Patient Care Neurology & Psychiatry - November 2007 - (Page 12)

I Dementia TABLE 1 ones are exhibiting failing cogclock drawing, is an even Dementia characteristics nitive or executive function, briefer screening test that is they can retrospectively note not limited by the subject’s Gradual onset that cannot be dated other examples of decline for a language skills or education.11 Chronic illness that characteristically full year previously. Then it It holds the promise of similar progresses over years takes another year on average sensitivity and specificity for Generally irreversible to persuade the loved one to dementia as the MMSE but reGenerally stable day to day (unless see a doctor. Commonly the quires further validation. The delirium develops) diagnosis is not made during clock drawing component of Less prominent physiologic changes that initial visit or by the first the Mini-Cog screen assesses Consciousness not clouded until doctor consulted, even after 2 executive function and visualterminal stage years of symptoms. When spatial skills more thoroughly Attention span not characteristically families report a loved one than the MMSE.12,13 But, like reduced being forgetful, asking the the MMSE, the clock test may Disturbed sleep-wake cycle with daysame question repeatedly, not not be sensitive at detecting night reversal, not hour-to-hour variation recognizing friends or family, mild dementia.14 Psychomotor changes late in illness getting lost in familiar settings, Differentiating AD from (unless depressed) or showing unwarranted susother primary dementing illpicion, then testing and a full nesses is usually done on clinworkup are indicated. In the setting of dementia ical grounds (see Table 2, page 14). For research symptoms, the workup is not considered screening purposes, and perhaps in the future clinically, con(see Table 1). centrations of T-tau (total tau), P-tau181 (phosphoScreening tests Given that the history and physirylated tau), and Abeta1-42 (beta amyloid 1-42) in cal examination performed routinely by primary care CSF are strongly associated with future developproviders are not specifically directed toward the ment of AD in patients with mild cognitive imdetection of dementia, the question of screening pairment (MCI).15 The Abeta1-42/Abeta1-40 ratio is sutests arises. The US Preventive Services Task Force perior to Abeta1-42 concentration with regard to (USPSTF) has concluded that evidence is insufficient identifying incipient AD in MCI (P .05).16 The to recommend for or against routine screening for deAmerican Association of Neurology (AAN) guidementia in older adults.7 The USPSTF could not deterlines also note that the CSF 14-3-3 protein is useful mine whether the benefits of screening outweigh the for confirming or rejecting the diagnosis of Creutzharms. Nevertheless, the established clinical definition feldt-Jakob disease and recommend its use in approof dementia is reliable and should be used in the clinpriate circumstances. ical setting to make the diagnosis.8 Laboratory studies The utility of routine laboraOnce the issue of dementia is raised, the first tool tory studies performed during a dementia workup the clinician turns to is often the Mini-Mental State has not been established. The AAN recommends Examination (MMSE).9 A score of less than 24 points screening for B12 deficiency and hypothyroidism, 2 (out of 30) is suggestive of dementia or delirium. common comorbidities in the elderly. Treatment may Population-based norms reveal that, while the not completely reverse cognitive dysfunction but MMSE had a sensitivity of 87% and a specificity of may offer improvement nevertheless. No genetic 82%, patient variables such as age, education, and testing is recommended for routine use in the diaglanguage impairments influence scores. Additionally, nosis of dementing illness, largely because 97% of the test may be less accurate in detecting mild deAD is polygenetic, involving more than 100 suscepmentia.10 tibility genes. Screening for neurosyphilis is recomThe Mini-Cog, a composite of 3-item recall and mended only for those patients in whom there is a 12 PATIENT CARE NEUROLOGY & PSYCHIATRY www.patientcareonline.com http://www.patientcareonline.com

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Patient Care Neurology & Psychiatry - November 2007 Contents Research Digest Medicine in the News The 15-Minute Visit Dementia workup and treatment: Do the drugs really work? Help for Your Patients Who Suffer from Specific Phobias Clinical Clips Case & Comment The Science of Healing Classified Advertising

Patient Care Neurology & Psychiatry - November 2007

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