The Mental Status Examination in Patients With Suspected Dementia (Dementia 2016)

Educational Objectives

The goal of this lecture is to improve the diagnosis and treatment of dementia. After hearing and assimilating this lecture, the clinician will be better able to:

1. Recognize typical and atypical presentations of dementia.
2. Diagnose primary progressive aphasia.

Summary

Context of examination: Mental status examination has changed over time; disease-modifying treatments for neurodegenerative diseases now being developed; mental status examination may serve as cost-effective screening tool for identifying patients eligible for expensive treatments; diagnosis of dementia encompasses not only issues with memory, but also disorders of language, social functioning, or visuospatial function; mental status examination may be used to screen for these conditions and their causes; dementia not diagnosed exclusively in elderly patients; important elements of history include demographic information, medical comorbidities, medications, and general review of symptoms.

Review of symptoms: Used to assess deficits of memory, language, executive function, and social comportment; general approach — to help direct choice of assessments to be incorporated into mental status examination, each domain of cognition should be reviewed in the history before performing examination; assessing deficits in different domains — asking direct questions about difficulties with memory may not reveal deficits because patients’ conceptualizations of “memory” may differ; for example, patients who have difficulty remembering names of objects or words while speaking may report this as a deficit of memory rather than of word finding; similarly, difficulty remembering how to perform complex activities (indicating deficit in executive functions that govern planning and organizing) may be interpreted by patients as memory deficit.

Specific questions: Examiner may find it helpful to ask questions about daily activities; to learn about episodic memory, patient may be asked how he or she shops for food (eg, does patient make shopping list or bring family member along to ensure that appropriate food purchased; do cupboards contain adequate assortment of food); to assess visuospatial problems, examiner may ask about difficulties with dressing or driving and parking; executive function may be assessed by asking, eg, how bills paid, whether patient can follow recipe when cooking.

Behavioral symptoms: Although asking patient questions about behavior worthwhile, patients with anosognosia may not appreciate own behavior from another’s perspective; family members accompanying patient should be queried as well, especially when assessing social functioning; abnormal behaviors may include disinhibition and unusual behaviors in public (eg, public urination, talking to strangers on street, making inappropriate comments); issues related to apathy, ability to initiate activities, and motivation should be explored; obsessive or ritualistic behaviors may entail repetitive movements or complex rituals (eg, insisting on eating in particular way, developing unusual collections); any type of cognitive change may cause patient to develop agitation and to become easily upset (can be primary feature of neurologic conditions such as frontotemporal dementia or may reflect depression, frustration, and/or anger about deficits); significant stress experienced by family members in these situations may color their responses about patient’s behavior.

Case 1: A 68-year-old attorney accompanied by her son; son concerned about her memory, but patient minimized problem; assessment — neurologist must consider Alzheimer disease or amnestic mild cognitive impairment; review of cognitive systems should focus on examples of difficulties with memory and whether problem progressing; other features associated with Alzheimer disease include word-finding problems and difficulties with comprehension, reading, writing, visuospatial function, or executive function; specific questions — in this patient, questions should be asked about status of law practice; if examination supports son’s assertions, advisability of continuing to practice law should be explored with patient and son; differential diagnosis — in 68-year-old, neurologist should ask about past medical history and vascular risk factors (patient may have had small strokes secondary to small-vessel ischemic disease); other concerns include side effects of medications, dietary habits, and endocrinologic status (eg, deficiency of vitamin B₁₂, malfunction of thyroid); functional ability — neurologist should ask whether patient living alone and determine whether she can safely self-administer medications; in this patient, stress of legal practice and/or mood disorder may contribute to problem.

Case 2: A 50-year-old high school teacher recently became flirtatious with several girls in his classes; patient secretive and withdrawn from family; he recently withheld disclosure of negative financial “adventures”; assessment — in 50-year-old with inappropriate social behavior, frontotemporal degeneration should be considered; patient may be asked about other examples of socially inappropriate, hypersexual, disinhibited, or hyperoral behavior (eg, change in eating habits); patient’s judgment should be assessed: he may have been victim of financial scam; neurologist should ascertain whether new rituals or inappropriate agitation has developed; to explore executive function, physician may ask whether patient having trouble organizing lesson plans; history from colleague or family member helpful when assessing social behavior; patients with frontotemporal dementia may have little insight into appropriateness of their behavior; teacher should be asked about his own insight into his flirtatious behavior; physician should determine whether changes progressive, acute, or sudden (ie, sudden onset could suggest head injury); as in previous case, patient’s behavior could result in legal consequences; therefore, documentation of onset highly important.

Case 3: A 55-year-old secretary came to office accompanied by coworker and friend, who expressed concerns about possibility that patient might lose her job; patient making “odd” mistakes and recently became incapable of understanding dictation recorded by boss; at times, she appears to have difficulty understanding coworker.

Assessment: Patient may have progressive aphasia; aphasia — disorder of language that takes three primary forms; patients with nonfluent agrammatic variant do not speak fluently and have difficulty with grammatical aspects of speech; they may “drop” short words and have difficulty understanding sentences; patients with semantic variant of primary progressive aphasia have difficulty understanding meanings of individual words, naming objects, and understanding nature of objects themselves; patients with logopenic variant have difficulty with word finding and repetition on examination; patients may have difficulty understanding single words but usually understand objects, or have difficulty understanding long sentences; neurologist should ask about fluency of speech and determine which types of difficulties with comprehension patient experiences; some patients with progressive aphasia have problems with reading and writing; those with semantic variant may have difficulty with sight vocabulary and may mispronounce words when reading; patients with nonfluent agrammatic variant may write and speak telegraphically; other issues — in 55-year-old, difficulty with hearing should be ruled out as possible contributing factor; some variants of progressive aphasia may be early features of Alzheimer disease; therefore, patients should be asked about memory, visuospatial function, and other cognitive domains.

Screening tests: Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) appropriate for use by general neurologist; such tools useful for screening but not for diagnosis; these instruments may be used to determine whether cognitive problems worsening over time or improving in response to treatment; consultation with neuropsychologist may be helpful in making specific diagnosis; neuropsychologists use battery of tasks that measure memory, language, visuospatial, and executive function; collaboration valuable for interpreting findings and providing longitudinal quantitative assessment.

Summary: Although patients or families may focus on language, neurologist should assess every aspect of cognition and social function and should become comfortable with set of key measures for each domain.

Readings

Grossman M. The mental status examination in patients with suspected dementia. Continuum (Minneap Minn) 2016;22(2 Dementia).

Disclosures

For this program, the following was disclosed: Dr. Grossman receives personal compensation for serving as a consultant for C2N Diagnostics, as a lecturer for the Lundbeck Institute, for serving on the international scientific advisory board of the Max Planck Institutes, and for serving as associate editor of Neurology. Dr. Grossman’s institution has received grant support from the National Institutes of Health (AG017586, AG038490, NS044266, and NS053488), and Dr. Grossman has received research support from the Arkin Family Foundation; the Samuel I. Newhouse Foundation, Inc; and the Wyncote Foundation. Unlabeled Use of Products/Investigational Use Disclosure: Dr. Grossman reports nothing to disclose. To view disclosures of planning committee members with relevant financial relationships, visit: audiodigest.org/continuumaudio/committee. All other members of the planning committee report nothing to disclose.

Acknowledgements

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

CA050501

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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