There She Goes Again Take Me to the Edge

"Md, do you diagnose dementia? Because I need someone who can diagnose dementia."

A man asked me this question recently. He explained that his 86 year-old father, who lived in the Bay Area, had recently been widowed. Since then the father had sold his long-time home rather rapidly, and was hardly returning his son's calls.

The son wanted to know if I could make a housecall. Specifically, he wanted to know if his male parent has dementia, such every bit Alzheimer's disease.

This is a reasonable concern to accept, given the circumstances.

Still, it's not very likely that I — or any clinician — will be able to definitely diagnose dementia based a single in-person visit.

Just I get this kind of request fairly frequently. And so in this mail service I want to share what I often detect myself explaining to families: the basics of clinical dementia diagnosis, what kind of information I'll need to obtain, and how long the process tin take.

At present, annotation that this mail is not about the comprehensive approach used in multi-disciplinary memory clinics. Those clinics have extra time and staff, and are designed to provide an extra-detailed evaluation. This is peculiarly useful for unusual cases, such as cognitive issues in people who are relatively immature.

Instead, in this post I'll be describing the pragmatic approach that I employ in my clinical practice. It is adapted to real-world constraints, pregnant it can be used in a master care setting. (Although like many aspects of geriatrics, it's challenging to fit this into a xv infinitesimal visit.)

Does this older person accept dementia, such as Alzheimer'due south disease? To understand how I become nearly answering the question, let's offset past reviewing the basics of what information technology ways to have dementia.

5 Key Features of Dementia

A person having dementia means that all five of the post-obit statements are true:

• A person is having difficulty with one or more types of mental role. Although it's common for retention to be affected, other parts of thinking part can be dumb. The 2013 DSM-5 manual lists these vi types of cognitive part to consider: learning and retentiveness, language, executive function, complex attention, perceptual-motor role, social noesis.

• The difficulties are a decline from the person'south prior level of ability. These can't be lifelong problems with reading or math or even social graces. These problems should represent a change, compared to the person's usual abilities as an adult.

• The problems are bad enough to impair daily life role. It's non enough for a person to accept an abnormal result on an office-based cerebral examination.  The problems also take to be substantial enough to touch how the person manages usual life, such as work and family responsibilities.

• The bug are not due to a reversible condition, such as delirium, or another reversible illness. Common conditions that tin can cause — or worsen — dementia-similar symptoms include hypothyroidism, depression, and medication side-effects.

• The problems aren't meliorate accounted for past another mental disorder, such as low or schizophrenia.

Dementia — now technically known equally "major neurocognitive disorder" — is a syndrome, or "umbrella" term; it'due south not considered a specific disease. Rather, the term dementia refers to this collection of features, which is caused by some class of underlying harm or deterioration of the brain.

Alzheimer'south disease is the most mutual underlying cause of dementia. Vascular dementia (damage from strokes, which can be quite minor) is besides common, as is having two or more underlying causes for dementia. For more on atmospheric condition that can cause dementia, see here.

What Doctors Need to Practise To Diagnose Dementia

At present that we reviewed the v key features of dementia, permit'south talk about how I — or another doctor — might go well-nigh checking for these.

Basically, for each feature, the dr. needs to evaluate, and document what she finds.

1. Difficulty with mental functions. To evaluate this, it'due south all-time to combine an office-based cerebral exam with documentation of real-world problems, as reported by the patient and past knowledgeable observers (eastward.g family, friends, assisted-living facility staff, etc.)

For cognitive testing, I generally use the Mini-Cog, or the MOCA. The MOCA provides more than data but it takes more fourth dimension, and many older adults are either unwilling or unable to become through the whole test.

Completing office-based tests is important considering it's a standardized mode to document cerebral abilities. But the results don't tell the doctor much nearly what's going on in the person's actual life.

So I always enquire patients to tell me if they've noticed any trouble with memory or thinking. I also try to get information from family members nearly whatsoever of the eight behaviors that are common in Alzheimer's. Lastly, I make note of whether there seem to exist whatever issues managing activities of daily living (ADLs) and instrumental activities of daily living (IADLs).

2. Decline from previous level of ability. This feature can be difficult for me to detect on my ain during a single visit. To document a reject in abilities, a doctor tin can interview other people, and/or document that she'south reviewed previous cognitive assessments. I have also occasionally documented that a patient is currently unable to correctly perform a cognitive task that is related to her career or education history. For case, if a former accountant tin can no longer manage basic arithmetic, it'southward reasonable to presume this reflects a reject from previous abilities.

3. Harm of daily life function.This is another feature that tin can be catchy to notice during a single visit, unless the patient is very impaired. I commonly beginning by finding out what kinds of ADLs and IADLs help the person is getting, and what kinds of problems have been noted. This frequently means talking to at to the lowest degree a few people who know the patient.

Driving and managing finances crave a lot of mental coordination, so as dementia develops, these are often the life tasks that people struggle with first.

In some cases — unremarkably very early on dementia — it can be quite hard to decide whether a person's struggles take become  plenty to authorize as "damage of daily life function." If someone isn't taking his medication, is that just regular forgetfulness? Ambivalent feelings near the medication? Or bodily impairment due to brain changes? If I'one thousand non sure, then I may document that the situation seems to be borderline, when it comes to impairment of daily life function.

4. Checking for reversible causes of cognitive damage. I mentally dissever this step into 2 parts. First, I consider the possibility of delirium, a very mutual state of worse-than-usual mental function that'due south often brought on by illness.  For case, I've noticed that older people are often mentally assessed during or afterward a hospitalization. But that'south not a proficient time to attempt to definitely diagnose dementia, because many elders develop delirium when they are ill, and it tin can have weeks or even months to render to their previous level of mental function.

(My approach to because dementia in older adults who are dislocated during or after hospitalization: Make a note that they may have underlying dementia, and programme to follow-up one time the brain has had a chance to recover.)

Later considering delirium, I check to see if the patient might accept another medical trouble that interferes with thinking skills. Common medical disorders that can impact thinking include depression, thyroid problems, electrolyte imbalances, B12 deficiency, and medication side-effects. I also consider the possibility of substance abuse.

Checking for many of these causes of cognitive damage requires laboratory testing, and sometimes additional evaluation.

If I exercise suspect delirium or another problem that might cause cognitive harm, I don't dominion out dementia. That's because it's very common to have dementia along with another problem that's making the thinking worse. But I do plan to reassess the person'south thinking at a later date.

5. Checking for other mental disorders.This stride can be a claiming. Depression is the most common mental health problem that makes dementia diagnosis hard. This is because depression is not uncommon in older adults, and it can crusade symptoms similar to those of dementia (such as apathy, and poor attention). We as well know that it's quite mutual for people to have both dementia and depression at the same fourth dimension.

In many cases, in that location may be no easy way to make up one's mind whether an older person's symptoms are depression, early dementia, or both. And then sometimes we stop up trying a course of low treatment, and seeing how the symptoms evolve over time.

It's also important to consider the older person'south mental wellness history. Paranoia and delusions are quite mutual in early dementia, but could be related to a mental wellness condition associated with psychosis, such equally schizophrenia.

Is it Dementia or Mild Cognitive Impairment?

Sometimes, when an older person is having memory problems or other cognitive issues, they finish upwards diagnosed with "mild cognitive impairment."

Mild cognitive impairment (MCI) means that a person's retention or thinking abilities are worse than expected for their historic period (this should be confirmed through office-based cerebral testing), but are non bad enough to impair daily life function.

The initial evaluations for MCI and dementia are basically the aforementioned: doctors need to do a preliminary part-based cognitive evaluation, ask nigh ADLs and IADLs, await for potential medical and psychiatric problems that might be affecting encephalon part, check for medications that affect knowledge, and and then forth.

I explain more near MCI in this article: How to Diagnose & Treat Balmy Cognitive Impairment.

Just think: in practical terms, if an older person'south memory bug take gotten bad enough that he can't grocery shop the way he used to, or she can no longer manage her finances on her own…those qualify as damage in daily life role. And so, a diagnosis of "balmy cerebral impairment" is probably not appropriate for those cases.

Can Dementia Be Diagnosed During a Single Visit?

Then can dementia be diagnosed during a unmarried visit? As yous can see from above, it depends on how much information is easily bachelor at that visit. It also depends on the symptoms and circumstances of the older adult being evaluated.

Memory clinics are more probable to provide a diagnosis during the visit, or shortly later on. That'south because they usually asking a lot of relevant medical information alee of time, ship the patient for tests if needed, and interview the patient and a family member (or other knowledgeable "informant") extensively during the visit.

Merely in the primary care setting, and in my own geriatric consultations, I find that clinicians need more than 1 visit to diagnose dementia or probable dementia. That's because we ordinarily need to order tests, asking by medical records for review, and gather more than information from the people who know the older person beingness evaluated. It's a bit similar a detective's investigation!

Tin Dementia be Inappropriately Diagnosed in a Unmarried Visit?

Sadly, aye. Although information technology's common for doctors to never diagnose dementia at all in people who accept it, I have as well come beyond several instances of busy doctors rattling off a dementia diagnosis, without fairly documenting how they reached this decision. (It'due south also common for them to hardly document annihilation in terms of the older peron's cognitive country, other than "confused, didn't know date.")

Now, oftentimes these doctors are right. Dementia becomes mutual equally people age, so if a family unit complains of retention problems and paranoia in an 89 year former, chances are quite high (at least 60%, according to UpToDate) that the older person has dementia.

But sometimes it'southward not. Sometimes it's slowly resolving delirium forth with a brain-clouding medication. Sometimes information technology's depression.

It is a major thing to diagnose someone with dementia. And then although it's not possible for an boilerplate doc to evaluate as thoroughly as the retentivity clinic does, information technology's important to document consideration of the five essential features of dementia that I listed above.

If You're Worried About Possible Alzheimer'due south or Dementia

Let'due south say you lot're similar the man I spoke to recently, and y'all're worried that an older parent might accept dementia. (Recall, nigh dementia is due to Alzheimer'south or a like underlying brain condition.) You're planning to take a doctor assess your parent. Here'south how yous can help the process along:

• Obtain copies of your parent'south medical information, so y'all can bring them to the dementia evaluation visit. The most useful information to bring is laboratory results and any imaging of the encephalon, such as Cat scans or MRIs. Run into this post for a longer list of medical information that is very helpful to bring to a new doctor.

• Write downwards worrisome behaviors and problems, and bring this documentation to the visit. Y'all can kickoff with this list of 8 behaviors to track if you're concerned about Alzheimer's.

• Consider who else might know how your parent has been doing and behaving recently: other family members? Close friends? Staff at the assisted-living facility?  Ask them to share their observations with you and jot downward what they tell you. Share these notes, along with the names of the informants, with your parent'southward md.

• Exist prepared to explicate how your parent'south abilities have inverse from before.

• Be prepared to explain how your parent is struggling to manage daily life tasks, such equally work, house chores, shopping, driving, or any other ADLs and IADLs.

• Bring information about any recent hospitalizations or illnesses.

• Bring information about any history of depression, depressive symptoms, or other mental affliction history.

By understanding what information technology takes to diagnose dementia, and past doing a trivial advance preparation when possible, you lot will improve your chances of getting the evaluation you need, in a timely style.

And if you lot take an aging parent who is refusing to get evaluated for memory loss or other concerning symptoms: my free online grooming for families (run across beneath) covers how to become past this, and includes a nifty PDF summarizing what to say and not say to your parent who may have dementia.

This article was showtime published in 2015, and was final updated by Dr. Thou in April 2022.

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Source: https://betterhealthwhileaging.net/how-to-diagnose-dementia-the-basics/

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