Dementia Series: Testing and Diagnosis of Cognitive Decline & Dementia
Age-old wisdom is that we only have 20/20 vision when looking through the rear-view mirror.
Never is that more apt than with cognitive decline and dementia. The conversation usually begins with, "When did you start noticing signs that something wasn't right?" "I guess that would have been three or four years ago when... (and the blank is always a little different for every person.)."
Except for the sudden onset of memory issues due to vascular dementia from transient ischemic attacks (TIAs) or strokes, cognitive decline and loss of executive function are nearly always slow and almost silent. For many, the first signs are increased anxiety, paranoia or withdrawal from usual activities rather than gaps in memory.
For some, such as those with an associated movement disorder, the first signs are tremors and shaking, and the initial diagnosis might be Parkinson Disease.
Mild cognitive decline is a normal part of aging, such as forgetting names or where your keys are. It is when you don't know who people are, forget what your keys are for, or getting lost in once-familiar neighbourhoods that are signs of advancing dementia.
Warning signs can include:
Increasing use of memory cues (notebooks and sticky notes)
Changes in the ability to do once familiar and easy tasks
Changes in behaviour and mood (anxiety, paranoia, mood swings, crying easily)
Changes in communication
Getting lost in familiar surroundings
Forgetting essential tasks and appointments
Confabulation: unintentional lies to cover memory gaps
Perseveration: getting stuck on a subject or saying the same thing over and over
Poor judgement
Hallucinations (a very rare but serious sign of Lewy Body Dementia)
Changes in gait or movement, especially falling.
Cognitive assessments always come first
Even if you have no concerns about your memory, ask your practitioner if having 'baseline' testing on file might be wise to monitor for future cognitive decline.
Except when there is an evident concern of organic brain disease (stroke or tumour), simple paper tests are the first line of determining someone's level of cognition. Your primary care practitioner or a community case manager can perform these. If there is a significant decline, a referral can be made to the correct neurologist or geriatric specialist.
Often, a family member or close friend must act as the interpreter and historian as the adult has little insight into their emotions and behaviours.
What have you noticed that is unusual?
When did you first start to notice these?
How have you noticed these things change over time?
Testing
MMSE: Mini-mental state exam
It is a shorter test than the MoCA and does not include testing for executive function. (I have never seen it used.)
MoCA: Montreal Cognitive Assessment
It is a paper test used to determine mild to moderate cognitive decline and is better at determining executive function than the MMSE. It tests short-term memory (delayed recall), executive function and visuospatial ability, language abilities, object naming, abstract thinking, attention, clock drawing, and orientation.
Both the MMSE and the MoCA tests are scored out of 30. If someone has a score under 20, they should be referred for further testing to a geriatric internist, a geriatric psychiatrist and then, possibly, to the UBC Centre for Brain Health for specific specialists for a more definitive diagnosis and possible treatments.
Brain CT Scans and MRIs:
A CT scan can show brain shrinkage and may be able to detect blood clots and strokes. Wait times for CT scans are relatively short. However, MRIs are the preferred test for vascular dementia as they can show more detail. Wait lists for MRIs can be long, so a CT scan is often ordered first while waiting for the MRI.
SPECT Scans:
These are the gold standard for brain imaging. They can show the type of dementia -- or if there is another underlying condition. These are costly machines, and there are few of them available. Therefore, only an advanced specialist can order if there is a clear indication that it will be helpful for diagnosis and treatment.
Sources & Resources
(Alzheimer's Society provides support for adults and families, no matter the type of dementia.)
What is dementia?: Alzheimer Society of Canada
Getting a Diagnosis Toolkit: Alzheimer Society of Canada
Talking to your Doctor: Alzheimer Society of Canada
MoCA test for Dementia: Very Well Health
A detailed summary of diagnoses by SPECT scans: (Important: This is a US site, and the scan's contact information is not relevant. Even if you went to the US for the scan, it is unlikely that a BC specialist would or could read the results.)
