—/jo Tataiscofe: lJnobabl 12 cog'i-.ivc ii-paim j1. < i*-□eflnlte cognitive impairment < :/

Fig. 8.2 A practical adaptation of the mini-mental state examination


The mini-mental status examination

Evidence of memory difficulty remains the best single indicator of dementia and should always be evaluated by formal memory testing. However, memory problems may be due to factors other than dementia, and demonstrating failure in other areas of cognitive functioning (language, spatial ability, reasoning) is necessary to confirm the diagnosis of dementia. 6 A number of screening tests are available but the minimental status examination depicted in Figure 8.2 can be used.

Laboratory investigations

The laboratory tests should be selected according to the evaluation of the patient and to costs versus potential benefits.

Recommended investigations for suspected dementia include: 8

renal function hepatic function thyroid function full blood screen blood glucose serum electrolytes (especially if on diuretics) urinalysis serum B12 and folate syphilis serology chest X-ray computerised tomography

Behavioural changes in the elderly

As general practitioners we are often called to assess abnormal behaviour in the elderly patient, with the question being asked, 'Is it dementia?' or 'Is it Alzheimer's, doctor?'

There are many other causes of behavioural changes in people over the age of 65 years and dementia must be regarded as a diagnosis of exclusion. The clinical presentation of some of these conditions can be virtually identical to early dementia.

The clinical features of early dementia include:

• poor recent memory

• impaired acquisition of new information

• mild anomia (cannot remember names)

• personality change, e.g. withdrawn, irritable

• minimal visuospatial impairment, e.g. tripping easily

• inability to perform sequential tasks

The differential diagnosis for behavioural changes apart from dementia include several other common and important problems (which must be excluded) and can be considered under a mnemonic for dementia. 7

drugs and alcohol depression ears eyes metabolic, e.g. hyponatraemia M diabetes mellitus hypothyroidism

E emotional problems, e.g. loneliness

N nutrition: diet, e.g. Vitamin B group deficiency, teeth problems

tumours of CNS trauma of CNS

I infection

A arteriovascular disease ^ cerebral insufficiency

All these conditions should be considered with the onset of deterioration in health of the elderly person. Even apparently minor problems such as the onset of deafness (e.g. wax in ears), visual deterioration (e.g. cataracts), diuretic therapy, poor mastication and diet, urinary tract intercurrent infection, boredom and anxiety can precipitate abnormal behaviour.

Elder abuse

It is important to keep in mind the possibility of abuse of the elderly, especially where there is a family history of abuse of members. The issue is as important as child and spouse abuse. Over 1 million elderly people are estimated to be the victims of physical or psychological abuse each year in the United States. 3 We should keep in mind the occasional possibility of Munchausen's syndrome by proxy.

Depression and dementia

The main differential diagnosis of dementia is depression, especially major depression, which is termed pseudodementia. The mode of onset is one way in which it may be possible to distinguish between depression and dementia. Dementia has a slow and surreptitious onset that is not clear-cut, while depression has a more definable and clear-cut onset that may be precipitated by a specific incident. Patients with dementia have no insight while those with depression have insight, readily give up tasks, complain bitterly and become distressed by their inability to perform their normal enjoyable tasks.

In response to cognitive testing, the typical response of the depressed patient is 'don't know', while making an attempt with a near miss typifies the patient with dementia (see Table 8.1).

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