Evaluation Of Suspected Dementia
NATHAN FALK, MD, and ARIEL COLE, MD, Florida Hospital Family Medicine Residency, Winter Park, Florida
T. JASON MEREDITH, MD, Offutt Air Force Base Family Medicine Residency, Offutt Air Force Base, Nebraska
Am Fam Physician. 2018 Mar 15 97:398-405.
Dementia is the fifth leading cause of death in Americans older than 65 years. The United States population is aging, with 46 million persons older than 65 yearsa number that is expected to double by 2060.1 Consequently, by 2050, the estimated number of Americans living with dementia will increase from 5 million to 14 million, and the estimated cost of dementia care will increase from $236 billion to $1 trillion.2 Early recognition of cognitive impairment is integral to patient counseling, advance care planning, assessment of secondary or reversible causes of impairment, and consideration of medical therapy. The U.S. Preventive Services Task Force and the American Academy of Family Physicians have concluded that current evidence is insufficient to assess the benefits vs. harms of screening for cognitive impairment in older adults.3,4
This article focuses on the evaluation of patients with suspected dementia, including diagnostic criteria, brief screening tests suitable for use during primary care office visits, and diagnostic testing .
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Disorientation Of Time And Place
“You might be out somewhere and suddenly forget where you are. Or you might be in a shopping centre and not know what direction to go in,” Dr Farrow says.
“Usually if someone just stops for a moment, they can work out ‘oh yes, that’s where I came in, I’ve got to go this way’ but someone with early dementia will be less likely to be able to work it out.”
Brief Initial Screening Tests For Cognitive Impairment
Brief screening tests are useful to quickly assess the need for further evaluation. In 2013, the Alzheimer’s Association recommended three screening tests that could be completed within the time frame of a Medicare wellness visit: Mini-Cog, Memory Impairment Screen, and General Practitioner Assessment of Cognition.33 These tools require less than five minutes to complete, can be administered by nonphysician personnel, and are validated in the primary care office setting. Subsequently, a systematic review called into question the sensitivity of the Memory Impairment Screen within well-designed studies.34 The Ascertain Dementia 8-Item Informant Questionnaire is also a quick, validated, and sensitive screening tool. Guidelines advocate combining the Mini-Cog with this questionnaire.29,35 Ascertain Dementia 8-Item Informant Questionnaire is also a quick, validated, and sensitive screening tool. Guidelines advocate combining the Mini-Cog with this questionnaire.29,35
This article briefly discusses the screening tests. A more detailed discussion was published previously in American Family Physician.36 Additional information can be found in the American Academy of Family Physicians National Research Network’s Cognitive Care Kit at .
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Why Do We Mix Up Words And Sounds
When we are talking, normally our brain does a good job of coordinating the ideas in our mind, the words and phrases we need to express those ideas, and the muscles in our throat, mouth, and tongue we need to make the sounds. When the brain does this coordination correctly, we are able to speak and carry on a fluid conversation.
But sometimes our brains arent able to keep up with everything that needs to be coordinated and something slips by. This could be due to factors such as the speaker being tired, the presence of external stimuli distracting the speaker, or a number of other reasons.
There are many ways our brain can make mistakes when speaking, and Spoonerisms are just one example.
Some other examples of speech errors include:
- Tip of the Tongue This is a common problem that many of us have experienced. We are about to say something and just cant seem to think of the word we are trying to say. The word may be something quite common, however, the wires in our brain have become crossed for a moment and we just cant recall the word.
- Malapropism Another common example is malapropism. This happens when a speaker replaces a word in a sentence for a similar-sounding but completely different word, such as This is unparalyzed in the states history.
Certain Speech Changes May Be Early Sign Of Mental Decline
Your speech may, um, help reveal if you’re uh… developing thinking problems. More pauses, filler words and other verbal changes might be an early sign of mental decline, which can lead to Alzheimer’s disease, a study suggests.
Researchers had people describe a picture they were shown in taped sessions two years apart. Those with early-stage mild cognitive impairment slid much faster on certain verbal skills than those who didn’t develop thinking problems.
“What we’ve discovered here is there are aspects of language that are affected earlier than we thought,” before or at the same time that memory problems emerge, said one study leader, Sterling Johnson of the University of Wisconsin-Madison.
This was the largest study ever done of speech analysis for this purpose, and if more testing confirms its value, it might offer a simple, cheap way to help screen people for very early signs of mental decline.
But don’t panic lots of people say “um” and have trouble quickly recalling names as they age. It doesn’t necessarily mean trouble is on the way.
“In normal aging, it’s something that may come back to you later and it’s not going to disrupt the whole conversation,” another study leader, Kimberly Mueller, explained. “The difference here is, it is more frequent in a short period,” interferes with communication and gets worse over time.
The study was discussed Monday at the Alzheimer’s Association International Conference in London.
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What Is Word Retrieval
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Accordingly, what is word retrieval difficulty?
A ‘word retrieval difficulty‘ or ‘word finding problem’ is when a person knows and understands a particular word, but has difficulty retrieving it and using it in their speech. A child with an acquired brain injury will also have greater problems with finding the right word when they are tired or stressed.
Additionally, how do I recover word retrieval? Harness a hidden opportunity to boost your brain power.
Activities Of Daily Living
Safe execution of activities of daily living is essential for minimizing morbidity and mortality in patients with cognitive impairment, so it is important to ask about activities of daily living. Specific activities of daily living should be probed, including bathing, toileting, eating, and dressing, as difficulties could lead to falls, aspiration, or infection. It is also important to note if patients have difficulty managing complex tasks that can have dangerous consequences such as cooking and administering medications. Access to finances and the Internet or telephone should be assessed to protect patients with frontal disease and poor judgment from being financially exploited, as in Case 1-3. Finally, determining the level of supervision provided on an average day is important in more severely impaired patients in order to prevent wandering or other dangerous events.
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Mood And Behaviour Changes
Some people start to have noticeable swings in their mood, going from calm to tears for no apparent reason.
For others there will be a shift to a different but more constant mood state usually this is a more withdrawn and depressed state, although some people will become more happy-go-lucky than they used to be, Dr Farrow says.
Loss Of Daily Life Skills
A home that may not be as well kept as usual may be a sign that the person living there has dementia. They may lose the ability to do many of the things they normally do themselves, such as preparing meals, household chores and eating and drinking properly.
They may also struggle to maintain their personal hygiene and getting dressed. Deciding what to wear, how to put things on and in the right order may become increasingly difficult. Getting around the house without walking into furniture and other items may also be a problem.
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How Is Primary Progressive Aphasia Diagnosed
A diagnosis of primary progressive aphasia is made if the following three criteria are met:
- The main clinical feature is problems with language
- Language problems are the main cause of impairment with daily living activities
- Language problems are the first symptom and the only impairment during the initial phase of the disease
In addition, the language problems cannot be caused by other nondegenerative nervous system disorders or other medical or psychiatric disorders. Also, changes in behavior should not be the main complaint and other declines in memory or other thinking skills should not be present during the early stages of the condition.
Brain imaging scans are performed to identify areas of the brain that are damaged. Areas of the brain affected in PPA are the frontal and temporal lobes of the left side of the brain.
A speech and language pathologist or a neurologist will perform a variety of tests to check speech and language functions. Tests assess abilities such as grammar, ability to form sounds and letters, understanding of words and sentences, and object knowledge. Tests may involve picture descriptions using single words to name pictures, foods, sounds matching spoken sentences to pictures answering yes/no questions following directions word-to-picture matching word-to-definition matching picture-picture matching gesture-object matching and other tests.
Social Interaction May Be A Bit Off
This goes a bit with the first point as to mood and personality.
Is grandpa still going to meet his friend for golf?
Is mom still going to lunch with her close friends?
Its also a good practice to invite family members over or out to an event to spend close time with them in order to see if you notice anything is off. Plus, it gives you an excuse to spend time with family.
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Mispronouncing Words = Early Sign : Dementia
Mispronouncing words = early sign? I have a 65-year old relative who has recently started dropping her ts when saying words like little so that theyre pronounced as lih-al instead, and to speak haltingly Frontal lobe, Have 11-year-old sons, walking, of normal cognitive decline that manyDementia and languageA person with any type of dementia can have problems with language, Mount Laurel,, neighbors and family members Î Using the wrong word when talking Î Jumbling words: mixing up or missing letters in words when talking Î Not following the conversation of friends or coworkers
Spotting Dementia In A Loved One
While many realise that repeatedly forgetting names can be a red flag for dementia, few know that using repetitive phrases as well as stuttering or mispronouncing words, can also be a sign.
There are around 850,000 people living with dementia in the UK and 225,000 more people will develop dementia this year thats one every three minutes. But it is obvious that the symptoms of Dementia are not all that clear… a YouGov survey of more than 4,000 adults revealed that many people are confused about what are and are not signs of dementia.
Many people thought that forgetting why you have walked into a room might be a sign, which could happen to anyone. For a person with dementia, it is not so much why they walked into a room that is troubling, but the room itself seeming unfamiliar.
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Social Functioning And Behavior
Examination of social comportment is challenging and often requires information from a reliable caregiver, as patients with ventral frontal disease often have little insight or concern into their difficulties. There are several valuable social questionnaires that can be completed by spouses, family members, or close friends concerning changes in personality, behavior, and social functioning. Examples include the Neuropsychiatric Inventory and the Frontal Behavioral Inventory, which probe day-to-day functioning, looking for changes in personality and behavior compared to baseline. The previous section on history details specific domains of social comportment that are affected by frontal lobe disease. Observation of patient interactions in clinic are also important as detection of behavioral disinhibition, simple repetitive motor rituals, and poor social discourse should prompt a more thorough examination for evidence of social comportment disorder and executive limitations. Other behavioral and emotional changes that should be noted include depression and anxiety since these can be significant and can also interfere with the mental status examination.
Why You Should Make An Appointment Now
The sooner you know, the better. Starting treatment may help relieve symptoms and keep you independent longer.
It also helps you plan better. You can work out living arrangements, make financial and legal decisions, and build up your support network.
Alzheimerâs Association: â10 Early Signs and Symptoms of Alzheimer’s,â âDiagnosis of Alzheimer’s Disease and Dementia,â âWhat Is Dementia?â
University of California San Francisco: âAlzheimer’s Disease Signs and Symptoms.â
National Institute on Aging: “Forgetfulness: Knowing When To Ask For Help.”
American Psychological Association: “Aging: When should I be concerned about a senior’s forgetfulness?”
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Being Confused About Time Of Day
When mom is up while everyone else is sleeping it may be just restlessness but can also be a sign of dementia. The confusion of waking up in the morning and going to bed in the evening can grow as dementia forms.
As dementia starts to creep in you may notice that your family member is taking naps during the day that they may have not taken before, and then they are up at night walking around the house. As this worsens they may even wonder why others are not up with them and try to wake others up. If there is a pattern of sleep walking or napping out of the norm it may be time to contact a doctor.
Epidemiology And Risk Factors
The overall prevalence of dementia is approximately 5%, increasing to 37% in persons older than 90 years.5 The lifetime risk of dementia is approximately 17%, with the incidence doubling each decade after 60 years of age.6 The median survival time after diagnosis of dementia is 4.5 years, but this varies based on age at diagnosis, ranging from 10.7 years for patients diagnosed in their 60s to 3.8 years for patients diagnosed in their 90s.7 Alzheimer disease accounts for 60% to 80% of dementia cases. Vascular dementia in isolation accounts for 10% of cases, but it commonly presents as a mixed dementia with Alzheimer disease. Lewy body dementia, Parkinson-related dementia, normal-pressure hydrocephalus, and frontotemporal dementia represent most of the remaining cases. Frontotemporal dementia, while accounting for less than 10% of total dementia cases, represents 60% of dementia cases in patients 45 to 60 years of age.2
Older age remains the greatest risk factor for dementia.13 Other strong risk factors include family history of dementia personal history of cardiovascular disease, cerebrovascular disease, diabetes, or midlife obesity use of anticholinergic medications apolipoprotein E4 genotype and lower education level.1417 Other potential risk factors with weaker supporting evidence include smoking atrial fibrillation use of substances and medications such as alcohol, proton pump inhibitors, and benzodiazepines and head trauma.1822
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How Is Primary Progressive Aphasia Treated
There are no treatments or cures for primary progressive aphasia .
A speech-language pathologist may help patients with early stage PPA learn new communication strategies. Some examples include using non-verbal communication techniques such as gesturing or pointing to cards with words, pictures or drawings. Electronic and computer devices and artificial voice synthesizers can also aid or replace speech in some people with PPA.
Are Early Signs Of Dementia Obvious
Changes in a person in the early stages of dementia can be so gradual they can often be mistaken for normal ageing. Because dementia affects people in different ways, symptoms may not always be obvious. In fact, failure to recognise early signs often leads to people not being diagnosed for several years.
So what to look for? Perhaps someone you care for is struggling to remember what they did yesterday and forgets the names of friends or everyday objects. They may have difficulty following conversations or TV programmes, repeat things over and over, or have problems thinking or reasoning. They may feel angry, anxious or depressed about memory loss or feel confused even in a familiar environment.
The healthtalk website presents a range of carers experiences of identifying the early signs of dementia. One carer put it this way.
The first stage is not recognisable I think, or certainly wasnt recognisable as far as I was concerned initially . I was certainly not understanding… the fact that my wife was at the beginning of a serious problem, a serious mental health problem. Because I was with my wife continuously, I think I was less likely to recognise some of the changes that were taking place than people who saw her less regularly.
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What Is Primary Progressive Aphasia
Primary progressive aphasia is a condition that results from damage to areas of the brain that control speech and language. Persons with PPA experience a gradual loss in their ability to speak, write, read, and/or understand what others are saying.
There are three subtypes of PPA, each defined by the language skills most affected:
The speed of decline and type of PPA varies from person to person. Language and speech are affected early in the course of PPA however, other brain functions and behavior may change later on. Examples of cognitive functions that that are initially spared include memory, focus and attention, and visuospatial skills (ability to understand what we see around us and the dimensions and location of our surroundings.