters in correct location).

3

Recall: Recall the three objects registered above.

2

Language: Name two objects (pencil and watch).

1

Repeat "No ifs, ands, or buts."

3

Follow a three-step command.

1

Read and obey: "Close your eyes" written in print large enough for patient to see clearly.

1

Write a sentence.

1

Copy a picture of intersecting pentagons.

Modified from Folstein MF, Folstein SE, McHugh PR. Mini-Mental State: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189.

*Total possible score: 30.

homocysteine levels and genetic testing for apolipoprotein E gene is not recommended (Feldman, 2008). Although neuroimaging is not recommended for all patients in the workup of dementia, selective use of CT or MRI is recommended for patients with suspected tumor, subdural hematoma, or normal-pressure hydrocephalus (NPH) (Feldman et al., 2008).

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