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.
