TESTS FOR DEMENTIA

In most cases, the family physician or internist is the first medical professional seen by a patient suspected of having dementia! As such, the physician needs to have the knowledge to know when a person is having cognitive difficulties and possess the tools to evaluate the patient on the spot. Family members or individuals close to the patient are usually the folks who recognize there is a problem and accompany the individual for an evaluation so the doctor has to have at hand a set of questions to ask the “informant.” It is rare for a truly demented patient to present to the doctor of his own volition having recognized they have a cognitive problem. If the patient comes to the doctor worried he/she is developing Alzheimer’s Disease, there is a huge likelihood they are not. Patients with dementia are rarely aware they have a problem.

The family physician/internist has two very basic screening tools at his discretion: the General Practitioner Assessment of Cognition (GPCOG) and the Mini-Cog. The GPCOG takes 4 minutes to complete and has questions for both the family member/caregiver and the patient. To establish if there is a reason for concern, the family member, or “informant,” is questioned first and is  asked, “Compared to 5 to 10 years ago….

     Does the patient have more trouble remembering recent events?

     Does he/she have trouble remembering recent conversations?

     Does he/she have more trouble remembering the right word or use the wrong word(s)?

     Is he/she having more trouble managing money or finances?

     Does he/she need more help with public, or private, transportation?

If those questions indicate a problem, then the doctor asks the following questions of the patient…..

     Repeat a fictitious name and address the doctor tells the patient to remember 

     Ask the patient today’s date

     Ask him/her to draw the face of a clock noting the location of 3, 6, 9, & 12.

     Tell him/her to place the hands of the clock at 10 past 11.

     Ask him/her to tell of a recent news event.

     Ask him/her to recall the name and address mentioned earlier

Correct/incorrect answers will indicate there are signs of dementia and thus, more extensive in- depth testing should be done. 

The GPCOG test is 79% sensitive and 92% specific meaning that 79% of patients will reveal they have a problem and 92% of the time it will be dementia. The Mini-Cog takes only 3 minutes and detects a problem 76%-100% of the time and 27%-85% of the time it is dementia.

The GPCOG and Mini-Cog are screening tools. When they indicate a problem, the patient needs to return to take the Mini Mental Status Exam (MMSE), the 10-minute Montreal Cognitive Asessment (MCoA), or the 7-minute St. Louis University Mental Status Exam (SLUMS). The latter three tests get to the heart of the matter very effectively, and expose cognitive deficits very clearly. Of these, the SLUMS has the best results—93% sensitivity and 96% specificity! Fail that test, and the patient has a very poor outlook. 

In practice, I used the MMSE nearly every day. It asks for memory, reasoning, and numerical organization. I would ask the patient the following list of questions and tasks:

   What is your name, address, date of birth, age, place of birth?

   What is the day of the week, month, year? What season of the year?

   I point to three objects in the room and ask patient to name them.

   Who is President of the U.S.? Who before him? Before him? Go back in order as far as you

      can remember.

   Subtract 7 from 100. Subtract 7 from that number. Continues as far back as you can go.

   What does this phrase mean? “A rolling stone gathers no moss.” “A bird in the hand is worth

      two in the bush.” “All that glitters isn’t gold.” Etc.

   Name the three objects I pointed to a few minutes ago.

   Draw the face of a clock and place the hands at 11:10. 

When these questions and tasks are done by the patient, they are also witnessed by anxious, concerned family members who could see as I did, the patient was performing the test poorly.

By this point, I have already decided the patient does or does not have a problem. If they can’t subtract 7 from 100, remember the Presidents, interpret the phrases, remember the three objects, and draw the face of a clock, I am ordering a head CT or MRI, and writing down the name and phone number of my favorite neurologist for the patient’s family. As I said, this scenario was nearly a daily occurrence in my later years of practice. As I aged so did my patients and thus the frequency of cognitive problems increased. 

Patients are living longer, today—at least those not killed by fentanyl. Dementias of various types are seen more often, too, and as I mentioned the primary care doctor needs to educate himself/herself on how to evaluate these cognitively declining seniors. It takes extra time, but it’s easy to do, and the patient’s family members will be very appreciative of the effort you put forth. It can be upsetting for them to see their loved-one is such a state of confusion, but it may serve to motivate them to help more and better understand the patient’s plight. 

Reference: “Point-of-care-Guides”: Initial Evaluation of Clinically Suspected Dementia by Kaplan and Merrill. Am Fam Phys 2023 December;108(6):624-625.