APPROACH TO A PATIENT WITH DEMENTIADr Sushil Kumar S VMB BS, MD (psychiatry), MHA, FIPSConsultant Neuropsychiatrist

DEFINITION• “Dementia “ means a loss of mental functions. It is

an acquired , persistent impairment in multiple areas of intellectual function not due to delirium.

• Operationally , there is a compromise in 3 or more of the following 9 spheres of mental activity:

• Memory, language, perception(especially visuospatial), praxis, calculations, conceptual or semantic knowledge, executive functions, personality or social behavior, and emotional awareness or expression.

• The compromise in mental functions is documented by mental status assessment;

• It involves a mental status history; bedside mental status evaluation ; and a optional use of clinical rating scales ; or neuropsychological testing.

CLINICAL HISTORY• First step: Interview caregiver(s) as well as patients• Patients may lack insight and may deny or minimize

any difficulty• Contrast between patient’s history and caregiver(s)

gives valuable information.

• Second step:• In addition to obtaining information of onset &

progression , specific examples of mental status difficulty needs to be collected.

• Ex: if complaint is memory difficulty ; one needs to ask what kinds if things or events are not remembered.

• In order to ascertain whether there really is a memory problem or any other difficulty.

• Third step:• Functional history of activities of daily living such as

dressing, eating, sleeping behavior, personal hygiene, continence, and instrumental activities such as making a change at a store, balancing a checkbook, cooking a meal or driving a vehicle.

• It reflects whether there is any decline in usual functioning and occupational performance.

• Fourth step:• Psychosocial history relevant to dementia• Patient’s source of support and help with daily

activities,• Current living and safety situations• The needs and wellbeing of the caregivers.

• Other relevant history :• Prior strokes, psychiatric disturbances, head trauma

and other neurological disturbances which may affect cognitive functions.

• Patient’s education, sociocultural background, primary language and handedness as an index of cerebral dominance are relevant to the interpretation of the mental status assessment.

• Dementia or cognitive decline among first degree relatives may reveal a familial or genetic risk.

MENTAL STATUS ASSESSMENT

• It is an integral part of overall assessment• Interpretation in the context of physical, neurological,

lab examination.• Physical exam may reveal signs of systemic illness or

changes consequent to dementia ( ex: significant weight loss in advanced dementia)

• Neurological exam may reveal evidence of focal deficits from CVA , gait & tone changes from parkinson’s disease, choreoathetotic movements from Huntington’s disease.

• Patients with advanced dementia may manifest primitive reflexes ( grasp or suck )

• Lab tests for assessing presence of systemic diseases that might affect mental status or may reveal malnutrition consequent to dementia.

MENTAL STATUS EXAMINATION

• Step 1• Determine integrity of fundamental functions ie

evaluating the levels of arousal and attention. • Recording any lessening of normal level of

wakefulness such as lethargy, drowsiness, stupor or coma

• Checking patient’s ability to maintain attention with a digit span or serial recitation task.

• Step 2• Screening language function:• Two subsets – naming ability and word list

generation( verbal fluency) are particularly sensitive ; abnormalities in either demand additional analysis of language function.

• Step 3: • Evaluate memory: • Information concerning ability to learn new material

is essential, • The examiner should supplement orientation tests

with a 3 to 4 word learning task with 5 min delayed recall.

• Step 4:• Screen perception and constructions:• The ability to copy 3 dimensional drawings is a

sensitive index of cerebral dysfunction. • In addition the clock drawing task is a widely used

screening test that includes visuospatial abilities as well as other cognitive skills.

• Step 5:• Evaluate personality , social behavior , and emotion. • Observations about the propriety of interpersonal

conduct and emotional behavior.

BEHAVIORAL RATING SCALES

• Mini mental state examination:(MMSE)• 30 item instrument which evaluates orientation, registration

of information, attention & calculation, recall, language, and constructions.

• MMSE takes 5 to 10 min to administer and has high inter- rater and test-retest reliability

• A total of 23 or less suggests the presence of dementia or other mental status impairment.

• MMSE also dependent on age and education of patient and scores as low as 18 may be normal in persons over 85 years of age.

• It is less sensitive for patients with mild cognitive impairment, frontal subcortical dementia.

• Mattis dementia rating scale( DRS)• Has 5 subsets: attention, initiation, perseveration,

construction, conceptualization, and memory.• Max score is 144 points. Proceeds from difficult to

easier items. 3o to 45 min needed. Considered equivalent to the extended mental status examination.

• A revision of DRS , the extended scale for dementia , adds new items and distinguishes among the orientation items.

• Blessed dementia scale (BDS)• Widely used 2 part scale ; 1: a rating scale assessing

functional status as reported by informants(BDS) , 2: a mental status examination ( the information- memory- concentration test)

• BDS includes cognitive, personality, apathy, and basic self care factors.

• Scores of 4 to 9 – mild impairment, and 10 or more – mod to severe impairment.

• 2nd part of the scale gives points for failure, scores of 10 or more are consistent with dementia.

STANDARDIZED NEUROPSYCHOLOGICAL TESTS

• They can confirm the presence of dementia or of deficits in the mental status.

• They can be useful in monitoring recovery, assessing interventions, or developing rehabilitation programs.

• Can provide diagnostic clues as to etiology. • Some of the tests : for memory ( wechsler memory scale,

california verbal learning test, Rey- Osterrieth complex figure recall)

• Drawbacks : duration (2 to 6 hours ), not performed in the usual clinical setting.

• Many dementia patients cannot respond to the test items producing information of little value.

CONCLUSION:• Mental status examination is more important in the

diagnosis and management of dementia than any other examination, procedure, or lab test.

• MSE is the main tool and skill needed to assess • Clinicians must know how to obtain a relevant clinical

history and perform mental status testing in order to assess the different mental status domains

• Behavioral rating scales, neuropsychological tests can be used as adjuncts in assessment of dementia.

THANK YOU !!!