In Part 5 of this series we looked at the various signs of dementia as listed by the Alzheimer’s Association and suggested that these are applicable to dementia in general and offered them as a useful tool for family, friends and caregivers. These symptoms of dementia experienced by patients, or noticed by people close to them, are exactly the same signs that healthcare professionals look for, albeit in a more detailed manner.
When the patient exhibits a significant number of these signs then the next step is usually general screening for cognitive impairment utilizing various cognitive testing procedures administered by a Clinical Neuropsychologist or a knowledgeable General Practitioner. Often lasting several hours, these are a comprehensive battery of tests designed to determine functional patterns of decline associated with varying types of dementia. Tests of memory, processing speed, attention, and language skills are relevant, as well as tests of emotional and psychological adjustment. These tests assist with ruling out other causes and determining relative cognitive decline over time or from estimates of prior cognitive abilities.
The first step in testing concerns about memory performance and cognitive health involves standard questions and tasks. Asking for knowledge of facts that should be known to any adult will give healthcare professionals an indication of whether there is dementia or not and help to guide a decision on further investigation. Simple word knowledge tests and drawing tasks are included alongside memory questions.
Today’s cognitive tests are in widespread use and have been verified as a reliable way of indicating dementia. They have changed little since being established in the early 1970s. The simple questions that are used come from a set first developed in 1972 by Professor Henry Hodkinson, working at the time in a London hospital as a UK specialist in geriatric medicine.
Prof. Hodkinson’s research identified the most effective 10 questions in a previous list of 26 to screen older people in confused states. The questionnaire – which is one of the dementia tools most commonly used by family and hospital doctors – is known as the Abbreviated Mental Test Score (AMTS).
The AMTS has 10 questions:
- What is your age?
- What is the time, to the nearest hour?
- Repeat an address at the end of the test that I will give you now (e.g. “42 West Street”)
- What is the year?
- What is the name of the hospital or town we are in?
- Can you recognize two people (e.g. the doctor, nurse, home help, etc.)?
- What is your date of birth?
- In what year did World War 1 begin? (Other widely known dates in the past can be used.)
- Name the president/prime minister/monarch.
- Count backwards from 20 down to 1.
Each correct answer counts for one point; scoring seven or more indicates normal functioning while getting six points or fewer suggests cognitive impairment.
The General Practitioner Assessment of Cognition (GPCOG) test, developed at Australia’s University of New South Wales, is briefer than the AMTS in terms of the questions asked of the patient, but if these raise concern there is an added element for recording the observations of relatives and caregivers. Designed for GPs, this sort of test may be the first formal assessment of a person’s mental ability that is done before fuller tests are considered. The doctor records the answers to questions and tasks given at the GPCOG test website.
The online diagnostic tool returns a score after the first, patient-based set of questions, and then prompts whether more information is required from relatives in a second step. At the end of the two-part test, a statement is given on whether cognitive impairment is indicated.
One task for the patient part of the GPCOG test is to write the hours of a clock face around a blank circle on a piece of paper – with accurate relative spacing – and then draw the hour and minute hands to show ten past eleven.
The Mini Mental State Examination (MMSE) is a fuller cognitive test. The shorter tests above are reliable alternatives to the MMSE, and considered more effective in some settings. Primary care doctors have less time but are in a good position to do the initial screening with shorter tests, while specialists will be referred to for further evaluation with, for example, the MMSE alongside other testing to confirm whether there is dementia and diagnose the particular type.
The MMSE measures:
- Orientation to time and place
- Word recall
- Language abilities
- Attention and calculation
- Visuospatial skills.
Abilities to name objects, follow verbal and written commands, write a sentence spontaneously and copy a complex shape are also tested. The maximum possible score is 30 points and dementia is suggested at scores of up to between 24 and 27, with normal being anything over this. Doctors are advised to consider adjustments for age and education because performance in the test can be influenced by demographic, non-dementia factors. Accordingly, the following are taken into account:
- Educational level, skills, prior level of functioning and attainment
- Language and culture
- Any sensory impairments (for example, hearing loss)
- Psychiatric illness or physical/neurological problems.
The cognitive screening tests above are central to diagnosing whether dementia is present and for tracking progression and severity after a particular disorder is confirmed. Depending on what the doctor thinks could need further investigation, other diagnostics include laboratory tests of blood and urine samples, brain scans (possibly including CT, MRI, and EEG), genetic testing in the case of suspected inherited disorders such as Huntington’s, and sometimes psychiatric assessment if, for example, depression may be involved. These will be discussed in the next Post in this series.
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