Assessment

When Should I be Concerned?
When someone’s behavior changes without clear cause (like irritability) or instrumental Activities of Daily Living (ADLs) like menu planning, cooking, become erratic – worry ensues. Or, when basic ADLs like personal hygiene, dressing appropriately, taking one’s medications correctly fail – concern results. Problems in basic ADLs often appear when family notices that the patient is not changing their clothes, or bathing as frequently as they once did. See the 10 Signs of Alzheimer's at the Alzheimer’s Association website for more information. When these problems are seen in conjunction with short-term memory loss, repeating oneself, impaired judgment, word-finding or fluency problems, and/or episodes of confusion, then an evaluation is called for.

Why Try to Discover Dementia Early?
First of all, it may not be dementia. Medical problems (e.g., a UTI), severe depression, or even over-the-counter sleep aides can cause confusion and memory difficulties. If it is dementia, then the earlier it is detected the sooner treatment can start. Remember, many types of Neurocognitive Disorder (NCD) can be reversed. We have four FDA approved medications that will not cure (i.e., repair the damage from) dementia or Major NCD, but they have been shown to slow its behavioral and, possibly, its neurological decline. Knowing one has dementia, or its precursor state Mild Cognitive Impairment, can allow time for important legal planning to protect one’s estate. Also, risk factors can be evaluated and reduced like diabetes and smoking. Steps to reduce AD risk like adding the right vitamins, certain types of exercise, eating dark chocolate, treat depression and moderate alcohol use can be started early, when they can help the most.

What to do?
The first step is to talk to the patient’s primary medical provider (PCP), usually a doctor, nurse practitioner or physician’s assistant. The PCP may do a brief screening using the Mini Mental State Exam (MMSE). The MMSE is not sensitive to Mild Cognitive Impairment (MCI, or Mild NCD as it is now called) nor is it very good at diagnosing early-stage Major NCD (dementia), so even though a patient does well on this measure, it cannot rule out Mild or very early Major NCD.

Doctors are now using the Montreal Cognitive Assessment (MoCA) which is a newer quick-to-give measure. You know it's the one President Trump’s doctor used to rule out any neurocognitive deficits in him. However, the MoCA is a “screening test” validated on fewer than 100 Canadians, so it has limitations. Neither the MMSE or MoCA are very good at ruling out early or Mild Neurocognitive Disorder (Mild NCD). In other words the screens are more likely to miss NCD when present, rather than fail to rule NCD out when not present. Confusing, but this is a basic testing tenet regarding a measures sensitivity vs. its selectivity which needs to be considered when determining if more testing than screening is needed.

If you are worried, talk to the patient’s PCP about a referral for more comprehensive neuropsychological (also called neurocognitive) testing. Call your local Council on Aging (COA), Alzheimer's Services (508-775-5656) or Elder Services (508-394-4630) for advice on a referral for dementia assessment in the Southeastern Mass area.

Do I need a Brain Scan?
The changes inside the neurons associated with Alzheimer's Disease (AD) are so tiny they can only be seen under a very powerful microscope, which requires a sample of brain tissue which most people are unwilling to provide, at least until after they die, when postmortem exam is possible. So brain scans are not helpful in diagnosing AD. However, they can pick up signs of stroke disease which can be useful in diagnosing vascular dementia (VD), or they might on a rare occasion pick up other pathology like a tumor that could be removed. Your doctor will help you decide if one is warranted.

If you have a brain scan and the report describes reduced brain volume, don't worry. The blood flow to the brain shrinks by about 30% by age 70 so one shouldn't be surprised if "atrophy" or loss of brain volume is determined. Studies continue to look at the volumetric size of the hippocampus, a small brain structure involved in new learning and forming new memories; however, there is not yet enough evidence to show that this is useful to diagnosis. Presently, according to Dr. R. Wilson, a neuropsychologist at Rush University's Alzheimer's Disease Center, on postmortem exam about a third of people who die without any signs of cognitive impairment have enough neurofibrillary tangles and plaques to meet current criteria for AD. So while postmortem exam can diagnose AD accurately, having AD only causes cognitive changes significant enough to alter life quality in about two-thirds of the cases.

Why Use Neuropsychological Tests?
There currently is no blood test, X-ray, physical exam or brain scan that can reveal changes in a person’s cognitive status (thinking ability) – which is why we rely on NP testing. Medical exams are always performed first in order to rule out issues like Lyme disease, hypothyroidism, etc. that might be easily treated and cured before going forward with NP testing. This is called ruling out reversible causes of NCD. To do this we require a physician’s referral to see someone for a NP evaluation, usually your PCP or a neurologist your PCP sent you to. Sometimes your doctor will order a brain CT or MRI scan to rule out things like brain tumor (which can be treated by surgery or radiation), as part of the ruling out procedure. Brain scans cannot diagnose NCD and the oft mentioned atrophy (shrinkage of the brain) is normal in aging people.

An important benefit in tests vs. interview is that they yield numerical scores which can be plotted to show improvement vs. stability vs. decline over repeated testings at yearly intervals. We often do repeat NP evaluations with Mild NCD patients in order to “catch” any progression to Major NCD in order recommend to physicians and neurologists when it may be time to start medications. Knowing the rate of decline, via repeat testing, in a patient with Major NCD can help family budget time and resources for care. Even when we don’t find evidence of NCD, the testing experience allows an opportunity to teach preventive strategies, which are detailed in our reports. For a more technical, but hopefully understandable, explanation of tests and the statistics involved, click here.

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