The Dartmouth Memory Handbook

Section 2: Evaluation

 

Getting a Diagnosis

Robert B. Santulli, M.D.
(revised September, 2016)

Often, there have been many years of active symptoms before a person with a cognitive
disorder finally gets a diagnosis. There are a number of reasons for this: the gradual
onset of Alzheimer’s disease or other dementia; the subtlety of early symptoms; the
reluctance of patients and their families to seek help; the time and expertise it takes for a
busy physician to take the necessary history and perform the necessary office tests; the
stigma associated with Alzheimer’s disease and other memory disorders; among others.
 
While it is never good news to get a diagnosis of Alzheimer’s disease or other serious
cognitive disorder, it is often a relief to patients and families who have long suspected
that something was wrong, but couldn’t identify exactly what the problem was.
 
The Importance of Getting a Diagnosis
Getting a diagnosis allows patients and families to begin to plan for the future, and for
patients (while they are still reasonably cognitively intact) to play an active role in that
planning. It also allows for steps to be taken to insure safety, and to lessen the chance
for exploitation of the cognitively impaired individual. Getting a diagnosis of dementia
should encourage individuals to begin the process of completing Advance Directives as
soon as possible, if these have not already been done. Waiting may mean that the
person with a cognitive disorder may have progressed to the point where he or she is no
longer able to complete these documents legally (see page 223 for more information on
Estate Planning, Durable Powers of Attorney, Advance Directives and Guardianship).
 
Getting a diagnosis of Alzheimer’s disease, or other dementia, also gives the patient and
family an opportunity to learn all they can about the disease, which is important for being
able to cope effectively with it. Finally, getting a diagnosis can lead to the initiation of
medication treatment, which may slow the progression of Alzheimer’s disease, and
possibly other dementias.
 
Beginning the Diagnostic Process
The diagnostic process must begin with the recognition on the part of an individual,
and/or his family, that something is wrong that needs to be investigated. There needs to
be a rejection of the notion that getting very forgetful is an inevitable part of the aging
process. Individuals and families should not be led into thinking that it will “get better”
with time; with time and without treatment memory disorders almost always get worse.
 
Getting a diagnosis usually begins with an evaluation by the primary physician. It is
essential that a care partner be part of that evaluation, as it is unlikely that a person with
a memory disorder will be able to tell the physician all that he or she needs to know to
make a diagnosis, and it is unlikely that the person with the memory disorder will be able
to recall enough of what went on during the visit with the doctor to be informative to the
care partner. A physician who does not permit a care partner to be part of the diagnostic
visit, or who dismisses the concerns of the individual, stating that “It’s normal to be
forgetful when you get older” may be the wrong physician for the person with memory
concerns, and another medical opinion should be sought. Fortunately, those attitudes
are more and more uncommon (but not unheard of) these days.
 
The evaluation by the primary physician may be limited or extensive, depending on the
usual practice of that physician. Some primary care physicians are very skilled at
diagnosing and treating persons with Alzheimer’s disease or other memory disorders,
while others prefer to refer most people with these concerns to a specialist. When
symptoms are atypical, rapidly progressive, not responding to appropriate treatment, or
causing a great deal of distress, a specialist should definitely be consulted. That
specialist might be a geriatrician, a neurologist, or a geriatric psychiatrist. The nature of
the individual’s symptoms may lead to a particular specialist referral.
 
The Detailed Evaluation
The detailed evaluation of someone with memory complaints involves taking a thorough
history of the symptoms from both the person with cognitive difficulties and his or her
primary care partner. It is common that the person with cognitive difficulties and the
primary care partner see the presence or severity of the symptoms quite differently.
Typically, those suffering from the condition tend to see the symptoms as less severe
than do their care partners, who are usually (but not always) more objectively accurate.
This can create a difficult state of “discordance” between the patient and caregiver,
which has a number of negative effects, including increasing the degree of stress
considerably. This issue is discussed in more detail on p.183.
 
Part of the evaluation involves determining what daily behaviors (instrumental activities
of daily living such as driving, handling finances, and the like; and routine activities of
daily living, such as dressing, bathing, eating, and toileting) are impaired; evaluating
what if any mood, behavior or personality changes are present; assessing whether or
not any blood relatives of the individual have had significant cognitive illness; and
reviewing in detail his or her current and past medical history and current medications.
There are many medical conditions and medications that can have a significant impact
on memory, thinking, concentration and other cognitive functions. It may be that a
change in medication or treatment of an underlying medical condition may improve if not
totally eliminate the cognitive difficulty. Depression, anxiety and other psychiatric
conditions, especially if untreated, can cause significant cognitive difficulties, not to
mention general distress.
 
It is also necessary for the physician to review any prior medical records in order to have
a clear picture of the individual’s general health and medication history prior to the
assessment. These should be obtained and sent to the evaluating physician for review
prior to the appointment.
 
Testing
As part of the evaluation, a physical examination should be performed if this has not
been done recently. Certain parts of the general physical or neurological examination
may need to be repeated to determine if there are any conditions present that could
contribute to the current cognitive symptoms.
 
Individuals being evaluated will generally undergo some form of cognitive testing during
the assessment. There are several brief cognitive tests commonly used for this purpose.
These take only a few minutes and are generally well tolerated, unless the individual has
considerable cognitive problems and/or significant defensiveness about his or her
difficulties. A more extensive battery of neuropsychological testing can be useful in
delineating the exact areas of cognitive difficulty, or can be helpful in obtaining a detailed
measure of current cognitive abilities to compare to a previous or future point (see p.
37).
 
Several blood tests are typically performed as part of the evaluation, to rule out
unexpected but generally readily treatable causes of cognitive difficulties, such as
thyroid disease. Laboratory tests are also useful to provide information about other
aspects of the individual’s general health.
 
Head imaging (CT, MRI, or PET scan of the brain) is commonly but not universally
performed as part of the diagnostic assessment. No head imaging study in common use
is able to make a definitive diagnosis of Alzheimer’s disease or any of the other common
dementias, but can be very helpful in ruling out the presence of a brain tumor, stroke,
blood clot, or other lesion that could be a cause of, or contributor to, the symptoms. A
diagnosis of vascular dementia almost always requires head imaging evidence of small
or large strokes or other vascular damage in the brain.
 
The diagnostic process may require more than one visit, and the second visit will often
take place after the laboratory testing and/or neuroimaging has been performed and the
results reviewed.
 
Accuracy of the Diagnosis
Given our current state of knowledge, it is not possible to make a diagnosis of a
particular form of dementia with 100% accuracy no matter how much information is
available, but experienced clinicians can be accurate up to 90% of the time, according to
research. While it is critical to rule out conditions (such as brain tumors) which may be
life threatening, or conditions such as underactive thyroid, which is generally reversible
once diagnosed, it may be difficult, initially, to determine the exact nature of the
dementing illness. However, following an individual over time will often help clarify the
diagnosis, and soon, it is hoped, there will be more accurate diagnostic tools which will
help make the diagnosis of a cognitive disorder earlier, and with greater accuracy.
 
Note: For information about the Dartmouth-Hitchcock Healthy Aging Brain Care Clinic,
please see p. 279.
 

Differential Diagnosis

 
Aleksandra Stark, MD
Assistant Professor of Neurology, Geisel School of Medicine at Dartmouth;
Attending Neurologist, Dartmouth-Hitchcock Medical Center
 
When an older individual presents to the neurologist with complaints of memory or
personality changes, or both, the physician must consider a wide variety of different
conditions. Is this some form of mild cognitive decline? Is it a condition brought on by a
physical disorder or other condition? Or is it some form of dementia?
 
A frequently asked question is “what is the difference between Alzheimer’s disease and
dementia?” Dementia is simply a term that means a person has had cognitive (memory)
decline that has become severe enough that they may require help with their activities of
daily living (paying bills, medication management, and so forth). Alzheimer’s disease is
the most common cause of dementia. A person may have very mild Alzheimer’s
disease, but not meet criteria for dementia if they can function completely independently
and suffer only mild memory impairment. Another question asked is: “Well, we know he
has dementia, so what kind is it?” Not all dementia and memory loss are due to
Alzheimer’s disease. The causes of memory loss can be explained as falling into two
categories: potentially treatable causes of memory loss (medical problems, medications,
vitamin deficiencies) and irreversible or neurodegenerative causes of memory loss. This
chapter will touch briefly on the medical/treatable causes of memory loss although a
thorough review of these is beyond the scope of this chapter, which will focus more on
the neurodegenerative causes of dementia.
 
Some kinds of memory loss are normal as we age. In general, age-associated memory
changes are characterized by some reduction in the ability to learn and remember new
material (mild changes in recent or short-term memory), as well as difficulty coming up
with names of people and places. These changes, although occasionally embarrassing,
are generally not considered to be pathological, but rather part of the normal aging
process. Memory deficits that are due to dementing disorders such as Alzheimer’s
disease are not part of normal aging. Signs and symptoms of Alzheimer’s disease are
discussed elsewhere in this handbook.
 
During a clinical evaluation, a doctor will determine whether the patient meets the criteria
for dementia. As mentioned above, dementia is not a disease, but a term used to signify
the loss of cognitive and functional abilities. Even if dementia is not present, it does not
mean that the patient’s cognition is normal. A patient may have more memory loss than
is normal for their age, but remain functionally independent, and this is called mild
cognitive impairment, or MCI (see p.9).
 
What Is the Cause of MCI or Dementia?
Up to 75% of all dementing illnesses in the elderly (65 and over) are due in whole or in
part to Alzheimer’s disease. Alzheimer’s disease is a neurodegenerative disease of the
brain characterized by a clinical dementia with prominent memory impairment and
specific microscopic pathology including senile plaques and neurofibrillary tangles.
 
Normal Aging, Dementia with Lewy Bodies, Vascular Dementia, Frontotemporal
Dementia – Things to Look for in the History:
Alzheimer’s disease typically starts insidiously with either memory loss or word-finding
difficulties. Other common signs and symptoms a clinician may ask about include
geographical disorientation (getting lost) and impairments in reasoning, problem solving,
and judgment. Apathy, depression, and anxiety are common in mild cognitive
impairment due to Alzheimer’s disease and become more noticeable in very mild and
mild Alzheimer’s disease dementia. Impairment in controlling one’s behavior increases
as the disease progresses.
 
The most common disorders that may be confused with Alzheimer’s disease are other
neurodegenerative dementias. If the patient showed behavioral problems and/or
personality changes first and foremost, or has prominent problems with reasoning and
judgment, then a behavioral variant frontotemporal dementia might be considered (see
p. 97). A primary progressive aphasia may be considered if problems with language
predominate (see p. 109).
 
If there is any evidence of visual hallucinations or illusions, or if there are signs of
parkinsonism (rigidity, slowness of movement, a tremor), dementia with Lewy bodies (or
other disorders that cause parkinsonism) may be considered (see p. 77).
 
Vascular dementia may be considered if strokes are seen on the structural imaging
scan (CT or MRI). It is also possible for a patient to have a mixed dementia of
Alzheimer’s disease plus vascular disease, depending upon the amount of vascular
disease present on the structural imaging study, and whether a number of the symptoms
are consistent with vascular dementia (see p. 75).
 
Dementia with Lewy bodies is a neurodegenerative disease of the brain characterized
clinically by dementia, visual hallucinations, Parkinsonism, and a sleep behavior disorder
known as a rapid eye movement (REM) sleep disorder (see p. 77).
 
Parkinsonism is a general term that refers to a group of neurological disorders that
cause movement problems similar to those seen in Parkinson’s disease, such as
tremors, slow movement and stiffness. Changes that may be noticed include decreased
facial (emotional) expression, a stooped posture, decreased arm swing while walking, a
“shuffling gait,” in which patients seem not to pick up their feet when walking, and
postural instability.
 
A REM sleep behavior disorder may be present for years preceding the onset of
memory impairment. In a person with REM sleep disorder, the paralysis that normally
occurs during REM sleep is incomplete, allowing the individual to "act out" his or her
dreams. He or she may yell out fearfully, accidentally kick or punch a wall or bed partner,
or even fall out of bed. RBD is characterized by the acting out of dreams that are vivid,
intense, and violent. Patients often do not remember having acted out their dreams
when they wake up. Other sleep disturbances, such as nightmares, difficulty
distinguishing dreams from being awake, and daytime drowsiness, may occur.
 
Another hallmark of dementia with Lewy Bodies is fluctuating attention or alertness. Brief
episodes of poor attention and/or being poorly responsive may also be present early on.
Family members often notice that their loved ones are much more alert at some times
during the day than other times, and that they may have “good days” and “bad days.”
In addition to visual hallucinations, visual illusions or perceptual misperceptions may
occur. Sometimes it may be as simple as problems with visual color and depth
perception (one patient could not see the shower water against the backdrop of the
shower wall) or complicated illusions (one patient believed his dresser to be a big
friendly furry monster).
 
Autonomic dysfunction may also occur, leading to low blood pressure upon standing
(also called orthostatic hypotension), fluctuations in pulse and blood pressure, urinary
incontinence, constipation, impotence, eating and swallowing difficulties, falls, and
fainting. Lastly, depression and apathy may precede the onset of dementia with Lewy
bodies.
 
The most common disorders that may be confused with Lewy Body Dementia are other
neurodegenerative dementias. Vascular dementia should be considered if there are
many large or small ischemic strokes on the structural imaging scan (CT or MRI).
Strokes in certain areas of the brain called the basal ganglia can produce Parkinsonism
that may look similar to that the Parkinsonism seen in dementia with Lewy bodies.
Progressive supranuclear palsy is another atypical parkinsonian disorder that may be
considered if there is an abnormality of vertical eye movements, rigidity of the neck and
trunk, difficulty swallowing, and frequent falls. Corticobasal degeneration (another
parkinsonian disorder) may be considered if there are strong asymmetric findings, such
as one sided or asymmetric rigidity, inability to control the motor function of one limb.
 
Primary Progressive Aphasia
Three variants of language disorder will be discussed in this chapter, and they all fall
under the rubric of primary progressive aphasia, or PPA (see also p.109).
 
Semantic dementia is a variant of PPA in which a patient loses memory for the
meaning of words. The patient may first start to have problems with word finding,
naming, and some problems with comprehension of words. Speech seems fluent, but he
or she may substitute words or phrases with “things” or “stuff.” When presented with a
word (for example, “microwave”), the patient may say “what is a microwave?” On
cognitive testing, the patient may have problems with naming an object and describing
its use. As the disorder progresses, in addition to problems with the expression and
comprehension of language, these individuals may have problems with self-control of
behaviors. There is also a loss of understanding of the meaning of things, such that they
may now know what a toothbrush is for, for example, or that a tree has green leaves.
Semantic dementia is usually due to brain pathology that causes frontotemporal
dementia, and is therefore usually considered a variant of frontotemporal dementia. Less
often, semantic dementia may be caused by Alzheimer’s disease pathology.
 
Progressive non-fluent aphasia (also referred to as a non-fluent/agrammatic primary
progressive aphasia) starts with problems with word finding and naming (similar to the
early pattern in semantic dementia). Language may be agrammatic (“cow jumped over
moon,” or “dog walk over bridge”), phonemic errors may be made (“efelant” instead of
“elephant”). They may demonstrate stuttering, hesitancy, and slow, effortful speech.
Frustration is common due to preserved insight into the disabilities early on in the
disorder. The difference between progressive non-fluent aphasia (PNFA) and semantic
dementia is that patients with PNFA do not lose their understanding of the meaning of
words. They have problems with word finding, naming, and fluency of language, but
maintain their understanding of language until late in the disease process. PNFA is
usually a variant of frontotemporal dementia, and less often, a variant of Alzheimer’s
disease.
 
Logopenic aphasia is a variant of primary progressive aphasia that starts with word
finding difficulties, problems with naming, and speech hesitancy. Comprehension of
language and grammar are preserved. Logopenic aphasia is usually a variant of
Alzheimer’s disease, and less often, a variant of frontotemporal dementia.
The most common disorders that may be confused with primary progressive aphasias
include stroke, Alzheimer’s disease, or brain injury. A clinician seeing a patient with
complaints of word finding and language problems will also inquire about and look for
signs of other neurological disorders. In a stroke or brain injury, symptoms of aphasia
start suddenly, and usually do not progressively worsen over time. The clinician may
also ask about other signs and symptoms that may be associated with stroke, such as
weakness or loss of function of one limb, sensory loss (numbness), or slurring of
speech.
 
Frontotemporal dementia (FTD) is a progressive neurodegenerative disorder with
three common clinical presentations (see p. 97). The three common clinical
presentations are: behavioral (or frontal) variant frontotemporal dementia, semantic
variant primary progressive aphasia (also called semantic dementia or temporal variant
frontotemporal dementia), and non-fluent/agrammatic variant primary progressive
aphasia (also called progressive non-fluent aphasia). As the latter two diagnoses were
described in detail above, they will not be addressed further in this section. We will focus
on behavioral variant FTD (bvFTD).
 
Behavioral variant frontotemporal dementia presents with gradual changes in
personality and social conduct early on in the disease process (in fact, they are likely to
be the very first changes noted by family, prior to cognitive changes). Patients may
demonstrate apathy, early disinhibition, and loss of insight and empathy. Early
disinhibition may present with inappropriate social remarks, improper sexual comments,
and poorly concealed use of pornography. Patients may demonstrate unusual eating
behaviors such as dramatic changes in food preferences (particularly sweets), poor
manners, gluttonous behavior, and eating strange things (such as a jar of mayonnaise).
Other abnormal behaviors include repetitive and/or ritualistic behaviors such as
repeatedly buying items they do not need (buying cases of coca cola to stock the
pantry), invasion of spaces not their own (stepping behind a check-out counter or
peering into a neighbor’s windows). Neglect of self-care and poor hygiene are common.
All of the aforementioned signs and symptoms could be present in other dementias,
such as Alzheimer’s disease; however, these symptoms are prominent early in
behavioral variant frontotemporal dementia, but late and less prominent presentations of
Alzheimer’s disease.
 
Other problems that may manifest in FTD are problems with executive function and
language (as these are functions of the frontal and temporal lobes, consecutively).
Sequencing problems are common in FTD, making it difficult for patients to perform
tasks such as preparing a snack or dressing (clothes may be put on backwards, in the
wrong order, or three or four pairs of socks may be put on). Patients with FTD may
experience delusions. For example, when watching TV, they may believe that a
character is talking directly to them. Patients with FTD may also have memory problems,
although they present a bit differently than memory problems in Alzheimer’s disease. In
FTD the memory problems tend to be related to problems with sustained attention and
decreased cognitive flexibility (the ability to hold onto information in ones mind and
manipulate it, such as in calculations). Unlike patients with Alzheimer’s disease, patients
with FTD may learn information with repeated exposure or practice. Once learned,
information is generally retained in memory, although there is often difficulty accessing it.
 
Because Alzheimer’s disease is so common, when suspecting a frontotemporal
dementia one must always consider the possibility that it is an atypical case of
Alzheimer’s disease. Alzheimer’s disease should be especially considered when the
patient is over the age of 65, as only one-quarter of cases of frontotemporal dementia—
but most cases of Alzheimer’s disease—present over age 65. Other disorders to
consider are dementia with lewy bodies (and other parkinsonian disorders) and vascular
dementia.
 
Usefulness of Neuropsychological Assessment
In the Evaluation of Dementia
 
Nadia Pare, Ph.D.
Clinical Neuropsychologist, Geriatric Evaluation and Management Clinic,
Omaha, NE
 
Dementia is an umbrella term that includes a wide set of neurodegenerative disorders.
Specifying the etiology and severity of the dementia is imperative to establishing a
treatment plan and determining the current and future needs of the patient, including
need for medical treatment, for change in residential arrangement and/or introducing
home health care, for assistance with financial planning, for alternative transportation,
to name a few. An interdisciplinary approach to evaluation is invaluable in establishing a
clear diagnosis and prognosis. As such, neuropsychological assessment plays an key
role not only by assessing which cognitive functions are affected by the dementia and
the extent of the impairment, as well as ruling out the contribution of personality and
mood factor but also by allowing to make recommendations regarding capacity to make
sound medical and financial decisions, safety to live independently at home or
modification needed to promote safety, safety to operate a motor vehicle, as well as
ways to compensate for cognitive loss, to keep the patient socially engaged in an
appropriate setting for their level of dementia, and to provide information that will help
the family and caregiver(s) cope with the burden of care.
 
Referring for a Neuropsychological Evaluation
Who refers to a neuropsychologist and when should such a referral be made? Referrals
can come from different sources. At times, family calls to request a neuropsychological
evaluation due to concerns with their loved one’s memory. Patients themselves can also
contact a neuropsychologist for such concerns. More frequently, physicians, especially
primary care physicians, but also geriatricians, neurologists, psychiatrists, and
physiatrists will call to refer a patient. Examples of referral questions include:
determining diagnosis (including ruling out depression as possible explanation for
cognitive symptoms), severity of dementia, safety of current living situation and need for
assistance at home, ability to continue or to resume driving, ability to return to work, as
well as capacity to make medical and financial decisions. Referral sources also often
request recommendations on techniques or resources to manage behavioral and
emotional issues.
 
Overview of the Evaluation Process
As opposed to cognitive screening performed in a primary care setting, a
neuropsychological evaluation allows for an in-depth evaluation of cognitive functions. In
fact, cognitive screens, while helpful to identify possible cognitive decline, tend to miss
subtle cognitive decline or to minimize the actual extent of the deficits. This is especially
true in individuals with a higher baseline of intellectual functioning and/or high level of
education. Neuropsychological evaluation includes a thorough review of the medical
records, interview with the patient and an informant (e.g. spouse, child, close friend),
assessment of cognitive functions, and feedback to the patient and family. Different
dementias can present with decline in different domains of cognitive functions. Typically,
specific types of dementia will have different profiles of cognitive impairments, hence the
importance of assessing all domains of cognitive functioning. Domains of cognitive
functions assessed usually include: orientation, speed of information processing,
attention, working memory, visual and verbal memory functions, language functions,
visuo-spatial functions, and executive functions. A more in-depth description of each of
these domains is provided below.
 
Review of Medical Records
A thorough review of medical records is essential when a patient is referred for a
neuropsychological evaluation. In fact, review of medical records will inform the
neuropsychologist of medical conditions that can affect the patient’s cognition, such as
poorly controlled diabetes, hypothyroidism, history of traumatic brain injury, stroke,
delirium, or seizure, among many others. Also, review of the medical record allows the
neuropsychologist to be aware of medication(s) taken by the patient that may have an
impact on cognitive functions and possibly explain or contribute to the cognitive decline.
For instance, anticholinergic medications, such as many of the prescribed medications
for urinary incontinence or over-the-counter sleeping pills, can have a significant effect
on memory. Finally, this review can reveal that the patient or his family expressed
concerns with memory several months or even years prior to the actual referral to
neuropsychology. The type of concerns expressed at the time can be useful in
determining diagnosis.
 
Interview with the Informant
An important part of the neuropsychological evaluation is the interview with an objective
informant, usually a family member who lives with the patient or has frequent contact
with him. That is because in most types of dementia, as the severity of the deficits
increase, the insight or awareness into these deficits declines. This decline in awareness
of deficits is part of the dementia process. The informant provides an objective view of
the patient’s cognitive impairment but most importantly, they provide a description of
changes in functional status and document safety in the home environment. For
instance, the informant can report changes in hygiene routine, presence of falls, ability to
safely use appliances, difficulty with medication management, suspicion of financial
abuse, issues with driving, among others. Having an objective informant is especially
important when there is a discrepancy between functional impairment in daily life and
performance on testing, as individuals with a higher baseline level of intellectual
functioning tend to be able to compensate better on tests of cognitive abilities than in
their activities of daily living.
 
Interview with the Patient
Interviewing the patient provides valuable information about the severity of the cognitive
deficits and level of awareness that he has into his deficits. Asking the patient about
autobiographical information (name, age, and location of his children, number of
grandchildren, number of years he has been married, etc.), as well as educational,
occupational, and medical history, is a very helpful way of assessing memory functions.
In addition, the interview provides information about the patient’s level of awareness into
his functional status, as it allows the clinician to assess whether the patient has noticed
decline in his ability to manage his finances, cook his meals, safely drive his car, etc.
The interview process also allows gathering of information regarding mood and
personality, information that is useful in interpretation of the results. In fact, dementia
occurs in the context of a baseline personality and no two patients have the exact same
clinical presentation, despite having the same diagnosis. Finally, the interview process
allows establishing rapport and making the evaluation process less threatening to the
patient.
 
Evaluation of Cognitive Functions
The process of neuropsychological evaluation can last anywhere from a couple of hours
to a full day, depending on the approach of the clinician. In a geriatric population, a
clinician should in most cases keep the evaluation process, including interview and
testing, to less than 3 hours, to avoid fatigue. Cognitive domains assessed in the
evaluation process are described below.
 
Orientation is divided into orientation to self, time, and place. Orientation to self refers to
the ability to provide autobiographical information (one’s age, date of birth, address,
children’s names, and so forth). Orientation to time refers to ability to state the current
year, season, month, date, day of the week, and time of day. Orientation to place refers
to ability to identify one’s current location (including state, county, city/town, and
building).
 
Speed of information processing refers to the time it takes to take in information (either
visually or verbally) and react to it (either verbally or with a motor response). An example
of this in a daily life situation would be the time it takes to find the “quick cook” button on
a microwave oven.
 
Simple attention or “attention span” is the ability to attend to visual or verbal material for
a short period of time. This would be for instance the ability to repeat a phone number
immediately after it is presented.
 
Working memory refers to the ability to manipulate information in mind for a short period
of time. Working memory is the ability required when calculating the amount of tip one
wants to leave on a check or when trying to retain a telephone number until written on a
piece of paper.
 
Verbal and visual memory refers to the ability to learn new information. This is for
instance the ability to retain news heard on television and that one wants to share with
their spouse a few hours later. It could also be the ability to remember where a pair of
glasses where last put down or to remember the location of your new doctor’s office.
 
Several aspects of language functions can be assessed during a neuropsychological
evaluation, including receptive (what one hears or reads) and expressive language (what
one verbally states or writes).. Expressive language usually refers to the ability to
rapidly come up with words or to access one’s “internal dictionary”. Receptive language
refers to the ability to understand verbal or written information.
 
Visuospatial function is the ability to perceive and analyze visual information, such as
scanning visual information, judging distances, distinguishing shapes, foreground, and
background, perceiving details, copying or reproducing shapes and forms, and
organizing visual information to perceive a global figure.
 
Executive functions refer to metacognition or the group of cognitive processes that
regulates, controls, and manages the other cognitive processes. This includes planning,
organizing/classifying, strategizing, judgment and problem solving, reasoning, deductive
thinking, abstracting, inhibiting irrelevant information or behaviors, self-regulating and
monitoring, initiating an action and disengaging from a task, self-awareness, and
multitasking or switching between tasks.
 
In addition to cognitive functions, a neuropsychologist assesses mood and personality.
This could be done during the interview with the patient and/or by use of psychometric
measures such as questionnaires filled out by the patient. However, these rating scales
cannot replace clinical judgment and behavioral observations.
 
Several tests or tools are used to assess each of the cognitive domains mentioned
above. The amount of time spent assessing each domain depends on the referral
question and suspected diagnosis. For instance, more time could be spent assessing
memory functions when a dementia of Alzheimer’s disease etiology is suspected, while
executive functions would be assessed more thoroughly when a fronto-temporal
dementia is suspected. Tests are administered following standardized procedures that
follow a specific set of instructions and demonstration. These procedures are important
to make sure that results of the evaluation cannot be attributed to testing variables (such
as poor understanding of instructions or distraction from the testing environment).
Interpretation of results is made by comparing the results to a set of norms, which
consists of average scores for a sample of healthy individual belonging to the same age
group and with a similar level of education as the patient. Norms also often control for
gender and at times control for ethnicity.
 
In establishing a diagnosis of dementia, the clinician looks for patterns of results that are
typical of a dementia. For instance, dementia of Alzheimer’s disease etiology will tend to
affect orientation, memory functions (especially ability to retain information over time), as
well as language functions (especially confrontation naming or ability to come up with
the name of images, and semantic fluency or ability to rapidly name words that belong to
a category, such as musical instruments). However, vascular dementia (or dementia due
to cerebrovascular disease in the brain) will tend to affect speed of processing, visuospatial
functions, and phonemic fluency (naming words starting with a specific letter).
Obviously, this is a gross generalization of how the concept of “patterns of results” works
and clinical judgment plays a major role in recognizing such patterns.
 
Providing Feedback and Beyond
Once the evaluation has been completed and a diagnosis has been made, a feedback
session will be scheduled to share the results of the evaluation and ensuing
recommendations. During this session, the patient and family should be encouraged to
ask questions to better understand the diagnosis and how it concretely affects daily life
and future plans and needs. Planning for future needs should be addressed during the
feedback session. This may include discussing power of attorney and living will,
residential preference, safety at home, among others. Patient or family may ask for
information that can be better provided by a social worker and it is imperative for the
neuropsychologist to recognize their limitation and to refer to the appropriate
professional (medical social workers and home health agency staff can help with this).
 
When referred by a physician, the physician will receive a copy of the report, as this may
allow him to adapt his treatment plan, such as prescribing appropriate medications (such
as donepezil or memantine), discontinuing medications (such as pills that can affect
cognition or increase risk of falls), ordering brain imaging or other medical tests, or
referring the patient to a specialist, such as a neurologist, as needed. Some patients
and physicians will request a follow-up evaluation, which is typically not done before a
year or two after the original evaluation, as significant decline is not expected to happen
before then. Results can also be shared with other professionals, such as speech
therapists, social workers, psychotherapists, or others, again with the goal of better
adapting their treatment plan to the needs of the patient.
 
Conclusion
A neuropsychology evaluation is an important tool to assess cognitive changes and
assist with the diagnosis of dementia. Using an interdisciplinary approach to dementia
care and knowing when to refer to other professionals is the most beneficial and
effective strategy for accurately diagnose a dementia and promote comprehensive care
of older adults.