Is It Important To Diagnose Dementia What Is Involved What Can Doctors Do
In this article, we look at the tough issues relating to diagnosis. It may take time, and some tests may be involved. But for most people, getting a clear diagnosis is a vital first step towards getting good support for the years ahead.
Facing a dementia diagnosis
It is hard to face going through any diagnosis process or to try to coax a loved one to do so. And when it comes to dementia, it is especially hard. There is still a lot of stigmas associated with dementia. Embarrassment and fear make people avoid talking about the topic, let alone taking any action on it.
Many people will have lived with a strange sense of something being wrong for some time months or even years. They know they are having difficulties, but the reason for them is unclear. Family members and friends may suspect there is something wrong too, but feel unsure whether it is worth pushing for further investigations.
Over recent years, there is a growing consensus that it is a basic right for people living with dementia to be given clear information about the illness they are living with. This is accepted for any other illness so why not dementia? So yes, it is important to diagnose dementia.
In some situations, the person with suspected dementia may have a clearly stated wish not to know the diagnosis this is also their right and needs to be respected.
Have the tests and scans
Consider the treatment options
Plan ahead
Reversible Dementias And How To Identify Them
Reversible dementias represent a minority of dementias but the importance of identifying them is obvious. Clinicians should have an understanding of what may differentiate reversible dementias from the progressive, largely untreatable neurodegenerative conditions. Some treatable dementias may not be cured, but the disease course may be modified by addressing the underlying cause . Causes of dementia amenable to treatment are outlined in table 6. Examples of non-neurological clinical features associated with specific, potentially treatable causes of dementia are shown in table 7.
Table 7
Examples of non-neurological clinical features associated with potentially treatable causes of dementia
Imaging can contribute to making a positive diagnosis of dementia, such as MRI showing hippocampal atrophy in early AD. It is, however, also of use in excluding some reversible causes of dementia, such as a benign tumour. Claims that clinical prediction rules can allow the clinician to differentiate between, say, early AD and space occupying lesions have not been borne out by the evidence, and we feel that, at the least, a brain CT is mandatory for investigating the dementing patient.
What Does A Neurologist Examine For A Dementia Patient
After taking a careful history of the symptoms, a neurologist will begin with a general physical examination.
Part of this includes the neurologic exam.
A neurologic exam contains six major components mental status exam, cranial nerve exam, motor exam, sensory exam, reflexes, and cerebellar exam.
Abnormalities on the neurologic exam may give the neurologist clues as to what the diagnosis is.
The mental status exam will assess for orientation, attention, memory, visuospatial function, and language. Some common tools are the MOCA and MMSE .
These are a short series of tasks a neurologist may ask you to fill out, and based on how you score, can help in categorizing the types of deficits and hint as to the type of dementia.
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Perform A Full Neurological Exam And Assess Cognitive Performance
Perform a full neurological exam to look for findings beyond cognitive loss, with a focus on cognitive performance. The Mini-Mental State Exam is a particularly powerful cognitive test that can be found online.
Multiple versions of cognitive evaluation tests are available online, all with their own nuances and interpretations. None of these evaluations are definitive, but low performance suggests a dementing process if other conditions have been ruled out.
What Medications Are Available To Treat Dementia
Drugs approved for the most common form of dementia, Alzheimers disease, are discussed below. These drugs are also used to treat people with some of the other forms of dementia.
- cholinesterase inhibitors
- NMDA receptor antagonist memantine
These two classes of drugs affect different chemical processes in the brain. Both classes have been shown to provide some benefit in improving or stabilizing memory function in some patients. Although none of these drugs appear to stop the progression of the underlying disease, they may slow it down.
If other medical conditions are causing dementia or co-exist with dementia, the appropriate drugs used to treat those specific conditions are prescribed.
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Psychiatrists And Neurologists: Differences
Understanding the difference between psychiatrists and neurologists is perhaps easiest if considered in the context of the symptoms they treat. The brain is the most complicated, yet least understood organ in the body and central, as it is ultimately in charge of our bodies, including both voluntary and involuntary functions.
This analogy, although imperfect, may help in understanding the difference: Psychiatrists focus on and treat symptoms originating in the brain that lead to abnormal voluntary functions, i.e human behaviors, whereas neurologists focus on and treat symptoms originating in the brain that produce abnormal involuntary functions.
In the case of depression, for example, the patient will present with voluntary symptoms, like social isolation, increased or decreased sleep or weight and stopping activities they once found enjoyable. By contrast, a stroke patient will present with involuntary symptoms, such as blurred vision, paralysis, headache, inability to communicate verbally and involuntary movements.
What Treatments Might A Neurologist Prescribe For Dementia
There are a few medications that are approved for the treatment of Alzheimer Disease. These include cholinesterase inhibitors .
These medications work by modulating neurotransmitters in the brain and have some modest symptomatic benefit in patients with dementia.
Another category of medication includes Memantine, which is an NMDA-receptor antagonist. This works by blocking a different neurotransmitter which may protect the brain.
This also has been shown to have very modest benefits.
Neurologists may prescribe medications to help certain symptoms of dementia, such as behavioral disturbances, hallucinations, sleep problems, depression, agitation, and aggression.
These may include antidepressants, antipsychotics and various other medications.
Nutrition, physical therapy and cognitive rehab are also things a neurologist may consider in the multidisciplinary approach to dementia care.
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What Doctors Need To Do To Diagnose Dementia
Now that we reviewed the five key features of dementia, lets talk about how I or another doctor might go about checking for these.
Basically, for each feature, the doctor needs to evaluate, and document what she finds.
1. Difficulty with mental functions. To evaluate this, its best to combine an office-based cognitive test with documentation of real-world problems, as reported by the patient and by knowledgeable observers
For cognitive testing, I generally use the Mini-Cog, or the MOCA. The MOCA provides more information but it takes more time, and many seniors are either unwilling or unable to go through the whole test.
Completing office-based tests is important because its a standardized way to document cognitive abilities. But the results dont tell the doctor much about whats going on in the persons actual life.
So I always ask patients to tell me if theyve noticed any trouble with memory or thinking. I also try to get information from family members about any of the eight behaviors that are common in Alzheimers. Lastly, I make note of whether there seem to be any problems managing activities of daily living and instrumental activities of daily living .
Driving and managing finances require a lot of mental coordination, so as dementia develops, these are often the life tasks that people struggle with first.
Checking for many of these causes of cognitive impairment requires laboratory testing, and sometimes additional evaluation.
Seeking Online Medical Second Opinion
A neurologist is the best person to diagnose the problem of dementia in individuals. Even after you ask a neurologist online about dementia and its related risks and various other aspects, you might still have many unanswered questions in your mind. There might be doubts regarding things to which you might not get proper answers. In such a situation, the best thing to do is to seek online medical second opinion. Look out for a good neurologist online from the various portals where the best of doctors from various fields are available for consultation. You can book an appointment with the doctor and send him all the reports and investigation test results and ask for a consultation or second opinion. You can also clear all your doubts.
It has been seen in many cases that initially the treatment that was being done for dementia was not proper. After the second opinion was taken, the patient received the right kind of treatment for the problem. It might be expensive, true, but taking second opinion for complicated cases is always a good option. Best neurology doctors are available in the various online portals, which offer consultation services to patients.
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Treatable Causes Of Dementia
There are many conditions that can cause dementia-like symptoms that can sometimes be stopped or even reversed with treatment. These conditions include:
- Side effects of certain medicines
- Emotional problems, such as stress, anxiety, or depression
- Certain vitamin deficiencies
- Blood clots, tumors, or infections in the brain
- Delirium, a sudden state of confusion and disorientation
- Head injury, such as a concussion from a fall or accident
- Thyroid, kidney, or liver problems
- Normal pressure hydrocephalus, an abnormal buildup of cerebrospinal fluid in the brain
Talk with your doctor if you experience serious memory problems or other symptoms of dementia. A proper diagnosis is important to getting the right treatment.
Some Of The Commonly Used Cognitive Tests Include:
Mini-Mental Status Examination
This test is usually conducted by your doctor or specialist in their office and takes around 5 minutes to complete. The MMSE is the most common test for the screening of dementia. It assesses skills such as reading, writing, orientation and short-term memory.
Alzheimers Disease Assessment Scale-Cognitive
This 11-part test is more thorough than the MMSE and can be used for people with mild symptoms.
It is considered the best brief examination for memory and language skills.
It takes around 30 minutes and is usually conducted by a specialist in their office, or you may be referred to a psychologist for the test.
Neuropsychological Testing
This involves a number of very sensitive tests administered by a neuropsychologist .
A typical testing session will take at least 2 hours and may be conducted over more than one visit.
A variety of tests will be used and may include tests of memory such as recall of a paragraph, tests of the ability to copy drawings or figures and tests of reasoning and comprehension.
Radiological tests
Standard X-rays may be taken and those who smoke will commonly require a chest X-ray to rule out lung cancer, which may be causing a secondary brain tumour. \
Brain imaging techniques
Various brain-imaging techniques are sometimes used to show brain changes and to rule out other conditions such as tumour, infarcts and hydrocephalus these include:
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Multidisciplinary Care Across Specialty Lines
In addition to affecting thinking abilities, dementia and related disorders often are associated with other symptoms. This means that multidisciplinary, collaborative care is essential not only for proper diagnosis, but also for developing a comprehensive treatment plan individually tailored for you. We partner with specialists from Neuropsychology, the Movement Disorders Program, Nuclear Medicine, Neuroradiology and the Sleep Disorders Center, plus Geriatrics and Geriatric Psychiatry. We are housed in the Turner Geriatrics Center, which is the first facility in the U.S. specifically designed for geriatrics research and clinical programs. In fact, U.S. News and World Report ranked the Center as one of the top geriatric programs in the country.
Psychiatrists And Neurologists: Similarities
Psychiatrists and neurologists follow a similar course of training, beginning with four years of medical school, followed by a residency in their respective specialties. Thereafter, they may elect to pursue a fellowship in a subspecialty within their field.
Thus, both of these professionals are MDs or DOs depending on the type of school they attended they can both conduct mental status exams, order imagining studies, diagnose dementia and prescribe medications as necessary. Both have been trained to manage multiple medical conditions, and to consult other departments.
And, importantly, both have to earn certification from the American Board of Psychiatry And Neurology. The certification exam requires full knowledge of both psychiatry and neurology, which may seem strange since they are different professions. However, because both disciplines deal with the brain/mind, the reality is that there is a tremendous overlap between the fields of psychiatry and neurology, and knowledge of both is essential to ensuring that all factors are considered in a diagnosis. So what’s the difference?
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Structural Signs Of Dementia
Structural imaging of the brain consists of computed tomography and the popularly known magnetic resonance imaging scans. This kind of imaging focuses on the morphology as well as the structural details of the brain’s composition. It is a very physical kind of scan, searching for solid, visible signs of degeneration or abnormalities.
Degenerative dementia causes a number of visible physical signs in the brain in some patients, but is not always easy to detect. CT scans can usually observe some atrophy of the brain’s medial temporal lobe, but the CT scans’ lack of sensitivity can occasionally be problematic. MRI scans, of much higher resolution, can capture atrophy of the hippocampus in nearly 90 percent of all cases of Alzheimer’s disease.
Order Laboratory And Diagnostic Imaging Tests
Order blood tests such as a complete blood count , metabolic panel, liver function tests, vitamin B12 levels, and thyroid function tests to rule out metabolic causes.
Figure 3. In the diagnosis of dementia, order laboratory tests such as complete blood count, metabolic panel, liver function tests, vitamin B12 levels, and thyroid function tests to rule out metabolic causes of dementia.
As well, order magnetic resonance imaging for the brain to rule out structural causes of dementia, such as tumors, chronic subdural hematoma, NPH, or infarcts. Volumetric assessment of various anatomic brain structures is not currently considered to be of diagnostic value for dementia. Computed tomography scans of the brain can be acquired if the patient cannot undergo an MRI, but these are less sensitive to various pathologies.
Although employed in some centers, positron emission tomography scanning, CSF biomarker analysis, genotyping, and encephalography are not routinely recommended for the work-up of dementia.
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Can A Primary Care Physician Diagnose You
Yes. A primary care physician needs to be able to diagnose Alzheimers particularly when theres not a neurologist practice nearby. Perhaps in some of the rural areas of the country.
But that diagnosis of Alzheimers from that PCP may be considered a preliminary diagnosis. Oftentimes the PCP will refer you to a neurologist to confirm their suspicions.
What Kind Of Doctor Tests For Dementia
A primary care doctor can perform a physical exam and find out more about your symptoms to determine what may be the cause. They will likely refer you to one or several specialists that can perform specific tests to diagnose dementia. Specialists may include neurologists, who specialize in the brain and nervous system psychiatrists or psychologists, who specialize in mental health, mental functions, and memory or geriatricians, who specialize in healthcare for older adults.
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Five Steps For Diagnosing Dementia
Dementia involves the progressive or fixed loss of cognitive functions in a person without previous deficiencies. In other words, a patient with dementia has lost cognitive capabilities that were previously present.
Dementia is a syndrome which may be caused by a broad array of pathologies. The cognitive loss associated with dementia goes beyond the mild to moderate degree of memory loss and cognitive slowing that is expected with normal aging.
Although the most common dementias are currently irreversible , there are multiple causes of dementia that are potentially reversible. These causes should be ruled out before assigning an Alzheimers disease diagnosis.
Memory And Thinking Tests To Identify Alzheimers Disease
In a person who is living a doctor diagnoses Alzheimers disease by administering a series of tests of memory and thinking performance. These tests are given one-on-one by a professionally qualified investigator.
The goal is to administer the test in the same exact way any person across the country would receive it. And then the scores of these tests are compared to what are called norms.
Norms are people who are about the same age, the same sex, the same background. So the results are compared to those scores to tell if the person is truly having memory and thinking problems.
These tests will be between 80 to 90 percent accurate. And a second opinion wont necessarily improve the chances of getting the correct diagnosis if they simply repeat the standard memory and thinking tests.
But, depending on where you are located, other tests may be available in addition to the learning and memory tests. Lets talk about these tests.
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Who Can Diagnose Dementia And Why A Neurologist
Dementia is a diagnosis made by a physician.
While it does not have to be a neurologist to diagnose dementia, many patients are referred to a neurologist to determine what type of dementia they have and to help with treatment options and symptom management.
A primary care physician can make a presumptive diagnosis of dementia if a patient fits certain criteria, and the symptoms are not explained by another mental disorder .
A neurologist can help distinguish between the different types of dementia.
In some cases, advanced neuropsychiatric testing is done to better clarify the type of dementia.
Neurologists: Do Seniors With Alzheimer’s Need One
When a loved one is diagnosed with dementia stemming from Alzheimers, understanding your options can be an emotional and difficult process. Though there is no cure, there are treatments available that can help reduce symptoms and help your loved one maintain their quality of life. While most experts agree that anyone with any form of dementia should see a specialist, there are several types to choose from. That can make it difficult to know what course of action to take.
One effective option is to visit neurologists specializing in dementia near you who can offer guidance. They can conduct a thorough neurological exam and recommend subsequent Alzheimers treatment. Combining a neurologists evaluation with the findings of other types of Alzheimers doctors near youpsychiatrists, psychologists and geriatricianscan help make the path to finding the best treatment for your loved one even clearer.
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