Diagnosis of Dementia

Dementia is the decline of cognitive functioning - learning and memory, language, reasoning, attention, perceptual-motor, and social cognition - to such an extent that it interferes with a person’s daily life and activities [National Institute on Aging definition]. Mild cognitive impairment is an intermediate state between normal cognition and dementia.

• Diagnosis requires formal neuropsychiatric testing. In almost all cases, neuropsychiatric testing should be deferred to the outpatient setting given high prevalence of delirium in hospitalized patients.
• Screening for reversible causes:
  • TSH for hypothyroidism
  • B12 level
  • Depression (common in the elderly, symptoms can masquerade as dementia)
  • Consider delirium (see delirium vs. dementia below)
  • Screening for other conditions is not routinely recommended per the American Academy of Neurology (AAN) but should be considered if there is high clinical suspicion:
    • RPR for neurosyphilis
    • HIV
    • Folate level
• Neuroimaging is not routinely required as an inpatient and can typically be deferred to the outpatient setting unless there is another indication for imaging.
  • AAN recommends structural neuroimaging with either a noncontrast head CT or MRI (preferred) in the initial evaluation of all patients with dementia though other guidelines do not recommend routine imaging.
  • If imaging is performed, evaluate for structural disease, cerebral atrophy, ventriculomegaly, and signs of ischemic cerebrovascular disease.

Assessment Instruments for Dementia

Administration (3 min)

1. Instruct patient to remember 3 unrelated words (e.g., apple, blue, happy) and then to repeat the words.
2. Draw a large circle on a blank page and instruct the patient to draw the face of a clock in it. After the patient puts the numbers on the clock face, ask him to draw the hands of the clock to read a specific time, such as 11:20. These instructions can be repeated, but no additional instructions should be given. Give the patient as much time as needed.
3. Ask the patient to recall the three words from Step 1.

Scoring

Give 1 point for each recalled word. A normal clock has all numbers present in the correct sequence and position with hands that display the correct time.

• 0 = positive screen for dementia.
• 1-2 with abnormal clock = positive screen for dementia.
• 1-2 with normal clock = negative screen for dementia.
• 3 = negative screen for dementia.

Other tests can be considered for a more formal evaluation but should be repeated once a patient is discharged. If limited for time, consult occupational therapy to conduct the assessment:

• MoCA: Montreal Cognitive Assessment - longer (10-15 minutes), better for mild impairment and memory evaluation, copyrighted.
• MMSE: Mini Mental State Examination - shorter (9-10 minutes), more focused on language skills, less sensitive for mild cognitive impairment.
• SLUMS: Saint Louis University Mental Status Exam - shorter (7 minutes), less validation and data on diverse populations.

Management of Patients with Dementia in the Hospital

Start thinking about discharge planning at admission: Will the patient be safe to go home? Should you involve social work and/or APS? Is hospice appropriate (see Palliative Care section)?

Patients with dementia are at increased risk for delirium; institute delirium prevention measures.

• Document dementia and degree of dementia (e.g. MMSE or mini-cog) on discharge summary.
• Dementia increases the risk of all procedures: weigh risks/benefits carefully.
• Many patients with dementia retain decision-making capacity for some procedures. Capacity is decision specific and determined by MD; competence is global and determined by the courts.
• Document patient’s wishes and advance directives. Use your institutional documentation tools where available to make this information accessible to other providers.
• Patients with dementia may not report pain. Consider ATC analgesia, particularly in patients with agitation.

Choosing Wisely

• Do not routinely use antipsychotics to treat behavioral and psychological symptoms of dementia. These medicines offer limited benefit and carry increased risk of stroke and premature death.
• Don’t recommend percutaneous feeding tubes in patients with advanced dementia as there is no mortality benefit; instead offer oral assisted feeding.

Delirium vs. Dementia

Choosing Wisely

• Avoid using restraints to manage behavioral symptoms of delirium in hospitalized elders.
• Don’t use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation, or delirium.

AGS Choosing Wisely Workgroup. American Geriatrics Society identifies five things that healthcare providers and patients should question. J Am Geriatr Soc 2013 Apr;61(4):622-31.

AGS Choosing Wisely Workgroup. American Geriatrics Society identifies another five things that healthcare providers and patients should question. J Am Geriatr Soc. 2014 May;62(5): 950-60.

Arvanitakis, Zoe, Raj C. Shah, and David A. Bennett. "Diagnosis and Management of Dementia." Jama 322.16 (2019): 1589-1599.

Borson S, Scanlan J, Brush M, et al. The mini-cog: a cognitive “vital signs” measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry 2000;15:1021–1027.

Inouye, SK. Current concepts: delirium in older persons. N Engl J Med 2006;354:1157-1165.

Knopman DS, DeKosky ST, Cummings JL, et al. Practice parameter: diagnosis of dementia (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2001 May 8;56(9):1143-53.

Stewart, Sarah, et al. "A preliminary comparison of three cognitive screening instruments in long term care: The MMSE, SLUMS, and MoCA." Clinical Gerontologist 35.1 (2012): 57-75.