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Early Alzheimer's Disease: Recognition and Assessment.
Guideline Overview No. 19

© Agency for Health Care Policy and Research

A focused history is critical in the assessment for dementia. It is particularly important to establish the symptoms' mode of onset (abrupt versus gradual); progression (stepwise versus continuous decline; worsening versus fluctuating versus improving), and duration.

A focused physical examination, including a brief neurological evaluation, is an essential component of the initial assessment. Special attention should be placed on assessing for those conditions that cause delirium, since delirium represents a medical emergency. During the focused physical examination, health care providers should be alert to signs of abuse and neglect of patients by caregivers and report suspected abuse to the proper authorities.

Informant reports (information obtained from family members or caregivers) can supplement information from patients who have experienced memory loss and may lack insight into the severity of their decline. Health care providers, however, should consider the possibility of questionable motives of informant reports, which may exaggerate, minimize, or deny symptoms.

Brief mental status tests can be used but they are not diagnostic. They are used to (1) develop a multidimensional clinical picture; (2) provide a baseline for monitoring the course of cognitive impairment over time; (3) reassess mental status in persons who have treatable delirium or depression on initial evaluation; and (4) document multiple cognitive impairments as required for a diagnosis of dementia.

Assessing for Depression
Depression can be difficult to distinguish from dementia, and it can coexist with dementia. Changes in memory, attention, and the ability to make and carry out plans suggest depression, the most common psychiatric illness in older persons. Marked visuospatial or language impairment suggests a dementing process. The clinical interview is the mainstay for evaluating and diagnosing depression in older adults. Two self-report instruments with established reliability and validity are the Geriatric Depression Scale (GDS) and the Center for Epidemiological Studies Depression Scale (CES-D).

Interpreting Findings
Three results are possible from the combination of findings from assessments of mental and functional status: (1) normal, (2) abnormal, and (3) mixed.

When results of both mental and functional status tests are normal and there are no other clinical concerns, reassurance and suggested reassessment in 6 to 12 months are appropriate. If concerns persist, referral for a second opinion or further clinical evaluation should be considered.

When both mental and functional status tests yield findings of abnormality, further clinical evaluation should be conducted. However, a laboratory test should not be used as a screening procedure or part of an initial assessment. Laboratory tests should be conducted only after (1) it has been confirmed that the patient has impairment in multiple domains that is not lifelong and represents a decline from previous levels of functioning; (2) delirium and depression have been excluded; (3) confounding factors such as educational level have been considered; and (4) medical conditions have been be ruled out.

Mixed results—abnormal findings on the mental status test with no abnormalities in functional assessment or vice versa—call for further evaluation. For example:

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