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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 1. 2. 3. 4. 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 • Fist – Edge – Palm test Go/no-go 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