- No evidence exists to support recommending some of the most
frequently used screening
tests over others.
- None of the tests has a high sensitivity for early or mild
dementia.
- No evidence supports the efficacy of a general screen for
Alzheimer's disease or related
dementias, given the lack of unequivocally effective treatment
and the difficulty of
recognizing early dementia.
The panel subsequently limited its scope specifically to the
subject of recognition and initial
assessment and therefore did not address differential diagnosis,
management, or treatment issues
after diagnosis.
Principal Objective
The panel's principal objective was to increase the likelihood of
early recognition and assessment
of a potential dementing illness so that (1) concern can be
eliminated if it is not warranted; (2)
treatable conditions can be identified and addressed
appropriately; and (3) nonreversible
conditions can be diagnosed early enough to permit the patient
and family to plan for
contingencies such as long-term care.
Specifically, the panel's goals were to:
- Improve the detection of Alzheimer's disease and related
dementias in their early stages
in persons exhibiting certain signs and behaviors.
- Educate health professionals, patients, and their families
about symptoms that suggest the
need for an initial assessment for a dementing disorder.
- Identify areas for further research on early recognition of
dementia.
Findings
The panel's major findings include:
- Certain triggers should prompt a clinician to undertake an
initial assessment for dementia
rather than attribute apparent signs of decline to aging.
- An initial clinical assessment should combine information
from a focused history and
physical examination, an evaluation of mental and functional
status, and reliable
informant reports. It also should include assessment for delirium
and depression.
- An assessment instrument known as the Functional Activities
Questionnaire is a
particularly useful informant-based measure in the initial
assessment for functional
impairment.
- Among effective mental status tests, the Mini-Mental State
Examination, the Blessed
Information-Memory-Concentration Test, the Blessed
Orientation-Memory-Concentration Test, and the Short Test of
Mental Status are largely
equivalent in discriminative ability for early-stage
dementia.
- Clinicians should assess and consider factors such as
sensory impairment and physical
disability in selection of mental and functional status tests,
and other confounding factors
such as age, educational level, and cultural influences in
interpretation of test results.
In asymptomatic persons who have possible risk factors (e.g.,
family history and Down
syndrome for Alzheimer's disease), the clinician's judgment and
knowledge of the patient's
current condition, history, and social situation (living
arrangements, support services, isolation)
should guide the decision to initiate an assessment for
dementia.
Initiating an Assessment
For a diagnosis of dementia, current criteria in the Diagnostic
and Statistical Manual of Mental
Disorders, Fourth Edition (DSM-IV), require evidence of decline
from previous levels of
functioning and impairment in multiple cognitive domains, not
solely memory. Because
evidence of decline in previous abilities is critical in
establishing dementia, a personal
knowledge of the patient is invaluable to the clinician in
assessing symptoms and interpreting
results of an initial assessment for dementia.