The diagnosis of dementia - 2 Dr Johan Schoeman Consultant in Old Age Psychiatry SEPT in Luton and Bedfordshire 2nd November 2010

Overview Diagnosis in Memory Assessment Service

Cognition Higher Brain Function – thinking for ourselves performing complex tasks reading writing calculation learning new information language use in communication short term memory

Cognition Executive function – having insight control of emotion control of inhibition social awareness awareness of physical surroundings aspects of memory aspects of language use of initiative level of motivation

What we measure Memory – verbal }immediate and delayed visual }immediate and delayed Language Visuospatial skills Executive function Attention and orientation WTAR

Cognition Use as screening tool Brief and simple Be aware of – educational level cultural background language sensory deficits TYM test MMSE Clock Drawing Test ACE-R

TYM (Test Your Memory) 1 Quick (5 minutes) Uses 10 cognitive tasks Validated against MMSE and Addenbrooke's Powerful in detecting mild Alzheimer's disease 1 Brown 2008

TYM - Example

Clock Drawing Test Takes 2 minutes Encompasses frontal lobe functioning Simplicity and non-threatening Instructions: Draw a large circle Mark in the numbers Draw the hands to indicate 11 minutes past two

Clock Drawing Test

Mini Mental State Examination1 10 minute test (scored out of 30 points) Test of cognition not of dementia No executive items Poor detecting cognitive impairment – well-educated poorly educated NICE use this as cognitive ‘gold standard’- 21/30 and above: minimal-no impairment 10-20 mild impairment <10 severe impairment 1 Folstein MF, 1975

MMSE

ACE-R 1 Addenbrooke’s Cognitive Examination – Revised 20 minutes to perform Contains in it the MMSE Executive function tests – Verbal and Category Fluency Limitations: Educational and Cultural At 88/100 sensitivity 72% (MMSE 27/30 36%) At 82/100 sensitivity 56% (MMSE 24/30 11%) 2 1 John R Hodges, 2000 2 Gaber T, 2008

ACE-R

Advanced Cognitive Testing WAIS-III

Phineas Gage Boston Post 21/09/1848

Executive function (frontal lobe) Phonemic (verbal) fluency – FAS test Name as many words starting with letter F A S Category fluency name as many animals you can starting with any letter Discrepancy in between above scores are sensitive indicator of organicity

Verbal and Category Fluency Letter - P >17 7 14-17 6 11-13 5 8-10 4 6-7 3 4-5 2 2-3 1 <2 0 Category - Animals >21 7 17-21 6 14-16 5 11-13 4 9-10 3 7-8 2 5-6 1 <5 0

Similarities What is the similarity between the following: monkey and dog shirt and dress table and chair banana and apple plant and animal

Trails A and B

Approximations How long would a window cleaner take to clean the windows of an average bungalow? - 1 and half days - 20 minutes - 45 minutes - 4hours 15 minutes What is the lifespan of a dog? What does an elephant weigh? How high is the Eiffel Tower? How fast can an average man run?

Luria Hand Test Go/no-go Test Fist – Edge – Palm test The patient is asked to make a response to one signal (the Go signal) and not to respond to another signal (the no-go signal). The most basic is to ask the patient to tap their knee when the examiner says, “Go” and to make no response when the examiner says, “Stop”

Physical Examination Blunted affect Expressionless facies Glabellar reflex Rooting reflex Pout reflex Grasp reflex Palmar-mental reflex

Questions and Discussion