BOSTON – Taking a good history and administering a brief cognitive screening test can go a long way toward identifying Alzheimer's disease and other dementias, according to one family physician.
Currently, too many patients with mild to moderate dementia–patients with significant functional impairment–are being missed in the office, according Dr. Kathleen R. Soch, associate professor in the department of family and community medicine at the Texas A&M Health Science Center in Corpus Christi.
But physicians can improve their track records by following a few simple steps: take a complete history, administer the Folstein Mini Mental Status Exam (FMMSE), rule out depression, perform routine laboratory testing, and consider ordering an imaging study, she said at the annual meeting of the American Academy of Family Physicians.
Most physicians know to ask patients and their family members about memory loss, Dr. Soch said, but they do not realize that family members often overlook problems with memory. A family caregiver may think their parent's memory loss is normal for their age and that they are doing well, when in fact the memory impairment could be significant, she said. In those cases, families often come to the office because of the behavioral problems sometimes seen in dementia patients. When taking a history, consider other symptoms such as aphasia, apraxia, agnosia, and problems with executive function.
For patients with symptoms of dementia, Dr. Soch recommends using the FMMSE as a screening tool. The test is one of the most widely used screening tests. It takes less than 10 minutes to complete in the office, and physicians can administer it themselves or train someone else in the office to do it, she said.
The FMMSE is a 30-point test that asks patients to identify where they are, the date and season, repeat words they have heard, recall words, spell a word backward, demonstrate simple language skills, and perform simple tasks. The cut off score is 24, and most people without any cognitive impairment should be able to score 29 or 30 on the test, she said.
The test has a sensitivity of 87% and a specificity of 82%. Most people who have a score of 24 or less will have some form of cognitive impairment, but the test also will miss a lot of people with early dementia, she said. The FMMSE also is less accurate in patients with higher and lower levels of education.
Dr. Soch said if she sees a patient who is very well educated and scores 28 or 29 points, she is more likely to consider a diagnosis of dementia. On the other hand, patients who are unable to read will have trouble with the test regardless of any dementia diagnosis. The test is also less accurate as patients get older. Dr. Soch said she often scores the test more leniently for a patient over age 80 years.
For those patients who score around the 24-point cutoff, Dr. Soch recommends ordering a few simple laboratory screens including CBC, a comprehensive metabolic panel, a test of TSH levels, and a check of the patient's vitamin B12 level to rule out reversible causes. Physicians also should order an imaging test, either a CT scan or MRI, to eliminate other possible conditions such as vascular dementia.
In addition, physicians should screen every patient being assessed for dementia for depression. Depression affects between 30% and 50% of dementia patients. Since depression often presents with fatigue, psychomotor slowing, and apathy, it might be misinterpreted as a worsening of dementia.
Dr. Soch advised physicians to have a high index of suspicion for depression and consider a trial with a selective serotonin reuptake inhibitor. He reported having no conflicts of interest.