This document provides guidance on assessing patients with dementia. It outlines obtaining a clinical history by interviewing both patients and caregivers to understand onset and progression of mental status difficulties. A mental status examination evaluates various domains including orientation, attention, memory, language, perception and construction. Behavioral rating scales like the Mini Mental State Examination and Mattis Dementia Rating Scale can further assess cognitive impairment. Neuropsychological tests may also help confirm dementia but require more time and specialized administration. The mental status examination is the primary tool for diagnosing and managing dementia.

1. APPROACH TO A
PATIENT WITH
DEMENTIA
Dr Sushil Kumar S V
MB BS, MD (psychiatry), MHA, FIPS
Consultant Neuropsychiatrist

2. DEFINITION
• “Dementia “ means a loss of mental functions. It is an
acquired , persistent impairment in multiple areas of
intellectual function not due to delirium.
• Operationally , there is a compromise in 3 or more of the
following 9 spheres of mental activity:
• Memory, language, perception(especially visuospatial),
praxis, calculations, conceptual or semantic knowledge,
executive functions, personality or social behavior, and
emotional awareness or expression.

3. • The compromise in mental functions is documented by
mental status assessment;
• It involves a mental status history; bedside mental status
evaluation ; and a optional use of clinical rating scales ; or
neuropsychological testing.

4. CLINICAL HISTORY
• First step:
Interview caregiver(s) as well as patients
• Patients may lack insight and may deny or minimize any
difficulty
• Contrast between patient’s history and caregiver(s) gives
valuable information.

5. • Second step:
• In addition to obtaining information of onset & progression ,
specific examples of mental status difficulty needs to be
collected.
• Ex: if complaint is memory difficulty ; one needs to ask what
kinds if things or events are not remembered.
• In order to ascertain whether there really is a memory
problem or any other difficulty.

6. • Third step:
• Functional history of activities of daily living such as dressing,
eating, sleeping behavior, personal hygiene, continence, and
instrumental activities such as making a change at a store,
balancing a checkbook, cooking a meal or driving a vehicle.
• It reflects whether there is any decline in usual functioning
and occupational performance.

7. • Fourth step:
• Psychosocial history relevant to dementia
• Patient’s source of support and help with daily activities,
• Current living and safety situations
• The needs and wellbeing of the caregivers.

8. • Other relevant history :
• Prior strokes, psychiatric disturbances, head trauma and
other neurological disturbances which may affect cognitive
functions.
• Patient’s education, sociocultural background, primary
language and handedness as an index of cerebral
dominance are relevant to the interpretation of the mental
status assessment.
• Dementia or cognitive decline among first degree relatives
may reveal a familial or genetic risk.

9. MENTAL STATUS
ASSESSMENT
• It is an integral part of overall assessment
• Interpretation in the context of physical, neurological, lab
examination.
• Physical exam may reveal signs of systemic illness or changes
consequent to dementia ( ex: significant weight loss in
advanced dementia)
• Neurological exam may reveal evidence of focal deficits from
CVA , gait & tone changes from parkinson’s disease,
choreoathetotic movements from Huntington’s disease.

10. • Patients with advanced dementia may manifest primitive
reflexes ( grasp or suck )
• Lab tests for assessing presence of systemic diseases that
might affect mental status or may reveal malnutrition
consequent to dementia.

11. MENTAL STATUS
EXAMINATION
• Step 1
• Determine integrity of fundamental functions ie evaluating
the levels of arousal and attention.
• Recording any lessening of normal level of wakefulness such
as lethargy, drowsiness, stupor or coma
• Checking patient’s ability to maintain attention with a digit
span or serial recitation task.

12. • Step 2
• Screening language function:
• Two subsets – naming ability and word list generation(
verbal fluency) are particularly sensitive ; abnormalities in
either demand additional analysis of language function.

13. • Step 3:
• Evaluate memory:
• Information concerning ability to learn new material is
essential,
• The examiner should supplement orientation tests with a 3
to 4 word learning task with 5 min delayed recall.

14. • Step 4:
• Screen perception and constructions:
• The ability to copy 3 dimensional drawings is a sensitive
index of cerebral dysfunction.
• In addition the clock drawing task is a widely used screening
test that includes visuospatial abilities as well as other
cognitive skills.

15. • Step 5:
• Evaluate personality , social behavior , and emotion.
• Observations about the propriety of interpersonal conduct
and emotional behavior.

16. BEHAVIORAL RATING
SCALES
• Mini mental state examination:(MMSE)
• 30 item instrument which evaluates orientation, registration of
information, attention & calculation, recall, language, and
constructions.
• MMSE takes 5 to 10 min to administer and has high inter- rater
and test-retest reliability
• A total of 23 or less suggests the presence of dementia or other
mental status impairment.
• MMSE also dependent on age and education of patient and scores
as low as 18 may be normal in persons over 85 years of age.
• It is less sensitive for patients with mild cognitive impairment,
frontal subcortical dementia.

17. • Mattis dementia rating scale( DRS)
• Has 5 subsets: attention, initiation, perseveration,
construction, conceptualization, and memory.
• Max score is 144 points. Proceeds from difficult to easier
items. 3o to 45 min needed. Considered equivalent to the
extended mental status examination.
• A revision of DRS , the extended scale for dementia , adds
new items and distinguishes among the orientation items.

18. • Blessed dementia scale (BDS)
• Widely used 2 part scale ; 1: a rating scale assessing
functional status as reported by informants(BDS) , 2: a
mental status examination ( the information- memory-
concentration test)
• BDS includes cognitive, personality, apathy, and basic self
care factors.
• Scores of 4 to 9 – mild impairment, and 10 or more – mod to
severe impairment.
• 2nd part of the scale gives points for failure, scores of 10 or
more are consistent with dementia.

19. STANDARDIZED
NEUROPSYCHOLOGICAL
TESTS
• They can confirm the presence of dementia or of deficits in
the mental status.
• They can be useful in monitoring recovery, assessing
interventions, or developing rehabilitation programs.
• Can provide diagnostic clues as to etiology.
• Some of the tests : for memory ( wechsler memory scale,
california verbal learning test, Rey- Osterrieth complex figure
recall)
• Drawbacks : duration (2 to 6 hours ), not performed in the
usual clinical setting.
• Many dementia patients cannot respond to the test items
producing information of little value.

20. CONCLUSION:
• Mental status examination is more important in the
diagnosis and management of dementia than any other
examination, procedure, or lab test.
• MSE is the main tool and skill needed to assess
• Clinicians must know how to obtain a relevant clinical history
and perform mental status testing in order to assess the
different mental status domains
• Behavioral rating scales, neuropsychological tests can be
used as adjuncts in assessment of dementia.

21. THANK YOU !!!