January 30, 2019

Screening for Dementia

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By Kevin Rowell, Ph.D.
Department of Psychology and Counseling, University of Central Arkansas

 

It seemed to Karen that her 78 year-old mother was having more trouble remembering people’s names, recalling the right words to use in a conversation, and driving with some confusion about which routes to take. Karen noted that her mother’s difficulties began occurring gradually over the past two years, and now she wondered if this is a part of normal aging or if it could be signs of Alzheimer’s disease. On two different occasions, Karen addressed her concern with her mother but was met both times with her mother’s refusal to discuss the matter.

Such a scenario is quite common in families, and with the Baby Boomer generation now in their 60’s and 70’s, it is becoming a reality to millions of Americans. When an elderly person begins to experience noticeable decline in memory, sense of direction, and other cognitive abilities, the concern is whether these are due to normal, age-related changes or due to a disease process like Alzheimer’s, the most common type of dementia. Receiving a diagnosis of dementia is certainly troubling and disconcerting, much like a cancer diagnosis, because some forms have no cure and are fatal within a few years of onset. As with most diseases, early detection leads to early intervention which even if not curable, can at least slow down the progression or assist in preserving cognitive function for a longer period of time.

While most of us are familiar with the terms Alzheimer’s disease and dementia, there is some confusion about their meaning. Dementia is a class of disorders that usually occurs after age 60 with abnormal decline in memory being the first symptom to be noticed. Other cognitive deficits include difficulty recalling names of people or objects, carrying out multiple step tasks, solving complex problems, and maintaining visual-spatial accuracy. Alzheimer’s disease is by far the most common type of dementia and represents approximately 60-70% of cases. Other common types include vascular dementia, dementia due to Parkinson’s disease, and Lewy Body dementia (American Psychiatric Association, 2013).

Determining whether or not an elderly family member has dementia usually involves some type of cognitive exam to measure the degree of function that is lost and may also include a brain scan such as a CT scan or MRI to evaluate the brain’s structural changes that have occurred. In both types of examination, the results from the current patient are compared to a large sample of people his or her age to determine if the changes are significantly below average, that is, if these changes are much greater than expected for the patient’s age group.

Cognitive examinations vary in terms of complexity and time: very brief scales have only a few items and take less than five minutes, intermediate tests require 30 minutes to an hour, and more comprehensive neuropsychological assessments involve several hours of testing. The kind of test administered depends upon the health care provider who is seen. Their choice of assessment will be based upon how much time they can allocate for the testing and the kind of assessment training that they have received.

Most people will make an initial appointment with their primary care provider (PCP) rather than with a psychiatrist, neurologist, or psychologist. PCP’s typically have very limited time to conduct an assessment, and they usually receive training on administering brief screening tests instead of more complex scales. If results of the screening test indicate a problem with memory or other kinds of cognitive functioning, the PCP may give a tentative dementia diagnosis but will typically refer the patient for more in-depth assessment by a psychiatrist, neurologist, or psychologist in order to confirm the diagnosis (Yokomizo, Simon, & de Campos Bottino, 2014).

Because of their common medical education and training, psychiatrists and neurologists often provide similar kinds of assessments. These tests usually require approximately 30 minutes to complete and involve several cognitive tasks such as memory, attention span, naming common objects, copying geometric figures, verbal ability, and orientation to time/date, place, and person. Each task is assigned a very limited number of points, usually ranging 0-3, and a total score is derived by summing all of the points. This total score is then compared to a normal range of scores expected for someone with the same age, and in some cases, with similar education. Psychiatrists and neurologists very often refer the patient for a CT scan or MRI which will help determine the specific type of dementia given that the cognitive testing indicates a significant level of impairment and warrants a diagnosis of dementia (Del Sole, Malaspina, & Biasina, 2016; Tsoi, Chan, Hirai, Wong, & Kwok, 2015).

Psychologists who specialize in geriatric assessment, typically receive the greatest amount of training in test administration. Whereas they often utilize the kinds of intermediate tests used by psychiatrists and neurologists, neuropsychologists may want to use more in-depth, more complex tests to precisely evaluate a person’s memory, attention span, and the other cognitive abilities measured in the intermediate tests. Similar to the other tests mentioned, the results are compared to a normative sample to determine the severity of impairment (Fields, Ferman, Boeve, & Smith, 2011).

If a family member begins to experience noticeable memory loss or problems in other kinds of cognitive tasks, it is advisable to seek a cognitive examination because it is critical to have this kind of information in determining whether or not the individual has dementia. These results can then be used to track changes in their cognitive abilities as they age which will be highly useful in determining the optimal type of intervention for them.

 

 

References.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Del Sole, A., Malaspina, S., & Biasina, A. (2016). Magnetic resonance imaging and positron emission tomography in the diagnosis of neurodegenerative dementias. Functional Neurology, 31, 205-215.

Fields, J. A., Ferman, T. J., Boeve, B. F., & Smith, G. E. (2011). Neuropsychological assessment of patients with dementing illness. Nature Reviews. Neurology, 7, 677-687. doi: 10.1038/nrneurol.2011.173.

Tsoi, K. F., Chan, J. C., Hirai, H. W., Wong, S. S. & Kwok, T. Y. (2015). Cognitive tests to detect dementia. A systematic review and meta-analysis. JAMA Internal Medicine, 175, 1450-1458. doi: 10.1001/jamainternmed.2015.2152.

Yokomizo, J. E., Simon, S. S., & de Campos Bottino, C. M. (2014). Cognitive screening for dementia in primary care: A systematic review. International Psychogeriatrics, 26, 1783-1804. doi: 10.1017/S1041610214001082.