Alzheimer's disease physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Amandeep Singh M.D.[2]

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Overview

Patients with Alzheimer's disease usually appear disoriented and disorganized. When a doctor or physician has been notified, and AD is suspected, the diagnosis is usually further supported by behavioral assessments and cognitive tests, often followed by a brain scan if available. Physical examination of Alzheimer's disease consists of a thorough neurological assessment of the patient. Patient may be disoriented to time, place and person. Diagnostic tools for the examination of the patient include mini- mental status examination (MMSE), Montreal Cognitive Assesment (MOCA) and instruments of activities of dailing living (IADL).

Neurologic

Dementia is a clinical condition rather than an exact diagnosis. Alzheimer's disease is usually diagnosed clinically, using the patient history, collateral history from relatives, and clinical observations, based on the presence of characteristic neurological and neuropsychological features and the absence of alternative conditions.[1][2] Advanced medical imaging with CT or MRI, and with SPECT or PET may also be used to help to diagnose the subtype of dementia and exclude other cerebral pathology.[3] Neuropsychological evaluation including memory testing and assessment of intellectual functioning can further characterize the dementia.[4] Medical organizations have created diagnostic criteria to ease and standardize the process for practicing physicians. Sometimes the diagnosis can be confirmed on autopsy when brain material is available and can be examined histologically and histochemically.[5]

Diagnostic criteria

The diagnostic criteria for Alzheimer of the NINCDS-ADRDA (National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association) are among the most commonly used criteria for diagnosing AD.[6] These criteria require that the presence of cognitive impairment and a suspected dementia syndrome be confirmed by neuropsychological testing for a clinical diagnosis of possible or probable AD, while they require histopathologic confirmation (microscopic examination of brain tissue) for the definitive diagnosis. They have shown good reliability and validity.[7] They specify as well eight cognitive domains that may be impaired in AD (i.e., memory, language, perceptual skills, attention, constructive abilities, orientation, problem solving and functional abilities). The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) criteria published by the American Psychiatric Association are similar to the NINCDS-ADRDA Alzheimer's Criteria.[8][9]

Criteria list

  • Definite Alzheimer's disease: The patient meets the criteria for probable Alzheimer's disease and has histopathologic evidence of AD via autopsy or biopsy.
  • Probable Alzheimer's disease: Dementia has been established by clinical and neuropsychological examination. Cognitive impairments also have to be progressive and be present in in two or more areas of cognition. The onset of the deficits has been between the ages of 40 and 90 years and finally there must be an absence of other diseases capable of producing a dementia syndrome.
  • Possible Alzheimer's disease: There is a dementia syndrome with an atypical onset, presentation or progression; and without a known etiology; but no co-morbid diseases capable of producing dementia are believed to be in the origin of it.
  • Unlikely Alzheimer's disease: The patient presents a dementia syndrome with a sudden onset, focal neurologic signs, or seizures or gait disturbance early in the course of the illness.

Diagnostic tools

Neuropsychological screening tests such as the Mini mental state examination (MMSE) are widely used to evaluate the cognitive impairments needed for diagnosis, but more comprehensive batteries are necessary for high reliability by this method, especially in the earliest stages of the disease.[10][11] The major diagnostic tool for diagnosis is clinical, can be done in an office-based setting also and includes the following:

  • Mini-Mental Status Examination (MMSE)
  • Montreal Cognitive Assesment (MOCA)
  • Instruments of Activities of Dailing Living (IADL)
  • Other neuropsychological testing

The neurological examination inn eary AD is often normal independent of cognitive impairment but is key for diagnosis of the other dementing disorders. Therefore, neurological examination is crucial in the differential diagnosis of Alzheimer's disease and other dementias.[4] In addition, interviews with family members are also utilised in the assessment of the disease. Caregivers can supply important information on the daily living abilities, as well how the patient's mental function has changed over time. [12] This is especially important since a patient with AD is commonly unaware of his or her own deficits (anosognosia).[13] Many times families also have difficulties in the detection of initial dementia symptoms and for adequately communicating them to a physician.[14] Finally, supplemental testing may provide extra information on features of the disease, or may rule out other diagnoses. Examples are blood tests, which can identify other causes for dementia different than AD,[4] which may even be reversible.[15] psychological tests for depression are also important, as depression can both co-occur with AD or even be at the origin of the patient's cognitive impairment.[16][17]

Mini-Mental Status Examination (MMSE)

MMSE is the most commonly used tool for evaluating cognitive impairment. It is scored on a 30-point scale and is adjusted based on education of the patient.

MMSE (a sample)[18]
Function Questions Max Score Score
Orientation “What is the year? Season? Date? Day? Month?” 5
“Where are we now? State? County? Town/city? Hospital? Floor?” 5
Registration The examiner names three unrelated objects clearly and slowly(over 1 second), then the instructor asks the patient to name all three of them. The patient’s response is used for scoring. Repetition can be used or avoided (preferably).If done, count the trials too. 3
Attention and Calculation “I would like you to count backward from 100 by sevens.” (93, 86, 79,72, 65, …)
Alternative: “Spell WORLD backward.” (D-L-R-O-W)
5
Recall “Earlier I told you the names of three things. Can you tell me what those were?” (1 point for each) 3
Language Show the patient two simple objects, such as a wristwatch and a pencil, and ask the patient to name them. 2
“Repeat the phrase: ‘No ifs, ands, or buts.’” 1
“Take the paper in your right hand, fold it in half, and put it on the floor.”(The examiner gives the patient a piece of blank paper.) 3
“Makeup and write a sentence about anything.” (This sentence must contain a noun and a verb.) 1
Visuospatial “Please copy this picture.” (The examiner gives the patient a blank piece of paper and asks him/her to draw the symbol below. All 10 angles must be present and two must intersect.) 1
Total 30

Interpretation

Interpretation of MMSE
Method Score Interpretation
Single Cut-off <24 Impaired
Education 21 Abnormal for 8th-grade education
<23 Abnormal for high school education
<24 Abnormal for college education
Severity 24-30 Normal cognition/No impairment
18-23 Mild cognitive impairment
0-17 Severe cognitive impaired

Montreal Cognitive Assessment (MOCA)

MOCA testing is a better tool for diagnosing cognitive impairment in a patient with Alzheimer's disease. It is also adjusted for the educational background of the patient. To view the MOCA test in different languages www.mocatest.org

References

  1. Mendez MF (2006). "The accurate diagnosis of early-onset dementia". International Journal of Psychiatry Medicine. 36 (4): 401–412. PMID 17407994.
  2. Klafki HW, Staufenbiel M, Kornhuber J, Wiltfang J (2006). "Therapeutic approaches to Alzheimer's disease". Brain. 129 (Pt 11): 2840–2855. doi:10.1093/brain/awl280. PMID 17018549.
  3. "Dementia: Quick reference guide" (PDF). National Institute for Health and Clinical Excellence. ISBN 1-84629-312-X. Retrieved 2008-02-22.
  4. 4.0 4.1 4.2 Waldemar G, Dubois B, Emre M, Georges J, McKeith IG, Rossor M, Scheltens P, Tariska P, Winblad B (2007). "Recommendations for the diagnosis and management of Alzheimer's disease and other disorders associated with dementia: EFNS guideline". European Journal of Neurology. 14 (1): e1–26. doi:10.1111/j.1468-1331.2006.01605.x. PMID 17222085.
  5. McKhann G, Drachman D, Folstein M, Katzman R, Price D, Stadlan EM (1984). "Clinical diagnosis of Alzheimer's disease: report of the NINCDS-ADRDA Work Group under the auspices of Department of Health and Human Services Task Force on Alzheimer's Disease". Neurology. 34 (7): 939–44. PMID 6610841.
  6. Dubois B, Feldman HH, Jacova C, Dekosky ST, Barberger-Gateau P, Cummings J, Delacourte A, Galasko D, Gauthier S, Jicha G, Meguro K, O'brien J, Pasquier F, Robert P, Rossor M, Salloway S, Stern Y, Visser PJ, Scheltens P (2007). "Research criteria for the diagnosis of Alzheimer's disease: revising the NINCDS-ADRDA criteria". Lancet Neurology. 6 (8): 734–746. doi:10.1016/S1474-4422(07)70178-3. PMID 17616482.
  7. Blacker D, Albert MS, Bassett SS, Go RC, Harrell LE, Folstein MF (1994). "Reliability and validity of NINCDS-ADRDA criteria for Alzheimer's disease. The National Institute of Mental Health Genetics Initiative". Archives of Neurology. 51 (12): 1198–1204. PMID 7986174.
  8. American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental disorders, 4th Edition Text Revision. Washington DC.
  9. Ito N (1996). "Clinical aspects of dementia". Hokkaido Igaku Zasshi (in Japanese). 71 (3): 315–320. PMID 8752526.
  10. Tombaugh TN, McIntyre NJ (1992). "The mini-mental state examination: a comprehensive review". J Am Geriatr Soc. 40 (9): 922–935. PMID 1512391.
  11. Pasquier F (1999). "Early diagnosis of dementia: neuropsychology". J. Neurol. 246 (1): 6–15. PMID 9987708.
  12. Harvey PD, Moriarty PJ, Kleinman L, Coyne K, Sadowsky CH, Chen M, Mirski DF (2005). "The validation of a caregiver assessment of dementia: the Dementia Severity Scale". Alzheimer Disease and Associated Disorders. 19 (4): 186–194. PMID 16327345.
  13. Antoine C, Antoine P, Guermonprez P, Frigard B (2004). "Awareness of deficits and anosognosia in Alzheimer's disease". Encephale (in French). 30 (6): 570–577. PMID 15738860.
  14. Cruz VT, Pais J, Teixeira A, Nunes B (2004). "The initial symptoms of Alzheimer disease: caregiver perception". Acta Med Port (in Portuguese). 17 (6): 435–444. PMID 16197855.
  15. Clarfield AM (2003). "The decreasing prevalence of reversible dementias: an updated meta-analysis". Arch. Intern. Med. 163 (18): 2219–29. doi:10.1001/archinte.163.18.2219. PMID 14557220.
  16. Geldmacher DS, Whitehouse PJ (1997). "Differential diagnosis of Alzheimer's disease". Neurology. 48 (5 Suppl 6): S2–9. PMID 9153154.
  17. Potter GG, Steffens DC (2007). "Contribution of depression to cognitive impairment and dementia in older adults". Neurologist. 13 (3): 105–117. doi:10.1097/01.nrl.0000252947.15389.a9. PMID 17495754.
  18. Folstein MF, Folstein SE, McHugh PR (1975). ""Mini-mental state". A practical method for grading the cognitive state of patients for the clinician". J Psychiatr Res. 12 (3): 189–98. PMID 1202204.

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