Dementia Evaluation

1. Dementia Evaluation John Brockington, MD Associate Professor of Neurology University of Alabama-Birmingham

2. What Is & Isn’t Dementia? • Is acquired, persistent impairment in multiple areas of cognitive function • Is not necessarily global impairment • Is not necessarily a memory problem • Is not inevitable part of aging • Does not have to impair insight • Can predominantly affect social behavior • Is not synonymous with Alzheimer’s

3. Is The Patient Normal? • Compared to self • Considering level of education • Compared to others of same age Take Into Consideration: • Family members’ reports • Patient’s own report • Clinical assessment/Neuropsych testing/Imaging

4. Which Major Cognitive Function Is The Patient’s Main Impairment? • Memory • Language • Executive • Visual-spatial capability • Personality/Social behavior

5. MEMORY • Short-term Memory Loss: rapid loss of newly learned information (impaired encoding into hippocampus) • Recent conversations • Important recent events • News (read or heard) • Repetitive questioning • No benefit from cues/clues

6. Caveat! MMSE and similar tests require intact language skills, and may be severely and misleadingly impaired (look like severe memory loss) in patients with language disorders.

7. Is Memory Impaired? (Stepwise Evaluation) 1) YES?  Then: Is there impairment of ADL’s or basic daily function as well (finances, bills, cooking, cleaning, driving, tool use)? 2a) YES?  Then: Possible Alzheimer’s  Need: MRI, +/- Neurology eval, consider neuropsychological testing 2b) NO?  Then: Possible Mild Cognitive Impairment (MCI), ? incipient AD

8. LANGUAGE • Symbolic communication, not mechanics of speech, composed of: • Fluency (spontaneity, flow of words) • Comprehension • Repetition • Naming • Reading and writing • Prosody (melody, inflections)

9. Is Language Impaired?(Stepwise Evaluation) 1) YES?  Then, is speech fluent, relatively effortless, good grammar? 2a) NO?  Then, consider Progressive Nonfluent Aphasia (very effortful to get words out) 2b) YES?  Is patient forgetting meaning, names of words or objects?  Semantic Dementia OR  Is patient losing individual words, can’t repeat?  Logopenic Aphasia 3) ANY ABOVE  MRI or PET may be diagnostic

10. Primary Progressive Aphasias(FTD language variants) • Progressive Nonfluent Aphasia: pts basically develop speech apraxia (forget how to speak); See MRI atrophy Left Fronto-temporal. Tau abnormality disorder. • Semantic Dementia: pts say “What is __?” can’t name words/objects, don’t understand word/object use or meaning. MRI atrophy Left anterior temporal (very tip). Tau disorder. • Logopenic Aphasia: slow speech, lots of word-search pauses, but intact grammar and comprehension; some cases end up as Alzheimer’s.

11. EXECUTIVE FUNCTION • Wide range of skills involved in strategic planning and task completion, including: • Motivation • Insight, judgement, impulse control • Information processing speed • Abstract and conceptual thinking • Vigilance, focus, concentration • Memory retrieval

12. Is Executive Function Impaired?(Stepwise Evaluation) 1) YES?  Then, is the patient socially appropriate, no unusual breakdown of interpersonal relationships? 2a) YES?  Then, consider: either  Cerebrovascular Disease (MRI) or  Depression, toxic/metabolic sources (thyroid, B12, HIV, cancer, temporal arteritis, sedatives, alcohol, poor sleep) 2b) NO?  Then consider FTD behavioral variant  MRI/Neurology/Neuropsych eval

13. Executive Impairment Can Mimic True Memory Loss • “Short term memory” or “working memory” can appear impaired in pts with executive deficits, due to impaired retrieval of memory information • If patients benefit from cues, clues, hints, extra time, then underlying problem may be executive, not true memory. • Alzheimer’s patients typically do not benefit much from cueing

14. VISUAL-SPATIAL FUNCTION • Visual recognition of objects and their arrangements and relationships in space, including self. Deficits can be seen as: • Getting lost or losing objects • Misjudging distance, speed, space, falling • Neglecting one side of self, environment • Failure to recognize familiar faces • Left-Right, other body part confusion *All this assumes intact standard vision*

15. Visual-Spatial Function Impaired?(Stepwise Evaluation) 1) YES?  Then, is the patient also visually hallucinating? 2a) YES?  Then consider Lewy Body Disease, especially if subtle parkinson’s symptoms present 2b) NO?  Then consider Posterior Cortical Atrophy (may be AD or CJD variant) 3) MRI to r/o vascular disease, occipital-parietal atrophy (PCA), may need Neuro-ophth eval

16. PERSONALITY & BEHAVIOR • Personality comprises habitual behavior patterns and character traits of an individual. • General rule: Any report of personality change (by pt or family) may be due to underlying potentially serious brain disorder. • Unusual but consistent changes in social interactions suggest possible basic personality change. • Mood/affect may be abnormal due to dementia

17. Personality/Behavioral Impairment?(Stepwise Evaluation) 1) YES?  Then, has there been a significant decline in social interactions? 2a) YES?  Then, strongly consider Fronto-temporal Dementia (FTD), especially if executive functions or language impaired also  Need MRI or PET  Consider neuropsych testing or neurology eval if imaging not helpful 2b) NO?  Then, consider possible psychiatric basis or cerebrovascular disease, toxic/metabolic etiologies

18. When In Doubt….. May need to perform repeat assessments over time (patients’ symptoms can evolve) May need to reconsider initial diagnosis (not all cases obvious) Pick up phone and call geriatrician, geriatric psychiatry, neurology, neuropsychology Trust your clinical judgement (and see all above)