The Dementia Diagnosis
April 20, 2019
By Karen Wilkinson, RN, NHA, CLNC
– CareerSmart® Learning Contributor
Diagnosis [dahy-uhg-noh-sis]: 1. Medicine/Medical. a: the process of determining by examination the nature and circumstances of a disease condition. b: the decision reached from such an examination. Abbreviation: Dx.
Being on the receiving end of a diagnosis is anxiety-provoking. At best, a diagnosis is received with relief because bad things have been ruled out. But, what happens when a medical workup rules out other bad things but still lands in uncertain, or even undesirable, territory? Such is the path for those with dementia. No one wants to hear that they have dementia; but, a diagnosis is important and necessary to provide a framework for care planning.
Dementia simply describes a set of symptoms, such as memory loss, difficulty with problem-solving or language, or even changes in mood or behavior. Each person’s symptoms are unique and are based on the disease causing the dementia and the areas of the brain that have been damaged. Alzheimer’s disease, the most prevalent form of dementia, is caused by abnormal proteins in the brain and affects 5.8 million Americans. It is projected that nearly 14 million Americans will be affected by 2050. Vascular dementia caused by a stroke or cumulative damage to blood vessels in the brain affects five to ten percent of cases and is the second most common type of dementia after Alzheimer’s. Other types of dementias include Lewy Body, Frontotemporal, Down syndrome & Alzheimer’s, Normal pressure hydrocephalus, Creutzfeldt-Jakob disease, Huntington’s disease, and Mixed Dementia. Despite the number of people affected and the multiple types of dementia identified, regular cognitive assessments are only performed during routine check-ups for 16% of seniors.
Doctors can determine a diagnosis of dementia fairly easily but may have more difficulty determining the type of dementia. Diagnostic evaluation will start with a thorough medical history and physical exam that includes a review of illnesses, medications, cognitive changes, psychiatric history, behavioral and mood changes, nutritional status, use of alcohol, and family history of dementia. Appropriate laboratory testing may be ordered to rule out treatable causes of dementia, such as infection, depression, vitamin deficiencies, thyroid dysfunction, side effects of medications, and/or the use of excessive alcohol. A mental status exam, such as the Mini-Mental Status Exam (MMSE) or the Mini-Cog™, may be used to assess mental skills. A neurological exam will rule out other brain disorders that may cause problems with memory or thinking. In some cases, more than one type of dementia is present and may require a neurologist or gero-psychologist to accurately diagnose.
Imaging studies of the brain may be ordered, most commonly magnetic resonance imaging (MRI) and computed tomography (CT). These tests will detect anatomical abnormalities in the brain and identify atrophy, a common feature in degenerative dementia, as well as vascular damage and infarcts in the brain, common in vascular dementia. Until recently, Alzheimer’s disease has only been accurately diagnosed after death by autopsy examination of the brain. However, research using Amyloid PET scans has allowed identification of amyloid plaques in living patients being evaluated for Alzheimer’s disease. A four-year study titled “Imaging Dementia – Evidence for Amyloid Scanning” (IDEAS) just published results of their phase one study which demonstrated that amyloid PET imaging can improve the timeliness and accuracy of Alzheimer’s diagnosis and result in better medical management through symptom management, care planning, and the ability to direct to appropriate clinical drug trials. Although Centers for Medicare & Medicaid Services (CMS) reimbursed the amyloid PET scans as part of the clinical study, the scans are not currently covered by Medicare or health insurance plans, so are unavailable to most people. Second phase results analyzing health outcomes following the scan will be available in 2020. A second study known as New IDEAS is currently being developed.
National guidelines for evaluating cognitive impairment have not been formulated, and many people have mild symptoms that are dismissed as being a normal part of aging. According to AARP, one thing that patients and providers do agree on is the importance of regular cognitive screening. Ninety-four percent of primary care physicians think it important to assess patients age 65 and older, and 82 percent of patients in that age group agree. As healthcare professionals, we can educate and encourage our patients to ask their physicians about cognitive screening. For most, a normal cognitive assessment will be a relief.
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6,7, Alzheimer’s Association. (2019). Medical Tests. Retrieved 04/16/2019 from https://alz.org/alzheimers-dementia/diagnosis/medical_tests
8 Bonifacio, G. & Zamboni, G. (2016). Brain imaging in dementia. Retrieved 04/16/2019 from http://dx.doi.org/10/1136/postgradmedj-2015-13759.
9 Centers for Medicare & Medicaid Services. (2018). Amyloid PET. Retrieved 04/16/2019 from https://www.cms.gov/Medicare/Coverage/Coverage-with-Evidence-Development/Amyloid-PET.html
10 IDEAS Imaging Dementia-Evidence For Amyloid Scanning. (2019, April). Alzheimer’s Diagnosis, Management Improved by Brain Scans. Retrieved 04/16/2019 from https://www.ideas-study.org/2019/04/01/results-of-the-ideas-study-just-published-in-jama/
11 Adler, S.E. (2019, March 05). Does Your Doctor Ask to Test Your Memory? AARP. Retrieved from https://www.aarp.org/health/dementia/info-2019/older-people-assessed-for-cognitive-issues.html