The starting point in assessing patients for early signs of dementia is to collect background information. A relative or friend of the patient can often provide useful details of their behaviour at home or at work.
They may also be able to confirm the patient's presenting problems, being well aware of how the patient has changed over time and whether they are coping.
Even if the relative or friend finds it difficult to pinpoint the precise nature of the cognitive decline, their impression that the patient is not themself may be a helpful warning sign that all is not as it should be.
Interviewing the patient
Patients may present with a range of mental problems, for example, feeling depressed, or physical difficulties, with many such complaints masking signs of failing intellect, of which they may be unaware.
It is important to elicit why they think they have come for examination, especially because many patients are reluctant to admit to any decline in intellect. If there is reason to suspect the patient has impaired cognitive functions, the following areas should be explored.
1. Impaired memory
Does the patient have problems with their memory? Is this confined to memory of recent events? Long-term memory may also be affected.
When was the problem first noticed, or the patient made aware of it? Is it becoming worse and is it relatively static, or variable? To what extent is it interfering with work, home or social life?
It is helpful if the patient can estimate in percentage terms how bad they perceive the problem to be - for example, memory that is half as good as it should be, or only 75% of what they feel it used to be.
2. Impaired language
Is there difficulty in thinking of words or phrases to say or write down? Is there a loss of train of thought when conversing with others or in 'taking things in', either through speech or by reading? To what extent does this interfere with home, work or social life? As with memory, estimation of the difficulty in percentage terms can be helpful, along with how much it varies.
3. Impaired spatial function
Does the patient have difficulty orientating, when walking or driving, or discriminating left from right?
Is there any problem with body image or difficulty with tasks normally performed without trouble, such as sewing, woodwork, following a pattern or carrying out other activities involving spatial judgment?
Is the impairment in spatial or visuomotor function relatively stable or variable in its course and, if so, to what extent in percentage terms?
4. Impaired concentration
Difficulties in concentration can be one of the earliest symptoms in declining ability, even when normal levels of concentration are still present but cannot be sustained for more than relatively brief intervals.
This may present as difficulty with recent memory, although, in effect, the patient's concentration span is not long enough to 'take in' the information available, even of a relatively uncomplicated nature.
5. Personality and behaviour
Are there indications of changes or difficulties in relationships with others, or increased irritability and lack of patience? Has the patient become more outspoken, less inhibited, more aggressive or more withdrawn? Is their mood state in keeping with the requirements of the situation?
Are there any indications of change in habits or self-care, or not attending to chores to an unusual extent?
Have the changes in personality or behaviour varied, or has there been a progressive decline? A relative or friend's estimate of the changes can be particularly helpful here.
Conversely, a change in personality from worse to better may be significant - for example, from being easily inclined to irritability or displays of temper and assertiveness, to being passive or unusually easy-going.
In general, any report of a decline in cognitive efficiency, or notable alteration in personality or behaviour, should be treated as a possible indication of organic impairment in brain function. The more problems reported or elicited, the more seriously the finding should be taken.
However, sometimes a single complaint, such as: 'I can't get my words out or think of what I want to say,' may be of greater diagnostic value than a host of minor or equivocal ones.
A comparative analysis of the kind of impairments reported may provide a lead as to the nature of the difficulties experienced by the patient.
The patient's medication should be reviewed, to ensure drug therapy is not responsible for their difficulties.
7. Fluctuations in mental or cognitive efficiency
It is important to know if there are times when the patient feels normal, as opposed to those cases where the severity of the impairment or level of difficulty varies, but there is virtually no return to normality.
For example, does the patient's day-to-day efficiency vary from 80-100% of normal, or only from 40-70% of what it should be?
Reports which indicate no return to normality, even when there is some variation in day-to-day (or even within a day) functioning are more likely to have an organic basis.
8. Formal testing
There are many tests and manuals available for assessing patients' intellectual performance. However, it is not recommended for clinicians who are unfamiliar with the detection of early signs of failing intellect to carry out formal testing.
If there is reason to suspect an underlying organic cause for the patient's difficulties, a neurological opinion should be obtained, and if necessary, assessment by a clinical psychologist with experience of neurological disorders.
- Mr Kaufman is a chartered clinical psychologist in Sheffield