Caring for a Person With Dementia — Diagnosis
Read Chapter #1 Assessment
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In the last chapter we looked at the dilemma the caregivers, relatives or friends face when a person close to them starts to display symptoms of Dementia. We talked about how to ensure we negotiate an early assessment.
Dementia is not a disease. It is, what we call in the medical parlance, a syndrome. A syndrome is a collection of symptoms and manifestations that can collectively represent a condition.
Dementia may be the presentation of many diseases and it may also be mimicked by many other diseases that are reversible.
It is, therefore, vitally important to get the right diagnosis so the physician can plan the right treatment and management plan. It is also important to exclude or confirm serious conditions that may present as dementia and to isolate those other diseases that are readily treatable.
Unlike many other conditions, diagnosing diseases that cause dementia is not easy. It needs a process of careful history taking, thorough evaluation, and accurate diagnostic tests. As many conditions start gradually, it is not unlikely that a person may get diagnosed more than 6-12 months after the onset of the condition. A period of observation is likely if the symptoms are very mild.
The Key Features of Dementia Syndrome
In the case of dementia, each person will experience the symptoms differently. This is based on their lifestyle, their pre-morbid personality, their surroundings, their employment and their family life. However, the main three features that denote a dementia syndrome are:
- A decline in memory, communication skills, and logical reasoning
- A gradual decline in skills required to function in daily life and activities
- Aspects of confusion and mood disturbance associated with this
Types of Dementia
This is the commonest type of Dementia affecting over 60-80 percent of people with Dementia syndrome. This has an insidious onset with an early middle and late stage. Loss of memory for recent events, forgetting names as well as apathy and low moods will be early symptoms. A Brain scan typically shows deposition of Plaques ( Beta -Amyloid protein ) and Tangles ( protein Tau) that cause brain degeneration
What Will the Primary Care Physician/General Practitioner Do?
The checklist in the previous chapter will help the affected patient and the caregiver to prepare for the doctor visit. A primary care physician is the best person to do the preliminary assessment of symptoms of memory loss. They will do the following during the visit/appointment:
- A careful medical history including previous illnesses and medications
- A careful personal history: work, home, lifestyle, habits
- A detailed list of symptoms presented objectively
- A memory assessment using a validated tool
- Physical exam including a basic neurological examination
- Order baseline tests: blood profile, urine analysis
Second most common. Often a result of atheroscelrosis/aretrisclerosis , multiple 'mini-strokes' that affect the blood supply of the brain and cause mini- infarcts. It was previously called 'multi-infarct Dementia'.
This is characterized more by impairment of completing tasks and judgement as opposed to recent memory loss on Alzheimer's. Brain scan will show vascular changes and infarctions.
Once they have done this and they have eliminated transient conditions that may cause memory problems and confusion, the Primary care Physician/GP will refer the patient to one of the following ( depends on the healthcare network in your country and the local arrangements)
- A Neurologist
- A Geriatrician/ Gerontologist/ Elderly care Specialist
- A Neuropsychiatrist
- A Dedicated Dementia/ memory assessment clinic
Lewy-Body and Mixed Dementia
Another presentation is a condition called Lewy-Body Dementia. But more often than not in the elderly you see a mixed picture with a combination of all of the above. This is called mixed Dementia.
While making these distinguishable is important for specialists in their academic curiosity and perhaps consideration of drug trials, for the lay person it does little to vary the actual management plan and treatment.
Dementia can also be a part of middle or late stages of Huntingdon's Disease, Parkinson's disease, can be caused Hydrocephalus and a major presentation of Vitamin B1 deficiency of chronic alcoholism ( Wernicke- Korsakoff's ).
One of the main problems in dementia is the person suffering from these symptoms may not always be the best person to make the appointment, give an accurate history and get the best out of a Doctors visit due to obvious reasons. Equally we need to respect the dignity and confidentiality of the person attending the Doctors as they may want to do this on their own especially in the early stages.
It is very hard to be objective when it is memory related symptoms in giving history as you may overestimate or underplay the symptoms to the Doctor. It is not uncommon in conditions of stress, busy life, tiredness that we all have memory lapses - as we said in the preivous installment it is important to triangulate facts and look for consistency, frequency and periodicity.
Ideally an accompanying family member is best placed to give accurate information, remember details of the plan for assessment and also make necessary appointments for follow- up and further tests. The person affected, if they attend on their own, may forget details and may even make false statements on their return from appointment to their family, hinting everything 'was ok'. We need to be wary of this.
While it is important to get as much an accurate diagnosis as possible, some of the more specialized diagnoses are merely academic exercises. The Specialists may not always be able to narrow down to a specific, but as long as they can determine the following :
a) Is this reversible or incurable
b) Will drug treatment help to slow down progress
c) Will drug treatment help with symptoms
d) Is the diagnosis sufficient to plan the future
A quick test for memory assessment:
a) Three objects are mentioned to the person. They have to remember and repeat back the three objects after a few minutes of other conversation
b) They have to draw the face of a clock indicating the times given by the examiner.
There may not always be time for the physician to explain all the tests they are ordering and what they are hoping to find from it. Here is a quick list of tests commonly done and the reasons for them to help you understand the sheer maze that is the medical assessment (no wonder we have to train for so many years!)
Note: A physician may not always perform all of these as based on the history given and other medical information they may go straight to specific tests.
A Full Medical History: review of major diseases and medications
A Physical Exam: BP, Pulse, Hearts and Lungs overall appearance, Weight, BMI
A Neurological Exam: Reflexes, Co-ordination, muscle movements, sensations, Fundoscopy
Memory Exam: One of the key tests in the initial diagnosis of Dementia is to perform an objective memory assessment using a validated tool (MMSE). After a series of questions they patient is scored out of 30. 20-24 will indicate possible mild dementia, 13-20 moderate and under 12 severe dementia. Note, the test is validated but also needs corroborating with other tests/ exams.
Mood : As assessment of mood is done using a series of questions about sleep, general mood, irritability, judgement, attitudes to things etc.
Brain Imaging: An MRI (Magnetic Resonace Imaging) , a CT (Computerised Tomographic) scan or a PET (Positron Emission Tomography) may be performed to assess the brain structure.
Conditions that can be mistaken for Dementia
Medications: Certain medications or a combination of medications can affect memory and mood.
Metabolic syndromes: Hypoglycemia can cause confusion, memory problems and lack of judgment. Low thyroid hormone can cause apathy, memory problems, depression and sluggishness.
Dietary deficiency: Chronic deficiency of Thiamine (B1) can cause memory problems, as do B6 (a disease called pellagra), and B12. Even dehydration can cause confusion and metal impairment.
Brain Tumors: in very rare cases a slow growing tumor in the brain can affect memory, personality and mood. A scan will pick this out.
Hypoxia: Low levels of oxygen due to surgical accidents, poisoning, heart and lung diseases such as Emphysema, heart failure can also lead to this sometimes.
- Diagnosing dementia may be painstaking and sometimes long drawn out due to late presentation, patient not being motivated to go to the doctors, and carer/family hesitation to 'label' the person. This could prove a problem.
- Early consultation helps to eliminate other reversible conditions.
- Always be prepared for the doctor visit with full medical history, all the drugs or supplements you take, diet or other information
- The tests form a package and should not be taken out of context, a physician is best placed to interpret them. Don't try to do a test in isolation and start panicking. Each test adds to the final conclusion.
- The mental state examination is also limited by a person's literacy level, language skills, and vision. One has to careful in jumping to conclusions.
- An accompanying carer/ family member is a key resource in aiding the patient in their diagnosis.
In the next part, we will look at what to do after the diagnosis and how best to plan the future.