Dementia physical examination: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{Template:Dementia}} | {{Template:Dementia}} | ||
{{CMG}} | {{CMG}};{{AE}},{{SAI}} | ||
==Overview== | |||
A thorough general physical examination followed by focused focal neurologic deficits examination that may be consistent with prior strokes, parkinsonism (rigidity and/or tremors), gait abnormalities or slowing, and eye movements should be preferably done. Some patients with Alzheimer disease (AD) generally have no motor or sensory deficits at presentation. | |||
==Physical Examination== | ==Physical Examination== | ||
The final diagnosis of dementia is made on the basis of the clinical picture, increasingly with neuroimaging results for backup. For research purposes, the diagnosis depends on both a clinical diagnosis and a pathological diagnosis (i.e., based on the examination of brain tissue, usually from [[autopsy]]). | The final diagnosis of dementia is made on the basis of the clinical picture, increasingly with neuroimaging results for backup. For research purposes, the diagnosis depends on both a clinical diagnosis and a pathological diagnosis (i.e., based on the examination of brain tissue, usually from [[autopsy]]).<ref name="pmid11342678">{{cite journal |vauthors=Knopman DS, DeKosky ST, Cummings JL, Chui H, Corey-Bloom J, Relkin N, Small GW, Miller B, Stevens JC |title=Practice parameter: diagnosis of dementia (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology |journal=Neurology |volume=56 |issue=9 |pages=1143–53 |date=May 2001 |pmid=11342678 |doi=10.1212/wnl.56.9.1143 |url=}}</ref> | ||
Proper differential diagnosis between the types of dementia (see below) will require, at the least, referral to a specialist, e.g. a geriatric internist, geriatric psychiatrist, neurologist, neuropsychologist or | Proper differential diagnosis between the types of dementia (see below) will require, at the least, referral to a specialist, e.g. a geriatric internist, geriatric psychiatrist, neurologist, neuropsychologist or gero psychologist. However, there are some brief (5-15 minutes) tests that have good reliability and can be used in the office or other setting to evaluate cognitive status. Examples of such tests include the [[abbreviated mental test score]] (AMTS), the [[mini mental state examination]] (MMSE), Modified Mini-Mental State Examination (3MS)<ref name="pmid3611032">Teng E L, Chui H C. The Modified Mini-Mental State (3MS) examination. J Clin Psychiatry 1987;48:314–18. PMID 3611032</ref>, the Cognitive Abilities Screening Instrument (CASI)<ref name="pmid8054493">Teng E L, Hasegawa K, Homma A, et al. The Cognitive Abilities Screening Instrument (CASI): a practical test for cross-cultural epidemiological studies of dementia. Int Psychogeriatr 1994;6:45–58. PMID 8054493</ref>, and the clock drawing test<ref name="pmid9598672">{{cite journal |author=Royall, D.; Cordes J.; & Polk M. |title=CLOX: an executive clock drawing task |journal=J Neurol Neurosurg Psychiatry |volume=64 |issue=5 |pages=588-94 |year=1998 |pmid=9598672|url=http://jnnp.bmj.com/cgi/content/full/64/5/588}}</ref>. | ||
An [[abbreviated mental test score|AMTS]] score of less than six (out of a possible score of ten) and an [[Mini-mental state examination|MMSE]] score under 24 (out of a possible score of 30) suggests a need for further evaluation. Scores must be interpreted in the context of the person's educational and other background, and the particular circumstances (for example, a person in great pain will not be expected to do well on many tests of mental ability). | An [[abbreviated mental test score|AMTS]] score of less than six (out of a possible score of ten) and an [[Mini-mental state examination|MMSE]] score under 24 (out of a possible score of 30) suggests a need for further evaluation. Scores must be interpreted in the context of the person's educational and other background, and the particular circumstances (for example, a person in great pain will not be expected to do well on many tests of mental ability). | ||
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{{main|Mini-mental state examination}} | {{main|Mini-mental state examination}} | ||
The [http://www.ahrq.gov/clinic/uspstfix.htm U.S. Preventive Services Task Force (USPSTF)] reviewed tests for cognitive impairment and concluded <ref name="pmid12779304">{{cite journal |author=Boustani, M.; Peterson, B.; Hanson, L.; Harris, R.; & Lohr, K.|title=Screening for dementia in primary care: a summary of the evidence for the U.S. Preventive Services Task Force |journal=Ann Intern Med |volume=138 |issue=11 |pages=927-37 |year=2003 |pmid=12779304|url=http://www.annals.org/cgi/content/full/138/11/927}}</ref>: | The [http://www.ahrq.gov/clinic/uspstfix.htm U.S. Preventive Services Task Force (USPSTF)] reviewed tests for cognitive impairment and concluded <ref name="pmid12779304">{{cite journal |author=Boustani, M.; Peterson, B.; Hanson, L.; Harris, R.; & Lohr, K.|title=Screening for dementia in primary care: a summary of the evidence for the U.S. Preventive Services Task Force |journal=Ann Intern Med |volume=138 |issue=11 |pages=927-37 |year=2003 |pmid=12779304|url=http://www.annals.org/cgi/content/full/138/11/927}}</ref>: | ||
* [[Mini-mental state examination|MMSE]] | |||
: sensitivity 71% to 92% | *[[Mini-mental state examination|MMSE]] | ||
: specificity 56% to 96% | |||
:sensitivity 71% to 92% | |||
:specificity 56% to 96% | |||
A copy of the [[Mini-mental state examination|MMSE]] can be found in the appendix of the original publication.<ref name="pmid1202204">{{cite journal |author=Folstein MF, Folstein SE, McHugh PR |title="Mini-mental state". A practical method for grading the cognitive state of patients for the clinician |journal=Journal of psychiatric research |volume=12 |issue=3|pages=189-98|year=1975 |pmid=1202204 |doi=10.1016/0022-3956(75)90026-6}}</ref> | A copy of the [[Mini-mental state examination|MMSE]] can be found in the appendix of the original publication.<ref name="pmid1202204">{{cite journal |author=Folstein MF, Folstein SE, McHugh PR |title="Mini-mental state". A practical method for grading the cognitive state of patients for the clinician |journal=Journal of psychiatric research |volume=12 |issue=3|pages=189-98|year=1975 |pmid=1202204 |doi=10.1016/0022-3956(75)90026-6}}</ref> | ||
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A copy of the 3MS is online.<ref>{{cite web |url=http://www.cjns.org/27febtoc/predicting_appendix_.html |title=Appendix: The Modified Mini-Mental State (3MS) |accessdate=2007-09-06 |format= |work=}}</ref> A [[meta-analysis]] concluded that the Modified Mini-Mental State (3MS) examination has:<ref name="pmid17178826">Cullen B, O'Neill B, Evans JJ, Coen RF, Lawlor BA. A review of screening tests for cognitive impairment. | A copy of the 3MS is online.<ref>{{cite web |url=http://www.cjns.org/27febtoc/predicting_appendix_.html |title=Appendix: The Modified Mini-Mental State (3MS) |accessdate=2007-09-06 |format= |work=}}</ref> A [[meta-analysis]] concluded that the Modified Mini-Mental State (3MS) examination has:<ref name="pmid17178826">Cullen B, O'Neill B, Evans JJ, Coen RF, Lawlor BA. A review of screening tests for cognitive impairment. | ||
J Neurol Neurosurg Psychiatry. 2007 Aug;78(8):790-9. Epub 2006 Dec 18. PMID 17178826</ref> | J Neurol Neurosurg Psychiatry. 2007 Aug;78(8):790-9. Epub 2006 Dec 18. PMID 17178826</ref> | ||
: sensitivity 83% to 94% | |||
: specificity 85% to 90% | :sensitivity 83% to 94% | ||
:specificity 85% to 90% | |||
===Abbreviated Mental Test Score=== | ===Abbreviated Mental Test Score=== | ||
{{main|abbreviated mental test score}} | {{main|abbreviated mental test score}} | ||
A [[meta-analysis]] concluded:<ref name="pmid17178826"/> | A [[meta-analysis]] concluded:<ref name="pmid17178826" /> | ||
: sensitivity 73% to 100% | |||
: specificity 71% to 100% | :sensitivity 73% to 100% | ||
:specificity 71% to 100% | |||
===Other Examinations=== | ===Other Examinations=== | ||
| Line 35: | Line 43: | ||
Further evaluation includes retesting at another date, and administration of other (and sometimes more complex) tests of mental function, such as formal neuropsychological testing. | Further evaluation includes retesting at another date, and administration of other (and sometimes more complex) tests of mental function, such as formal neuropsychological testing. | ||
=== Associated Conditions === | ===Associated Conditions=== | ||
* Behavioural disorders | |||
* [[Delirium]] | *Behavioural disorders | ||
* [[Delusion]] | *[[Delirium]] | ||
* [[Depression]] | *[[Delusion]] | ||
* [[Hallucinations]] | *[[Depression]] | ||
*[[Hallucinations]] | |||
===Criteria for Diagnosis=== | |||
*[[Amnesia]] | |||
*Impairment of abstract thinking | |||
*Limited judgment ability | |||
*Orientation disturbances | |||
*Impairment of higher cognitive functions: | |||
*:*Acalculia | |||
*:*[[Agnosia]] | |||
*:*[[Aphasia]] | |||
*:*[[Apraxia]] | |||
*:*Personality changes | |||
=== | ===Severity of Dementia=== | ||
*'''Mild''': Independent personal hygiene and judgment are retained, but a reduced performance in social activities or household activities is noticed | |||
* '''Mild''': Independent personal hygiene and judgment are retained, but a reduced performance in social activities or household activities is noticed | *'''Medium''': Some monitoring necessary, living independently is dangerous | ||
* '''Medium''': Some monitoring necessary, living independently is dangerous | *'''Severe''': Permanent care and monitoring absolutely necessary, serious loss of independence | ||
* '''Severe''': Permanent care and monitoring absolutely necessary, serious loss of independence | |||
==References== | ==References== | ||
Latest revision as of 14:57, 9 October 2020
|
Dementia Microchapters |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: ,Sabeeh Islam, MBBS[2]
Overview
A thorough general physical examination followed by focused focal neurologic deficits examination that may be consistent with prior strokes, parkinsonism (rigidity and/or tremors), gait abnormalities or slowing, and eye movements should be preferably done. Some patients with Alzheimer disease (AD) generally have no motor or sensory deficits at presentation.
Physical Examination
The final diagnosis of dementia is made on the basis of the clinical picture, increasingly with neuroimaging results for backup. For research purposes, the diagnosis depends on both a clinical diagnosis and a pathological diagnosis (i.e., based on the examination of brain tissue, usually from autopsy).[1]
Proper differential diagnosis between the types of dementia (see below) will require, at the least, referral to a specialist, e.g. a geriatric internist, geriatric psychiatrist, neurologist, neuropsychologist or gero psychologist. However, there are some brief (5-15 minutes) tests that have good reliability and can be used in the office or other setting to evaluate cognitive status. Examples of such tests include the abbreviated mental test score (AMTS), the mini mental state examination (MMSE), Modified Mini-Mental State Examination (3MS)[2], the Cognitive Abilities Screening Instrument (CASI)[3], and the clock drawing test[4].
An AMTS score of less than six (out of a possible score of ten) and an MMSE score under 24 (out of a possible score of 30) suggests a need for further evaluation. Scores must be interpreted in the context of the person's educational and other background, and the particular circumstances (for example, a person in great pain will not be expected to do well on many tests of mental ability).
Mini-Mental State Examination
The U.S. Preventive Services Task Force (USPSTF) reviewed tests for cognitive impairment and concluded [5]:
- sensitivity 71% to 92%
- specificity 56% to 96%
A copy of the MMSE can be found in the appendix of the original publication.[6]
Modified Mini-Mental State Examination (3MS)
A copy of the 3MS is online.[7] A meta-analysis concluded that the Modified Mini-Mental State (3MS) examination has:[8]
- sensitivity 83% to 94%
- specificity 85% to 90%
Abbreviated Mental Test Score
A meta-analysis concluded:[8]
- sensitivity 73% to 100%
- specificity 71% to 100%
Other Examinations
Many other tests have been studied [9][10] [11] including the clock-drawing test example form). Although some may emerge as better alternatives to the MMSE, presently the MMSE is the best studied. However, access to the MMSE is now limited by enforcement of its copyright (details).
Further evaluation includes retesting at another date, and administration of other (and sometimes more complex) tests of mental function, such as formal neuropsychological testing.
Associated Conditions
- Behavioural disorders
- Delirium
- Delusion
- Depression
- Hallucinations
Criteria for Diagnosis
- Amnesia
- Impairment of abstract thinking
- Limited judgment ability
- Orientation disturbances
- Impairment of higher cognitive functions:
Severity of Dementia
- Mild: Independent personal hygiene and judgment are retained, but a reduced performance in social activities or household activities is noticed
- Medium: Some monitoring necessary, living independently is dangerous
- Severe: Permanent care and monitoring absolutely necessary, serious loss of independence
References
- ↑ Knopman DS, DeKosky ST, Cummings JL, Chui H, Corey-Bloom J, Relkin N, Small GW, Miller B, Stevens JC (May 2001). "Practice parameter: diagnosis of dementia (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology". Neurology. 56 (9): 1143–53. doi:10.1212/wnl.56.9.1143. PMID 11342678.
- ↑ Teng E L, Chui H C. The Modified Mini-Mental State (3MS) examination. J Clin Psychiatry 1987;48:314–18. PMID 3611032
- ↑ Teng E L, Hasegawa K, Homma A, et al. The Cognitive Abilities Screening Instrument (CASI): a practical test for cross-cultural epidemiological studies of dementia. Int Psychogeriatr 1994;6:45–58. PMID 8054493
- ↑ Royall, D.; Cordes J.; & Polk M. (1998). "CLOX: an executive clock drawing task". J Neurol Neurosurg Psychiatry. 64 (5): 588–94. PMID 9598672.
- ↑ Boustani, M.; Peterson, B.; Hanson, L.; Harris, R.; & Lohr, K. (2003). "Screening for dementia in primary care: a summary of the evidence for the U.S. Preventive Services Task Force". Ann Intern Med. 138 (11): 927–37. PMID 12779304.
- ↑ Folstein MF, Folstein SE, McHugh PR (1975). ""Mini-mental state". A practical method for grading the cognitive state of patients for the clinician". Journal of psychiatric research. 12 (3): 189–98. doi:10.1016/0022-3956(75)90026-6. PMID 1202204.
- ↑ "Appendix: The Modified Mini-Mental State (3MS)". Retrieved 2007-09-06.
- ↑ 8.0 8.1 Cullen B, O'Neill B, Evans JJ, Coen RF, Lawlor BA. A review of screening tests for cognitive impairment. J Neurol Neurosurg Psychiatry. 2007 Aug;78(8):790-9. Epub 2006 Dec 18. PMID 17178826
- ↑ Sager, M.; Hermann, B.; La Rue, A.; & Woodard, J. (2006). "Screening for dementia in community-based memory clinics". WMJ. 105 (7): 25–9. PMID 17163083.
- ↑ Fleisher, A.; Sowell B.; Taylor C.; Gamst A.; Petersen R.; & Thal L. "Clinical predictors of progression to Alzheimer disease in amnestic mild cognitive impairment". Neurology. PMID 17287448.
- ↑ Karlawish, J. & Clark, C. (2003). "Diagnostic evaluation of elderly patients with mild memory problems". Ann Intern Med. 138 (5): 411–9. PMID 12614094.