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Screening for Dementia: Cerebral Dysfunctioning in the Elderly

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Mom is 83 and has Alzheimer's. It was really sad to watch a highly intelligent person slowly lose her memory, and revert to a child-like personality. When Mom first started forgetting things, she developed a knack of hiding the problem-she would change the subject of a discussion to something she could remember. She managed to hide her problem from her physician for a long time; when I tried to tell him what was happening to her, he thought I was exaggerating... Little by little, she forgot more things, until she could no longer even remember how to dress herself. As her mind got worse I started trying to get her to move in with me... She treasured her independence, though, and refused to budge!... One morning, when I called to remind her to take her pills, there was no answer. I rushed over to her house, where I found her lying on the floor! She had no idea what she was doing on there, or how long she had been there. I called an ambulance, and after a week in the hospital and three in a nursing home, I brought Mom home with me. That was the end of her independence - it just wasn't safe for her to live alone anymore... Mom is in a hospital bed. She "forgot" how to walk one day about a year and a half ago. I used to be able to at least get her in a wheelchair and take her for walks around the block, but she developed fluid on her brain, and gets so dizzy when she is upright that she is afraid to sit up now. - Sharon Muldoon

Introduction

Four to five million Americans are diagnosed with some cognitive deficit. Normal, non-progressive, and negligible declines among the aged do not dramatically impact daily functioning. More serious cognitive disorders are common, most being chronic, progressive and irreversible, wreaking devastation on victims and caregivers.

As the population ages, the frequency of dementias is increasing. Not all cognitive disorders are irreversible, but many require timely identification and intercession to offset permanent dysfunction. Dementia is socially costly due to the high cost of patient care, morbidity and mortality, and stress placed on caretakers and the community. Mental status evaluations are also needed to establish legal competence in composing wills, bestowing informed medical consent, or managing independently. Consequently, recognizing cognitive deterioration is clinically, medically, and legally essential for victims and their families.

Dementia and Delirium: Terminology and Discrimination

Primarily a disease of the elderly, dementia is a generic term most often applied to geropsychological problems, applying broadly to usually progressive, persistent losses of cognitive and intellectual functions, such as memory, language, visuospatial skills, emotion, and personality without impairment of perception or consciousness.

Dementia is often confused with delirium, or (formerly) Acute Confusional State. Delirium presents with (a) rapid onset, (b) a fluctuating course, (c) potential reversibility, (d) a negative impact on attention, and (e) focal cognitive deficits. In contrast, dementia (a) progresses slowly, (b) is irreversible, (c) causes profound memory deficits, and (d) global cognitive deficits.

Distinguishing between delirium and dementia is challenging as medical examinations are usually based on history and physical examination. Laboratory testing cannot reliably establish the etiology of many cognitive failures. Knowledge of baseline functioning, then, becomes indispensable when determining the extent of cognitive change and its rate.

The Etiologies and Statistics of Dementia

Dementia accounts for over 2.5 million cases, with one-half million more added each year. These statistics are dramatic and have staggering demographic and economic implications.

Dementias are caused by such factors as intoxication, long-term alcohol effects, endocrine disorders, metabolic disturbances, nutritional deficiencies, medication effects, cardiovascular disorders, neoplasms, seizure disorders, immunological disorders, degenerative diseases, and brain trauma.

Significantly affecting intellectual functioning in 5-10% of individuals over 65 years and 20% of those over 80, the above etiologies also indicate that dementia occurs among those under 65. Of all senile dementias, 50-60% are of the Alzheimer's type, 10-20% are vascular, and 20-30% blend both disorders. Another form strikes younger persons diagnosed with presenile dementia.

To the layperson, Alzheimer's disease (AD) has become virtually synonymous with dementia. It is, however, only one type. Unremittingly progressive, AD leads to death within 5 to 15 years from time of onset. Histological autopsies of AD victims demonstrate neurofibrillary tangles (twisted neural fibers) and neuritic plaques (masses of abnormal protein) interspersed amongst nerve cells. No known cure presently exists. Murray Rosenthal, M.D., Director of Behavioral & Medical Research, observes "Alzheimer's Disease is currently a diagnosis of exclusion. This means that other dementias and reversible causes of dementia have been ruled out... Most important is to not assume that a cognitive decline is hopeless and untreatable until it has been properly medically evaluated (Personal communication, 6/8/2000)."

Dementia Screening

Elderly patients are typically screened for various physical illnesses, but busy primary care practitioners (PCP) often fail to recognize signs of dementia, particularly as many patients conceal symptoms. Although there is insufficient evidence at this time to recommend routine screening for dementia among the asymptomatic elderly, changes in ordinary capability and attitude among the elderly are among the best warning signals that screening should be performed. These include (a) increased difficulty carrying out ordinary daily activities, (b) poor or declining cognitive skills, (c) deterioration in hygiene, (d) inability to fulfill normal responsibilities (e.g., unopened mail, paying bills), (e) health changes (e.g., weight loss, incontinence, appetite changes, bruises suggesting a fall), (f) increased isolation, (g) loss of ordinary interest in social contacts, activities or hobbies, (h) attitude changes including abuse of alcohol or drugs, reporting depression, unusual argumentativeness or suspiciousness (HealthAtoZ.com).

Clinical signs helpful in recognizing the need for dementia screening are departures from the patent's normal functioning as:

  • Difficulty learning and retaining new information.
  • Difficulty handling complex, sequential tasks.
  • Weakness in reasoning ability.
  • Weaknesses in spatial and temporal orientation.
  • Language and communication difficulties.
  • Behavior: patient appears more bland, passive, irritable, suspicious, or humorless.

Psychologists should periodically ask patients over 60 years (or relatives, if permitted) about their functional status at home and work, and should remain alert to changes in performance with age. Confounding the screening process, patients with major depression may also present with symptoms of cognitive impairment, as pseudodementia or reversible dementia. These differ from true dementia in the rapidity of onset and exaggeration of symptoms in contrast to minimalization often found in dementia.

Initial Psychological Assessment for Possible Dementia

With patient permission, obtain information from reliable collateral informants, including relevant medical, family, social, cultural, and medication history (and drug and alcohol use) as well as a detailed description of the chief complaint. Consider possible secondary gain in patients' or collaterals' reports, as this may suggest the patient's need for attention or sympathy, or if there is family discord, the relatives' wish to remove the parent from the household or gain control of their assets.

Interview information should be obtained in which delirium, dementia, and depression (or other comorbid conditions) are examined and a full mental status examination given, with emphasis upon the following:

  • Aphasia: Is it difficult for the patient to find the right word to express him or herself (anomic aphasia), substituting incorrect words (paraphasia), breaking off in midsentence or losing his or her train of thought, comprehension problems (sensory aphasia), and stuttering or repeating words?
  • Apraxia: Is there impairment in performing skilled or purposeful movements, as with personal grooming and feeding skills?
  • Agnosia: Is there impaired ability to recognize, or comprehend the meaning of, or recognize, familiar people, places, objects, or personal items?
  • Executive Dysfunction: Is there a reduced ability to shift mental sets, to produce unique verbal or nonverbal information, and execute serial motor activities? Determine (from the individual and informants) the impact of the disturbances on the individual's daily life.

Screening tests (e.g., the Mini-mental Status Examination (MMSE) or Clinical Dementia Rating (CDR) Scale) are useful but, typically, do not measure mood or thought disorders and do not substitute for a complete mental status examination. Significant declines in daily functional abilities may not show up on psychometric instruments because tests are not sensitive enough. Although their mental skills are intact, some patients do poorly on tests due to anxiety, depression, fatigue, medication effects, or lack of comprehension of instructions. At this time, no single mental test is clearly superior in screening for dementia. Visual and sensory impairment and physical disability should be considered in selecting tests. Age, language, educational level, and cultural influences are confounding factors to be considered when interpreting mental status and test scores.

An activities of daily living (ADL) questionnaire is valuable in assessing functional impairment, by systematically questioning ordinary daily activities.

If findings for both mental status and functional status tests are abnormal, further clinical evaluations should be conducted. If results are mixed (e.g., abnormal mental status findings and a normal functional assessment or the reverse), referral for neuropsychological, neurological, or psychiatric evaluation should be considered.

Referral, Treatment and Recommendations

If mental status, ADLs, and testing are normal, with no concerns apparent in the clinical assessment, reassure the patient with normal age-related memory decline (and their family) that senile dementia is not inevitable. Suggest possible reassessment in six to twelve months.

  1. Consider referral when
    • Testing is abnormal but the functional assessment is normal.
    • Tests are within the normal range, but reliable family members express concern and illustrative information suggesting dementia.
    • When testing or the functional assessment is abnormal and the patient has more than a high school education or an occupation that indicates high premorbid intelligence, as these may indicate the ability to mask symptoms.
  2. Referral Procedure: before making the next referral(s)
    • Consult with the PCP, who may request that the patient visit for in-depth physical testing for a possible etiology. Tests may include thyroid function, blood (glucose level, tolerance, chemistry), syphilis, toxins, liver functions, urinalysis, EEG, CT scan, MRI, or spinal tap.
    • The PCP may then refer for neuropsychiatric, neuropsychological, neurological or neurophysiological examinations.

The treatment of coexisting sensory, medical and psychiatric disorders may provide some improvement in cognitive functioning: The PCP or a psychiatrist may stop or change medications exacerbating confusion (e.g., sedatives and hypnotics); psychotropics may be implemented to control aggressive, agitated, or dangerous behaviors; new cholinesterase inhibitors (e.g., Cognex, Exelon, and Aricept) are effective in slowing symptoms in the early stages but, clinically, the effect of these agents is only modest.

The following are recommended:

  • Psychotherapy may overtax the limited cognitive resources of a dementia patient. Although supportive counseling may help, it should be considered on a case-by-case basis in consultation with the PCP or specialists.
  • Examine and identify all treatable/modifiable factors.
  • Identify and reduce home hazards.
  • Encourage physical exercise as prescribed by the PCP.
  • Consider day care centers that may offer resources for the patient and provide some respite for the family.
  • Be alert for signs of elder abuse by overstressed caregivers. If there is some question that this exists, contact PPA to discuss your obligation to report abuse.
  • Consider legal counsel regarding plans for continued life and asset management. An advance directive may be created early in the disease course to allow patient input into difficult future decisions.
  • Provide supportive counseling for the patient's family. Encourage them to read The Thirty-Six-Hour Day, by Mace and Rabins (Time-Warner, 1994), The Complete Eldercare Planner, (Random House, 2000) or other useful guides to dealing with dementia.
  • Community resources and support groups.

References

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About the Article: Published as: Cooperstein, M. A. & Angert, M. R. (2000, August). Screening for Dementia: Cerebral Dysfunctioning in the Elderly, Pennsylvania Psychologist Quarterly, 60(8), 13,15,18,22, 35.