Screening for Dementia: Cerebral Dysfunctioning in the Elderly
M. Allan Cooperstein, Ph.D. and Marlene Rubin Angert, Ed.D.
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.
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.
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
Delirium: Terminology and Discrimination
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
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.
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.
Etiologies and Statistics of 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
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.
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.
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).”
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,
signs helpful in recognizing the need for dementia screening are departures from
the patent’s normal functioning as:
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.
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:
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.
activities of daily living (ADL) questionnaire is valuable in assessing
functional impairment, by systematically questioning ordinary daily activities.
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
Treatment and Recommendations
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.
Consider referral when
Referral Procedure: before making the next referral(s)
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.
following are recommended:
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