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Dementia: Tracey Holsinger, MD, discusses the clinical examination for dementia.
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Dementia: Tracey Holsinger, MD, discusses the clinical examination for dementia.
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Upload Date:
2022-02-28T00:00:00.0000000
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Language: EN.
Segment:0 .
>> I'm Joan Stephenson, Editor of JAMA's Medical News and Perspectives section. Today, I have the pleasure of speaking with Dr. Tracey Holsinger about dementia, a condition that affects up to 4 and 1/2 million individuals in the United States. Dr. Holsinger, why don't you introduce yourself to our listeners? >> My name is Tracey Holsinger. I am a Geriatric Psychiatrist primarily at the Durham VA Medical Center and also at Duke. >> Dr. Holsinger, what do we know about the prevalence of dementia? And are there important demographic characteristics?
>> Well, the prevalence of dementia can vary fairly widely depending on the population that's being studied. In community populations, the prevalence generally is considered about 5% of those looking at everyone over the age of 65 or so. It's as low as 0.3% in those 60 to 64 years old and up to 1/3 of those over 90. In primary care populations, we think the prevalence is between 15% to 20% of older adults.
>> How does dementia differ from delirium? >> Delirium represents an acute confusional state. Attention is the primary deficit generally, and it comes on fairly rapidly. There's often an underlying medical condition which can be identified. Dementia is several cognitive deficits in different categories of cognition that develop after the person's adulthood. Memory is often the cardinal problem in dementia, and there are other cognitive facets that are involved.
>> Which history and physical examination findings are helpful when detecting dementia? And which findings are not helpful in this regard? >> The history is often very helpful and particularly if there's an informant who's familiar with a patient, spouses in particular. Informants who live with patients are the best providers of information, but history regarding a person's functional status is often the most important thing. A patient's subjective memory complaints are very common.
In some series, it's up to 50% of older adults have memory complaints, and there's conflicting data about how important those are. Sometimes, they've been found to be more related to depressive symptoms and anxiety than to actual cognitive problems, so informant information tends to be more important. As far as physical exam, physical exam findings can be more helpful in the differential diagnosis of dementia and the types of dementia, Alzheimer's disease versus vascular dementia versus frontotemporal dementia, than in the initial diagnosis.
>> How are cognitive deficits detected? >> Memory is usually detected by asking recall of fairly recently presented information. Autobiographical details and information from further back in a person's life are not as helpful. So, memory is often asking to recall words or phrases or information that was just presented. Aphasia is detected by asking a person to repeat a phrase and noting the spontaneous fluency of a patient's speech.
Apraxia is detected by asking a person to mimic behavior, like brushing one's teeth or combing one's hair or blowing out a match, that they should know how to do. And agnosia is detected via naming of objects. >> It sounds like there's a variety of approaches for evaluating dementia. Could you give us some recommendations that balance out the accuracy of the tests with the time and the expertise it takes to use them? >> There are a lot of brief cognitive tests that are available.
Many are available without copyright concerns, and there are multiple tests that can be done without any props, pictures, or word cards or anything. When trying to evaluate a person in a brief period of time, as most office visits are short, usually focusing on the memory is the path that most clinicians take because memory impairment is prominent in Alzheimer's disease, and Alzheimer's disease is the most common of the dementia subtypes.
Even asking for a brief list of three or four words with a free and then a cued recall, it can be done in a few minutes, and it can give you information about the memory. Problems arise in a higher functioning, higher educated population when you can have a ceiling effect so that everyone scores a perfect 30 out of 30 on the MMSE or a perfect score on whichever test you're using. In those cases, sometimes more in-depth and complicated tests are required, something like a longer list of words or other types of tasks to try and determine if there seems to have been a decline from previous levels of cognitive functioning.
So, it depends on the patient population. >> So, if the patient is starting at a higher level of functioning, it might take more probing to determine if there's been cognitive loss. >> Exactly. >> Is there anything else that JAMAevidence users should know about dementia? >> Well, the primary risk factor for dementia is still age and the prevalences as they rise fairly linearly with increasing age after the age of 60 or 65. It's the older adults that people should think of evaluating.
Undiagnosed dementia can be a safety concern. Patients are less able to be compliant with their medications, to drive safely, to live safely on their own. So, it's older adults that we are really more concerned about. >> Thank you, Dr. Holsinger, for this overview of dementia. And for more information, JAMAevidence subscribers can consult an online-only chapter of the Rational Clinical Examination. Thank you, Dr. Holsinger.
