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Screening for Dementia: Recommendation and Rationale - U.S. Preventive Services Task Force
Early Diagnosis of Dementia - Article
ABSTRACT: Until recently, the most significant issue facing a family physician regarding the diagnosis and treatment of dementia was ruling out delirium and potentially treatable etiologies. However, as more treatment options become available, it will become increasingly important to diagnose dementia early. Dementia may be suspected if memory deficits are exhibited during the medical history and physical examination. Information from the patient's family members, friends and caregivers may also point to signs of dementia. Distinguishing among age-related cognitive decline, mild cognitive impairment and Alzheimer's disease may be difficult and requires evaluation of cognitive and functional status. Careful medical evaluation to exclude treatable causes of cognitive impairment is important. Patients with early dementia may benefit from formal neuropsychologic testing to aid in medical and social decision-making. Follow-up by the patient's family physician is appropriate in most patients. However, a subspecialist may be helpful in the diagnosis and management of patients with dementia with an unusual presentation or following an atypical course.
ABSTRACT: Patients with advanced dementia are among the most challenging patients to care for because they are often bedridden and dependent in all activities of daily living. Difficulty with eating is especially prominent and distresses family members and health care professionals. Health care professionals commonly rely on feeding tubes to supply nutrition to these severely demented patients. However, various studies have not shown use of feeding tubes to be effective in preventing malnutrition. Furthermore, they have not been demonstrated to prevent the occurrence or increase the healing of pressure sores, prevent aspiration pneumonia, provide comfort, improve functional status, or extend life. High complication rates, increased use of restraints, and other adverse effects further increase the burden of feeding tubes in severely demented patients. Feeding tubes should be avoided in many situations in which they are currently used. The preferable alternative to tube feeding is hand feeding. Though it may not be effective in preventing malnutrition and dehydration, hand feeding allows the maintenance of patient comfort and intimate patient care.
ABSTRACT: Family physicians must decide how to screen for depression or dementia and which patients to screen. Mental health questionnaires can be helpful. In practice-based screening, questionnaires are administered to all patients, regardless of risk status. In case-finding screening, questionnaires are administered only when depression or dementia is suspected. The 2002 U.S. Preventive Services Task Force report recommends screening adults for depression to improve detection and patient outcomes but does not suggest the use of any particular screening instrument. Serial or sequential testing with the Patient Health Questionnaire-2 and the Patient Health Questionnaire-9 is a good strategy for detecting major depressive episodes in primary care settings. The Patient Health Questionnaire-2 consists of two questions that assess the presence of anhedonia and dysphoria. If a patient answers "yes" to either question, the more specific Patient Health Questionnaire-9 is administered to assess the severity of depressive symptoms and to ascertain the presence of major depressive episode. The Patient Health Questionnaire-9 also can be used to monitor symptom severity and treatment response. The 2003 U.S. Preventive Services Task Force report does not recommend for or against routine screening for dementia in older adults. However, the report does assert that cognitive function should be assessed when impairment is suspected. The Folstein Mini-Mental State Examination and the Functional Activities Questionnaire are suggested tools. The Clock Drawing Test also has been shown to be useful in primary care settings.
ABSTRACT: Gait instability, urinary incontinence, and dementia are the signs and symptoms typically found in patients who have normal pressure hydrocephalus. Estimated to cause no more than 5 percent of cases of dementia, normal pressure hydrocephalus often is treatable, and accurate recognition of the clinical triad coupled with radiographic evidence most commonly identifies likely responders. Magnetic resonance imaging or computed tomography typically demonstrates ventricular dilation with preservation of the surrounding brain tissue. The abnormality in normal pressure hydrocephalus occurs secondary to an abnormality in fluid removal, leading to an increase in ventricular size and encroachment of enlarged ventricles on adjacent brain tissue. The pressure exerted on the cerebral parenchyma by immense fluid-filled cavities deforms white matter tracts, instigating gait abnormalities and incomplete control of the bladder, as well as difficulties in processing incoming stimulation and in producing expeditious responses. Signs and symptoms often occur as sequelae to an imbalance between the expected ongoing production of cerebrospinal fluid and continuous efflux. Ventriculoperitoneal shunting is used to relieve excess ventricular fluid not absorbed by normal physiologic channels. Multiple studies have explored various techniques to identify patients with normal pressure hydrocephalus in an effort to predict likely benefit from shunting. However, the effectiveness of cerebrospinal fluid diversion has never been proven in a randomized controlled trial comparing use of a shunt versus no shunt.
ABSTRACT: Dementia is a common disorder among older persons, and projections indicate that the number of patients with dementia in the United States will continue to grow. Alzheimer's disease and vascular dementia account for the majority of cases of dementia. After a thorough history and physical examination, including a discussion with other family members, a baseline measurement of cognitive function should be obtained. The Mini-Mental State Examination is the most commonly used instrument to document cognitive impairment. Initial laboratory evaluation includes tests for thyroid-stimulating hormone and vitamin B12 levels. Structural neuroimaging with noncontrast computed tomography or magnetic resonance imaging also is recommended. Other testing should be guided by the history and physical examination. Neuropsychologic testing can help determine the extent of cognitive impairment, but it is not recommended on a routine basis. Neuropsychologic testing may be most helpful in situations where screening tests are normal or equivocal, but there remains a high level of concern that the person may be cognitively impaired.
ABSTRACT: Psychosis may pose a greater challenge than cognitive decline for patients with dementia and their caregivers. The nature and frequency of psychotic symptoms varies over the course of illness, but in most patients, these symptoms occur more often in the later stages of disease. Management of psychosis requires a comprehensive nonpharmacologic and pharmacologic approach, including an accurate assessment of symptoms, awareness of the environment in which they occur, and identification of precipitants and how they affect patients and their caregivers. Nonpharmacologic interventions include counseling the caregiver about the nonintentional nature of the psychotic features and offering coping strategies. Approaches for the patient involve behavior modification; appropriate use of sensory intervention; environmental safety; and maintenance of routines such as providing meals, exercise, and sleep on a consistent basis. Pharmacologic treatments should be governed by a "start low, go slow" philosophy; a monosequential approach is recommended, in which a single agent is titrated until the targeted behavior is reduced, side effects become intolerable, or the maximal dosage is achieved. Atypical antipsychotics have the greatest effectiveness and are best tolerated. Second-line medications include typical antipsychotics for short-term therapy; and, less often, anticonvulsants, acetylcholinesterase inhibitors, antidepressants, and anxiolytics. Goals of treatment should include symptom reduction and preservation of quality of life.
AAFP and ACP Release Guideline on Dementia Treatment - Practice Guidelines
Brief Screening Instruments for Dementia in Primary Care - Point-of-Care Guides
A Night at the Nursing Home - The Last Word