History and examination

Diagnosis of dementia should be made only after through assessment which should include history, cognitive and mental state examination, physical examination, appropriate investigations and a review of medication which might affect cognitive function (1).

The history should be gathered from a person who has known the patient for a period of six months at least and if possible directly from the patient and includes:

• age
• medical and psychiatric history of the family e.g. - dementia or other mental health problems (1)
• origin and progression of condition
• associations:
  • myoclonus
  • seizures
  • depression, anxiety (1)
• past and present medical and psychiatric history - e.g. diabetes, hypertension, cerebrovascular accident
• exposure to toxins:
  • alcohol
  • lead
    • drugs e.g. barbiturates (1,2)

Examination of the demented patient should:

• exclude dysphasia as a cause for apparent dementia
• find information about the patient's social functioning which would not be normal in dementia
• physical examination – to recognize physical disorders which may be responsible for cognitive impairment
  • cardiovascular system – for evidence of CVA
  • neurological examination – to detect focal deficits, gait abnormalities, speech abnormalities
  • endocrine system – signs of hypothyroidism
• mental state examination – to identify other psychiatric disorders (e.g. – depression) or non-cognitive symptoms that may be associated with dementia (e.g. – delusions, hallucinations) (1)
• cognitive examination – to estimate the extent of how different cognitive domains are affected and should include examination of attention and concentration, orientation, short and long-term memory, praxis, language and executive function. Standardised screening tests used for this purpose include (2)
  • 30-item Mini Mental State Examination (MMSE) – commonly used
  • 6-item Cognitive Impairment Test (6-CIT)
  • the General Practitioner Assessment of Cognition (GPCOG)
  • 7-Minute Screen
  • the clock drawing test – to assess praxis and executive function (1)
• investigations
  • FBC
  • urea and electrolytes
  • blood sugar
  • thyroid and liver function test
  • B12 and folate levels
  • lipid profile (3)

Reference:

• (1) National Collaborating center for mental health 2007: Dementia: A NICE-SCIE guideline on supporting people with dementia and their carers in health and social care
• (2) Royal College of Psychiatrists 2009. Dementia and people with learning disabilities: Guidance on the assessment , diagnosis, treatment and support of people with learning disabilities who develop dementia
• (3) Royal Australian College of General Practitioners 2003. Care of patients with dementia in general practice