The word Dementia is scary. The word Alzheimer’s can be devastating. Let’s distinguish between the two terms. Dementia is an umbrella term for 13 types of neurocognitive disorders which are labeled as dementias. Alzheimer’s is the most common of the dementias but there are other types of dementia such as Lewy Body, Vascular, Frontal Lobe, etc. The definition of dementia is a reduction in a variety of neurocognitive skills with the most notable being a decline in memory functioning.
What should one do if they are concerned about a decline in their memory and/or other cognitive functions, or have a strong family history of dementia? The first step is to come to the realization that memory or other cognitive functions have changed over time. Consulting with family members is encouraged, as the patient may not be fully aware of the degree of decline in their neurocognitive functioning. The next step is to obtain an evaluation. Discussing your concerns with your primary care physician is reasonable. Alternatively, seeking a specialist directly to perform a neurological evaluation, or a neuropsychological evaluation, may speed up the process of making an assessment and diagnosis.
If you choose to be initially evaluated by a neurologist, this is what you should expect. They will obtain a detailed medical history on you, as well as conduct a neurological physical examination to determine what neurological conditions could explain your symptoms. Patients who present with memory or cognitive concerns in which no further neurological conditions have been found are generally prescribed the standard protocol in which memory and cognitive issues are prevalent. Your neurologist is likely to have you undergo an MRI of your head. This is primarily to “rule out” brain tumors which can cause memory impairment. Blood work is also common as low levels of B-12 and Thyroid can cause memory decline. Assessment of genetic biomarkers of dementia as well as an Amyloid PET scan may be ordered. Your neurologist is likely to refer you for a neuropsychological evaluation to more fully develop an understanding of your strengths and limitations.
Let’s examine in detail the process of a neuropsychological evaluation. Medical records sent by your neurologist or primary care physician are reviewed in detail prior to your visit with the neuropsychologist. It’s important to note that your neuropsychologist will be understanding and compassionate about your condition. They have had extensive training and experience. and their task is to understand the nature and severity of your symptoms in order to develop a comprehensive and personalized treatment plan for you.
The first question asked is usually “Why do you think you were referred for this type of assessment?” Most patients have a good understanding of the nature of the referral, while some patients have a limited understanding of the reason for the referral. The neuropsychologist will explain the reason for the referral, and then will briefly outline the evaluation process. You will realize that your psychologist will administer a battery of different tests on you. It’s important to realize that they will not touch you, poke you or hurt you in any way. This understanding usually allows the patient to become more relaxed, as most patients referred for a neuropsychological evaluation are not familiar with the procedures of this type of examination.
The assessment begins with obtaining a detailed history. A review of presenting symptoms and concerns as well as the longevity of such issues is made. Demographics, education, and work experience are obtained. Marital status and living arrangements are ascertained. Assessment of previous mental health treatment is reviewed, as well as evaluating ongoing mental health symptoms such as anxiety and depression. Medical conditions that are germane to this type of evaluation are reviewed. Your neuropsychologist is most interested in medical conditions that are vascular in nature, such as strokes, heart disease, and other neurological conditions. Your current medication regime is then reviewed.
The next step is to obtain what is called a Mental Status Examination, which is a brief summary as to how the patient presents. General information about appearance, effort, motivation, and a conclusion about the validity of testing is provided. Brief testing of mental control, memory, attention, and concentration is made. Any specific observations that may impact the results of the evaluation are noted, such as a hand tremor, hearing, or visual impairment.
A detailed history of a person’s functional capacities is obtained. There are multiple questions about your ability to independently function in your environment. Such questions will include your ability to manage money, ability to drive, use a cell phone and computer, word finding difficulties, balance issues, and many other questions regarding activities of daily living. The reason that functional capacities are so important is that if there is a decline in neurocognitive functioning, there is almost always a decline in functional capacities. Your neuropsychologist will use two sets of data in making your assessment. The first is your performance on all of the neuropsychological tests that you will be administered, as well as your functional capacities. It’s preferable to have a collateral person present during this evaluation. This is usually a family member or friend who is familiar with the patient’s strengths and limitations. At times a patient may not be fully aware of their decline in functioning, and their collateral will be able to provide objective information regarding their level of functioning.
Formal testing is now started. Often the first question asked is “Can you please raise your right hand and put your left hand on the desk.” Almost everyone can do this. The patient is then told that this is the first test of the test battery. They’re then informed that these are the types of questions that will be asked of them, and are encouraged to relax and “go with the flow” for the remainder of the tests. Patients generally have a positive response to this approach, and are not as anxious about participating in a neuropsychological examination.
A full battery of neuropsychological tests is then administered. Please see sidebar addendum which describes, in detail, these neurocognitive tests and related charts.
The test battery includes a test that evaluates multiple dimensions of neuropsychological functioning. Some of the domains of neuropsychological functioning assessed include attention, concentration, executive functioning, problem solving, cognitive functioning, and memory. As memory is usually one of the presenting issues, multiple tests of different aspects of memory are evaluated. These include visual memory, verbal memory, general memory, and graphic memory. Cognitive functioning is also evaluated by administering several subtests of a standard IQ test. Inventories to evaluate symptoms of anxiety and depression are also completed, as comorbid depression and anxiety are often found in individuals who are diagnosed with a neurocognitive disorder.
This is the end of the formal neuropsychological assessment. It’s preferable for the patient and their collateral to return within a reasonable time frame to obtain verbal feedback on their performance. The results from each of the tests from the neuropsychological battery should be disclosed and interpreted for the patient. Recommendations for treatment will be discussed. Any questions that the patient or collateral has will be addressed and answered. A written report to the referring physician is composed. The patient should request a copy of this report for their medical records.
One final word. As previously reported, a collateral should be present at the testing and at verbal feedback regarding the results of the assessment. This is usually a spouse or adult child. Collaterals are used in the assessment by asking them probing questions about the patient. When present at verbal feedback, they are able to ask questions and hear the results of the neuropsychological assessment. This will allow them to better understand the patient’s condition, to understand treatment options, and have realistic expectations regarding prognosis.
Editor’s note: Dr. Keith Bauer is a neuropsychologist who evaluates patients to determine if they have Dementia or Alzheimer’s disease.
