ACT on Alzheimer’s
Disease Curriculum
Module VII: Disease Diagnosis
Disease Diagnosis
• These slides are based on the Module VII:
Disease Diagnosis text
• Please refer to the text for all citations,
references and acknowledgments
2
Module VII: Learning Objectives
Upon completion of this module the student
should:
•Identify screenings and examinations used to
diagnose and assess current state of cognitive
functioning.
•Gain an understanding of the benefits of early
diagnosis.
•Understand the steps involved in identifying and
diagnosing Alzheimer’s and related dementias.
Disease Diagnosis
• A dementia or Alzheimer’s disease diagnosis
is most commonly made by a specialist, such
as neurologist, geriatrician, or geriatric
psychiatrist
• A diagnosis requires the collection of both
subjective and objective information
Disease Diagnosis
• A Minnesota collaboration known as ACT on
Alzheimer's has developed a Clinical Provider
Practice Tool which consists of four steps:
– Obtain patient history and perform a neurological
examination
– Gather further diagnostics to address other potential
causes of dementia
– Review objective and subjective data to establish a
diagnosis
– Organize a meeting with the patient and family to
discuss diagnosis, prognosis and treatment strategy
Step 1 – Medical History
• Step 1 begins with obtaining a medical history
of the patient
• The major historical elements to cover in a
medical history include:
– Symptom quality
– Symptom onset
– Course
– Impact on social/occupational function
Step 1 – Medical History
• Step 1 continues with a cognitive review of
systems
• A complete cognitive review should be
performed to assess:
– Memory
– Executive function
– Language
– Visuospatial function
Step 1 – Medical History
• The third phase of Step 1 is to conduct a
neurological examination
• A neurological exam is used to assess mental
status, rule out a stroke and assess for
parkinsonism
• A neurological examination includes: mental
status, cranial nerve evaluation, motor and
coordination exam, sensory evaluation, testing
of reflexes and gait assessment
Step 1 – Medical History
• The last element of Step 1 is cognitive
assessment and cognitive screening
• In contrast to neuropsychological testing,
cognitive screening does not confirm a
diagnosis
• There are multiple cognitive assessment tools
that are available to providers
Step 1 – Medical History
• There are a wide range of cognitive
assessment options
– Mini-Cog
– Mini-Mental State Exam (MMSE)
– St. Louis University Mental Status Exam (SLUMS)
– Montreal Cognitive Assessment (MoCA)
– Kokmen Test of Mental Status
Mini-Cog
• Mini-Cog is a five point cognitive screen
– 3 word verbal recall
– Clock draw
• Takes 1.5 to 3 minutes
• Short administration time makes it ideal for
rushed primary care settings
Mini-Cog
• Pros
 Takes only 1.5-3 minutes
to administer
 Clock drawing sensitive to
both visuospatial &
executive dysfunction
 Simple scoring and
interpretation
• Cons
 Not considered as
sensitive for MCI or early
dementia when
compared to longer
screens
 Brevity means less
information to interpret
MMSE
• Mini Mental Status (MMSE) is one of the most
widely used cognitive assessment tools
• Test has a 30 point scale and tests orientation,
memory, visuospatial, construction and
language
• Takes seven minutes to administer
MMSE
• Pros
 Widely accepted and
validated tool for
dementia screening
 30-point scale well known
and score is easily
interpretable
 Measures orientation,
working memory, recall,
language, praxis
• Cons
 Scale developed 40 years
ago, before MCI criteria
and when early dementia
less well understood
 Lacks sensitivity to MCI
and early dementia
 Takes 7 min. to administer
 Copyright issues
SLUMS
• The St. Louis University Mental Status Exam
(SLUMS) was one of the first cognitive
assessment tools to address MCI
• Test has a 30 point scale
• Takes 10 minutes to administer
SLUMS
• Pros
 More measures of executive
functioning
 Good balance between easy
and difficult items
 More sensitive than MMSE in
detecting MCI and early
dementia
 30-point scale similar to MMSE
 Score range for MCI and
dementia
 Free online
• Cons
 Takes 10 min. to administer
 Slightly more complex
directions than MMSE
 Less name recognition than
MMSE
MoCA
• The Montreal Cognitive Assessment (MoCA)
was developed at the Montreal Neurological
Institute
• MoCA is one of the most sensitive cognitive
screens available
• Takes 12-15 minutes to administer
• Tests executive function in addition to
language, visuospatial function and memory
MoCA
• Pros
 Much more sensitive than
MMSE in detecting MCI
and early dementia
 More content tapping
higher level executive
functioning
 30-point scale similar to
MMSE
 Translations available in
35+ languages
 Free online
• Cons
 Takes 10-14 min. to
administer
 More complex
administration and
directions than MMSE
Kokmen Test of Mental Status
• The Kokmen Test was developed at the Mayo
Clinic
• Has a 38 point scale
• Takes longer than the MMSE to administer
• More sensitive to MCI by including a longer
word list for recall
Step 1 – Medical History
• The decision to proceed to neuropsychological
testing is a function of a patient’s score on a
cognitive assessment as well as the patient’s
medical history
• Formal neuropsychological is recommended
for individuals scoring in the following ranges:
– MoCA: 19-27
– SLUMS: 18-27
– MMSE: 18-28
Step 2 – Diagnostic Evaluation
• Step 2 involves a diagnostic evaluation
• After completing Step 1 which includes
medical history, examination and cognitive
screening, the provider should obtain
objective studies to rule out reversible causes
of dementia
• The diagnostic evaluation outlined in Step 2
includes laboratory studies, neuroimaging and
neuropsychological testing
Step 2 – Diagnostic Evaluation
• The purpose of obtaining the laboratory
studies is to rule out reversible causes of
dementia
• Approximately 9% of dementias are reversible
Step 2 – Diagnostic Evaluation
• The American Academy of Neurology
recommends neuroimaging for all individuals
undergoing a dementia evaluation
• This imaging may involve a CT scan or an MRI
• The main purpose of the imaging is to rule out
a structural lesion that could be the cause of
the dementia
Step 2 – Diagnostic Evaluation
• The third phase of the diagnostic evaluation
includes neuropsychological testing
• Neuropsychological testing focuses on brain
function
• Neuropsychological testing can help
determine whether memory changes are
normal age-related changes or a neurological
disorder
Step 2 – Diagnostic Evaluation
• A neuropsychologist utilizes a battery of tests
to address the same cognitive modalities
addressed in the cognitive review
– Learning / memory
– Executive function
– Language
– Visuospatial function
– Mood and personality
Step 3 – Establish Diagnosis
• A neurodegenerative disease diagnosis requires a
provider to integrate elements from the previous
two steps:
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Clinical history
Neurological exam
Cognitive screening
Laboratory studies
Neuropsychological testing
Neuroimaging
• Alzheimer’s disease accounts for 60-80% of
dementia cases
Step 3 – Establish Diagnosis
• Providers successfully diagnose Alzheimer’s disease
only 50% of the time
• There are numerous barriers to an effective diagnosis
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Insufficient training, knowledge
Belief that there are no effective treatments
Time constraints
Insufficient reimbursement
Disclosure discomfort
Fear of individual, family reaction
Belief that specialists are more appropriate to make
diagnosis
– Association of dementia with the geriatric population
Step 3 – Establish Diagnosis
• There are other causes, other than dementia, that may
result in memory loss:
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Vascular
Infectious
Toxic
Autoimmune
Metabolic
Neoplastic
Traumatic
Endocrine
Episodic
Neurodegenerative
Step 4 – Family Meeting
• Following a dementia diagnosis, the provider
should arrange a family meeting
• During the meeting the following should be
addressed:
– Communicate the diagnosis
– Discuss potential interventions
– Provide suggestions for disease management
• Ideally the meeting is multidisciplinary including
physician, social worker and neuropsychologist
Step 4 – Family Meeting
• Studies have shown meaningful benefits of
providing a wide array of services and
interventions
– Appropriate use of available treatment options
(pharmacological and non-pharmacological)
– Effective management of coexisting conditions
– Coordination of care among providers
– Referral to community-based resources
– Participation in activities that enhance quality of
life
Step 4 – Family Meeting
• The individual and families benefit from an early
diagnosis. Benefits include:
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Rule out other causes
Start treatment early
Manage co-existing conditions
Understand symptoms and how to manage them
Plan for the future
Build a support system
Lower anxiety
Avoid crisis driven care
Participate in clinical trials or other research