2. The presence of the following three elements: a. Clear evidence of decline in memory and learning and in at least one other neuro-cognitive domain: complex attention, executive function, language, perceptual motor, or social cognition (from detailed history or multiple neuropsychological testing). b. Progressive cognitive decline. c. An absence of evidence of mixed etiology. Elements of diagnostic workup Individuals who experience disconcerting memory and cognitive issues should have a comprehensive diagnostic workup from their primary care physician, a neurologist, or a gerontologist. The diagnostic evaluation for a person suspected of having AD will include the following elements: ● A complete patient history: Including a detailed description of what memory or cognitive issues are present and how and when these symptoms developed, should be obtained. A pertinent medical history should also be obtained, including a review of such risk factors as history of head trauma and/or neurological or cardiovascular conditions. Current prescription and over-the-counter medications should be scrutinized. ● A physical examination : Should include vital signs assessment (to rule out orthostatic hypotension and cardiac irregularities), comprehensive neurological screening, and hearing and vision screens (individuals who do not hear or see well can seem confused and forgetful). ● A psychosocial assessment : Should investigate the patient’s emotional state, including screening for depression (depression can cause pseudo-dementia). ● An environmental assessment : Should evaluate the patient’s living environment. Ideally, information regarding the patient’s psychosocial status and living environment (including behavioral issues and safety concerns) should be corroborated with others because cognitive impairment can preclude effective and accurate communication between a patient and a healthcare provider. ● Laboratory blood tests: Typically include a complete blood count, serum electrolyte levels, chemistry and thyroid panels, glucose levels, liver function studies that include blood urea nitrogen and creatinine levels, vitamin B 12 and folate studies, erythrocyte sedimentation rate, and drug (e.g., digoxin) levels. These tests are conducted to assess potential causes of reversible conditions. ● Neuroimaging : Such as a computed tomography (CT) scan or MRI, rules out strokes or tumors and can reveal changes in the brain’s structure and function that may suggest a specific dementia diagnosis. PET imaging reflects the brain’s metabolic activity, and in patients with AD, the temporal and parietal lobes may exhibit diminished activity. Single photon emission computed tomography (SPECT) and electroencephalography (EEG) may also be used. ● Neuropsychological testing : Includes measures of intelligence, memory, language, executive function, visuo-perceptual skills, and other abilities related to brain functioning. A comprehensive neuropsychological assessment involves multiple tests over several hours. During an initial workup with a physician, screening tools are used to indicate the need for further testing; these screening tools do not diagnose dementia, but identify the need for further workup. The most commonly performed screening tests are the Mini-Mental State Examination (MMSE), the Mini- Cog Assessment, and the Montreal Cognitive Assessment (MoCA). These screening tools are briefly reviewed next and positive findings would ideally lead to more extensive neuropsychological testing to determine a true diagnosis of dementia. Cultural and language barriers can impact performance on these tests. The MMSE (Folstein, Folstein, & McHugh, 1975) is a widely employed screening tool that has been used extensively in research studies with individuals who have dementia to
The diagnosis of mild, or “minor” NCD due to AD is made using the same criteria as those used for major NCD due to AD, except that memory and learning represent the only impaired neurocognitive domain. For minor NCD due to AD, the absence of a genetic mutation changes the diagnosis of AD from probable to possible.
provide some objective classification of the cognitive status of participants. The tool assesses orientation, registration/ repetition, attention/calculation, recall, and language. Specific questions include: ● Orientation to time (year, season, date, day, month). ● Orientation to place (state, county, town, hospital or building, floor). ● Registration and immediate repetition of three unrelated items. ● Recall memory of three unrelated items after delay and distraction. ● Serial subtraction of 7 from 100, or correct spelling of a five- letter word backwards. ● Naming of visualized objects. ● Following a three-part instruction. The MMSE generally takes about 10 minutes to complete, and respondents receive a point for each correct response for a maximum score of 30. A cutoff score of 24 or 25 is often cited in the literature as consistent with dementia (Creavin, 2016), although a higher cutoff score (27 or greater) has been identified as the optimal sensitivity/specificity balance to delineate no cognitive impairment from MCI for college educated people (O’Bryant et al., 2008). The specific cutoffs to delineate mild from moderate or moderate from severe impairment are often operationally defined in specific studies. ● Writing a sentence. ● Copying a figure. The Mini-Cog Assessment involves remembering three items and completing a clock drawing test (CDT; Borson, Scanlan, Brush, Vitaliano, & Dokmak, 2000). The CDT entails drawing the face of a clock in a provided circle, including numbers and hands indicating a specified time (“ten past eleven”). While seemingly simple, the CDT is a measure of memory, strategy, vision, and processing of information, and it also serves as a recall distractor to the three uncued items that are shared prior to the CDT. Instructions to draw the clock showing the designated time can be repeated, and individuals are given as much time as needed for the drawing. The CDT is “normal” if all numbers are present in the correct sequence and position and if the hands accurately display the requested time. After completion of the CDT, the person is asked to recall the three items. A recall of all three items (regardless of the CDT outcome), or a recall of one or two items and a normal CDT drawing, indicate a negative screen for dementia. A recall of zero items, or a recall of one or two items with an abnormal CDT, is a positive screen for dementia. The MoCA was developed as a quick way for primary care physicians to screen for MCI (Nasreddine et al., 2005). The most recent version of the tool consists of: ● Visuospatial/executive functioning tasks, consisting of an abbreviated alternating trail-making test (linking 1 to A to 2 to B . . .), copying a cube, and the clock drawing test. ● Naming three animals from pictures. ● Memory task with five words requiring immediate and 5-minute delayed recall. ● Attention tasks, including repeating a list of numbers (5 digits) and repeating a list of numbers in reverse order (3 digits), responding to a specific letter in a list of letters, and serial seven subtractions. ● Language tasks, including repetition of two sentences and fluency assessment of naming words in a category.
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Book Code: PTNY3622B
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