Thats My Name Ask Me Again and Ill Tell You the Same

"Doctor, do you lot diagnose dementia? Because I need someone who tin diagnose dementia."

A human asked me this question recently. He explained that his 86 twelvemonth-old begetter, who lived in the Bay Area, had recently been widowed. Since then the father had sold his long-time home rather chop-chop, 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 begetter has dementia, such as Alzheimer's illness.

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

Notwithstanding, it'southward not very probable 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. So in this mail service I want to share what I often discover myself explaining to families: the basics of clinical dementia diagnosis, what kind of data I'll need to obtain, and how long the process can take.

Now, note that this post is non nearly 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 particularly useful for unusual cases, such every bit cognitive problems in people who are relatively young.

Instead, in this mail I'll be describing the pragmatic approach that I use in my clinical practice. It is adapted to real-world constraints, meaning it tin be used in a primary care setting. (Although similar many aspects of geriatrics, it's challenging to fit this into a 15 infinitesimal visit.)

Does this older person accept dementia, such equally Alzheimer'south disease? To understand how I go about answering the question, let's get-go by reviewing the basics of what it means 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 ane or more types of mental function. Although it'due south mutual for retentivity to be afflicted, other parts of thinking function can be impaired. The 2013 DSM-5 manual lists these 6 types of cognitive function to consider: learning and memory, language, executive function, complex attention, perceptual-motor function, social cognition.

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

• The problems are bad enough to impair daily life function. Information technology'south not plenty for a person to take an abnormal result on an office-based cerebral test.  The problems also have to be substantial enough to affect how the person manages usual life, such as work and family responsibilities.

• The problems are not due to a reversible condition, such as delirium, or another reversible disease. Common weather that can cause — or worsen — dementia-like symptoms include hypothyroidism, depression, and medication side-effects.

• The problems aren't ameliorate accounted for by another mental disorder, such every bit depression or schizophrenia.

Dementia — now technically known as "major neurocognitive disorder" — is a syndrome, or "umbrella" term; information technology's not considered a specific disease. Rather, the term dementia refers to this collection of features, which is caused by some form of underlying damage or deterioration of the brain.

Alzheimer's disease is the nearly common underlying crusade of dementia. Vascular dementia (damage from strokes, which can be quite small-scale) is as well common, every bit is having ii or more underlying causes for dementia. For more on conditions that tin can cause dementia, see here.

What Doctors Need to Do To Diagnose Dementia

Now that we reviewed the v primal features of dementia, let's talk about how I — or some other dr. — might go nigh checking for these.

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

ane. Difficulty with mental functions. To evaluate this, it'due south best to combine an function-based cognitive test with documentation of existent-earth problems, as reported by the patient and by knowledgeable observers (due east.m family unit, friends, assisted-living facility staff, etc.)

For cognitive testing, I by and large use the Mini-Cog, or the MOCA. The MOCA provides more data just it takes more than time, and many older adults are either unwilling or unable to go through the whole test.

Completing part-based tests is important because it'southward a standardized way to document cerebral abilities. But the results don't tell the doctor much about what's going on in the person's actual life.

And so I ever inquire patients to tell me if they've noticed any trouble with retentiveness or thinking. I besides endeavor to become information from family members about any of the eight behaviors that are mutual in Alzheimer's. Lastly, I make note of whether there seem to exist any problems managing activities of daily living (ADLs) and instrumental activities of daily living (IADLs).

2. Decline from previous level of ability. This characteristic can exist hard for me to observe on my ain during a single visit. To certificate a decline in abilities, a medico tin interview other people, and/or document that she's reviewed previous cognitive assessments. I have too occasionally documented that a patient is currently unable to correctly perform a cognitive task that is related to her career or education history. For instance, if a former accountant can no longer manage bones arithmetics, information technology's reasonable to assume this reflects a decline from previous abilities.

3. Impairment of daily life function.This is another characteristic that can be tricky to observe during a single visit, unless the patient is very impaired. I usually commencement by finding out what kinds of ADLs and IADLs help the person is getting, and what kinds of bug have been noted. This ofttimes means talking to at least a few people who know the patient.

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

In some cases — usually very early dementia — it can be quite hard to decide whether a person's struggles have become  enough to qualify equally "impairment of daily life function." If someone isn't taking his medication, is that just regular forgetfulness? Ambivalent feelings about the medication? Or actual impairment due to brain changes? If I'm non sure, and so I may certificate that the situation seems to be deadline, when it comes to harm of daily life function.

4. Checking for reversible causes of cognitive damage. I mentally divide this step into two parts. Start, I consider the possibility of delirium, a very common state of worse-than-usual mental function that's often brought on past disease.  For case, I've noticed that older people are frequently mentally assessed during or subsequently a hospitalization. Merely that's not a good time to attempt to definitely diagnose dementia, because many elders develop delirium when they are sick, and it can take weeks or even months to return to their previous level of mental office.

(My arroyo to considering dementia in older adults who are confused during or after hospitalization: Make a note that they may have underlying dementia, and program to follow-up once the brain has had a chance to recover.)

Afterward considering delirium, I bank check to encounter if the patient might take another medical problem that interferes with thinking skills. Common medical disorders that tin can bear upon thinking include depression, thyroid problems, electrolyte imbalances, B12 deficiency, and medication side-effects. I besides consider the possibility of substance abuse.

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

If I do suspect delirium or some other trouble that might cause cognitive impairment, I don't rule out dementia. That'due south considering information technology'due south very common to have dementia along with another problem that's making the thinking worse. Simply I do plan to reassess the person's thinking at a later date.

5. Checking for other mental disorders.This step tin can be a challenge. Depression is the well-nigh common mental health problem that makes dementia diagnosis difficult. This is considering depression is not uncommon in older adults, and it tin can crusade symptoms similar to those of dementia (such as aloofness, and poor attention). We also know that information technology'due south quite mutual for people to have both dementia and depression at the aforementioned fourth dimension.

In many cases, at that place may be no easy way to decide whether an older person'south symptoms are low, early dementia, or both. So sometimes nosotros terminate up trying a course of depression treatment, and seeing how the symptoms evolve over time.

It's also of import to consider the older person'south mental health history. Paranoia and delusions are quite common in early dementia, only could be related to a mental health status associated with psychosis, such every bit schizophrenia.

Is it Dementia or Mild Cognitive Impairment?

Sometimes, when an older person is having retentiveness bug or other cerebral issues, they end upwardly diagnosed with "mild cognitive impairment."

Mild cognitive impairment (MCI) means that a person's memory or thinking abilities are worse than expected for their age (this should be confirmed through office-based cerebral testing), just are swell plenty to impair daily life function.

The initial evaluations for MCI and dementia are basically the same: doctors demand to do a preliminary office-based cognitive evaluation, ask about ADLs and IADLs, look for potential medical and psychiatric problems that might be affecting brain function, cheque for medications that affect cognition, and then along.

I explain more about MCI in this article: How to Diagnose & Care for Balmy Cognitive Damage.

Just remember: in practical terms, if an older person'southward memory problems have gotten bad enough that he tin can't grocery shop the way he used to, or she can no longer manage her finances on her own…those authorize as impairment in daily life function. And then, a diagnosis of "mild cognitive impairment" is probably not appropriate for those cases.

Can Dementia Exist Diagnosed During a Unmarried Visit?

So can dementia be diagnosed during a single visit? Equally you lot can encounter from above, it depends on how much information is hands available at that visit. Information technology also depends on the symptoms and circumstances of the older adult being evaluated.

Memory clinics are more likely to provide a diagnosis during the visit, or before long afterwards. That'due south because they normally request a lot of relevant medical information ahead of time, transport the patient for tests if needed, and interview the patient and a family member (or other knowledgeable "informant") extensively during the visit.

But in the master care setting, and in my own geriatric consultations, I find that clinicians need more than one visit to diagnose dementia or probable dementia. That's because nosotros usually need to order tests, request past medical records for review, and gather more information from the people who know the older person being evaluated. Information technology's a bit like a detective's investigation!

Tin can Dementia be Inappropriately Diagnosed in a Unmarried Visit?

Sadly, yeah. Although information technology'south common for doctors to never diagnose dementia at all in people who have it, I have likewise come up across several instances of busy doctors rattling off a dementia diagnosis, without fairly documenting how they reached this conclusion. (It's also mutual for them to hardly document anything in terms of the older peron's cognitive state, other than "dislocated, didn't know date.")

Now, oftentimes these doctors are right. Dementia becomes common as people age, then if a family complains of memory issues and paranoia in an 89 yr former, chances are quite high (at least 60%, according to UpToDate) that the older person has dementia.

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

It is a major matter to diagnose someone with dementia. And so although it's non possible for an average doctor to evaluate equally thoroughly as the memory dispensary does, it's important to document consideration of the five essential features of dementia that I listed to a higher place.

If You lot're Worried Almost Possible Alzheimer'south or Dementia

Permit'southward say you're similar the man I spoke to recently, and you're worried that an older parent might have dementia. (Remember, most dementia is due to Alzheimer'south or a similar underlying brain condition.) You're planning to have a doctor assess your parent. Here'due south how you can help the process along:

• Obtain copies of your parent'south medical information, so you tin bring them to the dementia evaluation visit. The most useful information to bring is laboratory results and any imaging of the brain, such every bit CAT scans or MRIs. See this post for a longer listing of medical information that is very helpful to bring to a new physician.

• Write downwardly worrisome behaviors and problems, and bring this documentation to the visit. You can start with this list of eight 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?  Enquire them to share their observations with you and jot down what they tell you. Share these notes, along with the names of the informants, with your parent's doctor.

• Exist prepared to explain how your parent's abilities have changed from before.

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

• Bring information well-nigh whatsoever contempo hospitalizations or illnesses.

• Bring information near whatever history of depression, depressive symptoms, or other mental disease history.

Past understanding what it takes to diagnose dementia, and past doing a fiddling advance training when possible, you will meliorate your chances of getting the evaluation you need, in a timely fashion.

And if yous have an aging parent who is refusing to become evaluated for retentivity loss or other concerning symptoms: my gratuitous online training for families (see below) covers how to get by this, and includes a nifty PDF summarizing what to say and not say to your parent who may have dementia.

This article was first published in 2015, and was last updated by Dr. K in Apr 2022.

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

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