Psychological/Psychiatric Evaluation to Diagnose Alzheimer’s Disease

Psychological evaluation represents the collection of the specific targeted procedures that are used to obtain detailed information about past and current mood, thinking, or behavioral problems. The person with suspected Alzheimer's symptoms and the primary caregiver should be interviewed separately in order to gain a complete picture of what is going on. This "double interview" technique is particularly important when a person's memory for past and present information is impaired, because he or she may inadvertently provide inaccurate information during the interview. This evaluation should include an assessment for anxiety and depression, which can create Alzheimer's-like symptoms in older people, as well as occur concurrently with Alzheimer's or another form of dementia. Depression, in particular, can result in a reversible set of symptoms collectively known as pseudo-dementia.

The following tests may be used in a psychological/psychiatric evaluation:

The Geriatric Depression Scale (GDS) - The GDS is a screening instrument used to detect depression among older adults. Clinicians may use it to help determine whether someone is depressed (and doesn't have AD), or if depression coexists with Alzheimer's or another form of dementia. Results from the GDS are interpreted in the context of the other information collected about the person. For example, people with depression often complains about memory problems and is upset about them, while individuals with dementia will often deny memory problems or minimize their importance. Also, depressed people are less likely to exhibit large mood swings, remaining "down in the dumps" most of the time (except when they have bipolar disorder, a shift in moods from extreme highs to extreme lows). On the other hand, people with dementia usually show a range of emotions, and sometimes respond with an inappropriate emotion (e.g., laughing while others are sad). If a mood disorder such as depression is detected, it can be treated alongside other disorders, such as Alzheimer's. Generally speaking, high scores on the GDS suggest that people are experiencing depressive symptoms.

Mental status exam - Mental status exams assess memory, concentration, and other cognitive skills. The most frequently used mental status exam is called the Mini-Mental State Exam (MMSE), a research-based set of questions that results in a score representing a person's general level of cognitive functioning.

The MMSE is generally a reliable and valid indicator of cognitive impairment that can correctly distinguish between individuals with dementia, individuals with pseudo-dementia due to depression, and individuals with depression and no cognitive impairment. However, the test must be used with caution in certain groups of people. For example, highly educated people frequently score high on the MMSE, even if they have Alzheimer's Disease. Similarly, people with less than an eighth grade education or whose first language is not English often score poorly on the MMSE, even though they may not have cognitive impairment.

The MMSE takes only 5 - 10 minutes to administer and taps five areas of cognitive functioning:

1. ORIENTATION

Ask the patient what (year) (season) (date) (day) (month) it is (5 Points).
Ask the patient where he/she is (province) (country) (town or city) (hospital) (floor) (5 Points).

2. REGISTRATION

Name 3 common objects (e.g., “apple”, “table”, “penny”). Take 1 second to pronounce each word. Then ask the patient to repeat all 3 words. Give one point for each correct answer. Then repeat them until he/she learns all 3. Make a maximum of 6 trials (3 Points).

3. ATTENTION AND CALCULATION

Ask the patient to subtract 7 from 100 and keep subtracting 7 until you tell him/her to stop. (93, 86, 79, 72, 65)

OR

Ask him/her to spell “WORLD” backwards. The score is the number of letters in correct order (D_L_R_O_W) (5 Points).

4. RECALL

Ask the patient for the 3 objects repeated above. Give 1 point for each correct answer. (Note: Recall cannot be tested if all 3 objects were not remembered during registration.) (3 Points).

5. LANGUAGE

Show the patient a “pencil” and a “watch” and ask him/her to name them (2 Points).
Ask your patient to repeat the following: « No ifs, ands or buts. » (1 Point).
Ask your patient to follow a 3-stage command: « Take a paper in your right hand, fold it in half, and put it on the floor. » (3 Points).
Ask the patient to read and obey the following:
- Close your eyes. (1 Point).
- Write a sentence. (1 Point).
- Copy the following design. (1 Point).

The maximum score on the MMSE is 30. In general, scores of 24 or more are considered within the "normal" range of cognitive functioning; scores between 20 and 23 are suggestive of mild cognitive impairment or possible early-stage Alzheimer's Disease; scores between 10 and 19 are associated with middle-stage Alzheimer's; and a score of 9 or less is considered consistent with severe or late-stage Alzheimer's Disease.

While the test has wide acceptance, one weakness is that the examiner must interpret responses, a subjective process. Different examiners might score the same response differently, and local adaptations can affect comparisons. Internal consistency and test-retest validity have been reported from 0.68 to 0.95.

Although the MMSE is a useful screening tool, test results should not be the only information used to make a diagnosis. In other words, a person's MMSE score can indicate a need for concern, and additional testing and follow-up.

Sources and Additional Information:
http://www.mentalhelp.net/poc/view_doc.php?type=doc&id=15333&cn=231
http://www.dementiacoach.com/2009/09/is-it-alzheimers-disease-an-overview-of-the-mini-mental-status-exam/
http://seniors-health-medicare.suite101.com/article.cfm/mmsepopular_mental_status_exam

Medical History, Physical exams, and Lab Tests in Alzheimer’s Disease Diagnostics

Alzheimer's disease is diagnosed with a medical history and a physical exam. A physical exam is used to help find out if a physical problem may be causing a person's dementia symptoms. It may be possible to correct some of these problems. For example, sometimes a simple hearing or vision problem can cause confusion, social withdrawal, or a change in behavior, such as hostility or unresponsiveness. The person may have an undiagnosed illness or infection that is causing the symptoms.

Personal medical history

The physician will need the following:

- A detailed description of changes in mental abilities, personality, mood, and behavior, including when and how the changes began and how they have affected the individual's ability to function. Letters, checkbooks, household lists, or other materials that illustrate changes in cognition may also be helpful.
- Information about physical complaints or symptoms, such as loss of coordination, sudden vision problems, or weakness.
- A complete medical history, including injuries and recent illnesses.
- A list of medications the patient is taking, including nonprescription drugs and herbal supplements.
- Information about the medical problems of family members, especially relatives with a similar illness.
- This may seem like a lot of information, but the person's history provides the foundation for the doctor's diagnostic workup. It enables the physician to construct a list of possible diagnoses that will guide the medical evaluation that follows.

Physical examination

Disorders as diverse as heart failure, liver disease, kidney failure, thyroid disorders, and respiratory diseases can cause dementia-like changes. What's more, elderly people don't always have typical symptoms of an illness. The sensation of pain is often dulled in the older person, for example, and it's not unusual for confusion, rather than chest pain, to be the main symptom of a heart attack.

Therefore, the physician will evaluate the cardiovascular system, lungs, and other organs for any signs of abnormalities. Because sensory losses can add significantly to a person's cognitive difficulties, the doctor will also test the individual's vision and hearing. The physician will also pay close attention to the nervous system, because neurologic abnormalities may signal a brain disorder other than Alzheimer's disease.

Muscle tone and strength, coordination, reflexes, senses, eye movement, and the pupils' reaction to light can tell the physician about the health of specific areas of the brain. For example, unequal reflexes or weakness on one side of the body suggests localized brain damage (perhaps from stroke or tumor), while tremors or other involuntary movements may indicate a degenerative disorder such as Parkinson's disease. These types of abnormalities are not usually features of early Alzheimer's disease.

Summarizing, the following tests should be included in the physician’s examination:

- Vital signs (temperature, blood pressure, pulse)
- Height and weight
- Skin
- Head, eyes, ears, nose
- Throat/neck
- Chest, including lungs and heart
- Breasts
- Abdomen
- Bones and muscles
- Nerves
- Rectal/genital area

Lab tests

A small number of people with dementia have a condition that proper treatment can reverse (unlike Alzheimer's disease). Lab tests may be done to rule out other possible causes of a person's symptoms, such as levels of certain minerals or chemicals in the blood that are too high or too low, liver disease, abnormal thyroid levels, or nutritional problems, such as folate or vitamin B12 deficiencies. Treatment for these conditions may slow or reverse mental decline.

Blood tests often done to check for these conditions include:

- Complete blood count (CBC), which shows the kinds and number of cells in your blood to help your doctor evaluate your symptoms.
- Liver function tests (AST, ALT, alkaline phosphatase, bilirubin), which detect liver damage or disease.
- Folate (folic acid) test, which detects the level of the B vitamin folic acid either inplasma (the liquid part of blood) or in the red blood cells. Folic acid is needed for the production of both red and white blood cells.
- Vitamin B12 concentration, which detects the level of vitamin B12 in your blood. Vitamin B12 is needed to produce red blood cells and to maintain a healthy nervous system.
- Electrolyte and blood glucose levels (sodium, potassium, creatinine, glucose,calcium), which are needed to keep the body's balance of fluids at the proper level and to maintain normal functions, such as heart rhythm, muscle contraction, and brain function.
- Thyroid function tests. Abnormal thyroid hormone levels are a common cause of forgetfulness, confusion, lethargy, and other symptoms of dementia in older people. Medicine can easily improve symptoms if a thyroid problem is present.
- Human immunodeficiency virus (HIV) infection test, if the person has risk factors for HIV or the medical history suggests it. Untreated HIV can cause symptoms such as personality changes or problems concentrating.


Sources and Additional Information:
http://www.webmd.com/alzheimers/tc/alzheimers-disease-exams-and-tests
http://alzheimers.about.com/od/diagnosisofalzheimers/a/diagnosis.htm
http://www.aarp.org/health/conditions/articles/harvard__a-guide-to-alzheimer-s-disease_7.html
http://www.cchs.net/health/health-info/docs/2300/2346.asp?index=9176