(Editor’s Note: I recently came across an excel­lent book and resource, The Alzheimer’s Action Plan: The Experts’ Guide to the Best Diag­no­sis and Treat­ment for Mem­ory Prob­lems, recently released in paper­back. Dr. Murali Doraiswamy, one of the authors and lead­ing Alzheimer’s expert, kindly helped us cre­ate a 2-part arti­cle series to share with Sharp­Brains read­ers advice on a very impor­tant ques­tion, “How can we help the pub­lic at large to dis­tin­guish Alzheimer’s Dis­ease from nor­mal aging — so that an inter­est in early iden­ti­fi­ca­tion doesn’t trans­late into unneeded wor­ries?” What fol­lows is an excerpt from the book, pages 72–78, dis­cussing the Pros and Cons of the most com­mon assessments).

—

While no sin­gle test (other than a brain biopsy, which is a very inva­sive and risky pro­ce­dure) can con­clu­sively prove that a per­son has Alzheimer’s, many tests can give us a good idea. A list of all the tests that help us assess mem­ory and think­ing prob­lems appears at the end of this chap­ter. Mean­while, let’s take a good look at the whys and hows of a thor­ough mem­ory assessment.

WHAT A DIFFERENCE AN EXTRA TEST CAN MAKE

To under­stand why get­ting tested (and retested as symp­toms change and the dis­ease pro­gresses) is impor­tant, check out the expe­ri­ence of Kather­ine, who went to the doc­tor com­plain­ing of a mem­ory slow­down. She took five of the most impor­tant neu­ropsy­cho­log­i­cal tests, which assess brain func­tion with­out actu­ally phys­i­cally look­ing at the brain. Then she under­went brain scans, a car­dio­vas­cu­lar workup, and blood tests to see what else was going on that might be under­min­ing her men­tal function.

- BUT FIRST, PAYING FOR THE DIAGNOSIS–

Igno­rance can be costly, yet so is infor­ma­tion. At the first visit, ask the doc­tor to spell out which tests he or she wants to run, then check that your insur­ance cov­ers those tests and whether there are any con­di­tions that are not cov­ered. At the end of this chap­ter you will find the approx­i­mate costs of dif­fer­ent tests.

Was it all worth it? Well, if she had stopped at just the two most com­mon tests, she could have walked away with a very inac­cu­rate diagnosis.

First, the doc­tor wanted to know if she had a fam­ily his­tory of Alzheimer’s and, if so, at what age the rel­a­tive devel­oped Alzheimer’s. The doc­tor also needed to know her age. That’s not surprising—seems the older you get, the more peo­ple ask. But for an Alzheimer’s diag­no­sis, age really mat­ters, because after age six­ty­five the risk of Alzheimer’s dou­bles every five years, and below age fifty the dis­ease is rel­a­tively rare.Your edu­ca­tion level is impor­tant, too. Peo­ple who didn’t com­plete high school have a greater risk of devel­op­ing Alzheimer’s than peo­ple with a higher level of edu­ca­tion. Finally, women are more likely to get Alzheimer’s than men.

Kather­ine was seventy-two, a col­lege grad, and had no fam­ily his­tory that she knew of.Her par­ents both died before their seventy-fifth birth­days, but they cer­tainly didn’t have early-onset Alzheimer’s.

THE STANDARD OF MEMORY TESTS

The test that all doc­tors should give at the first mem­ory assess­ment, which Katherine’s doc­tor did, and at every follow-up visit is the Mini-Mental State Exam (MMSE), a short but very use­ful test that assesses a lot of dif­fer­ent abilities.

• To demon­strate orientation:The patient tries to answer, “What is today’s date?” and “What county are we in?”
• To demon­strate mem­ory skills: The patient tries to repeat the names of three objects imme­di­ately and again after five minutes.
• To demon­strate con­cen­tra­tion: The patient tries to count back­ward or to spell backward.
• To demon­strate lan­guage abil­i­ties: The patient tries to name objects in the room, repeat a tongue twister, or fol­low sim­ple direc­tions such as to take, fold, and put a piece of paper on the desk.
• To demon­strate motor skills: The patient tries to copy a pic­ture that includes inter­sect­ing shapes.

• Serves as a quick screen for demen­tia of any kind
• Pro­vides a gen­eral mea­sure of brain function
• Helps deter­mine if the patient is in the early, mid­dle, or late stage of Alzheimer’s
• Mon­i­tors changes in men­tal func­tion­ing over time, includ­ing the effects of treatment
• Pro­vides a com­mon lan­guage. Every­one from a gen­eral prac­ti­tioner to a mem­ory spe­cial­ist under­stands the test results, so they serve as a com­mon lan­guage spo­ken across dif­fer­ent specialties.

What the MMSE Doesn’t Do

The MMSE doesn’t do sub­tle. It was devel­oped thirty years ago to help doc­tors screen hos­pi­tal patients for prob­lems with their men­tal func­tion­ing. Now peo­ple are dri­ving them­selves to the doc­tor for a mem­ory test, and the MMSE is not sen­si­tive enough to pick up on sub­tle prob­lems in think­ing and mem­ory. Nor does it probe any one aspect of men­tal func­tion­ing in depth or dis­tin­guish among mem­ory disorders.

Some indi­vid­u­als with a very high IQ or those who are really good test tak­ers appear merely “nor­mal” on the MMSE when in fact they have an Alzheimer’s-induced mem­ory slow­down. Doc­tors should, though not all do, con­sider IQ, gen­der, occu­pa­tion, edu­ca­tion level, and an individual’s age when scor­ing the MMSE. An assess­ment may not include a for­mal IQ test, but the doc­tor should find out about the person’s per­son­al­ity, capa­bil­i­ties, and occu­pa­tion prior to devel­op­ing mem­ory prob­lems, because Alzheimer’s is about a decline or change in mem­ory and think­ing. For exam­ple, the MMSE score of 26 is nor­mal for a man in his early six­ties who has an eighth-grade edu­ca­tion, but it would be below nor­mal if he had gone to col­lege. (A chart show­ing what MMSE score is nor­mal for a person’s age and edu­ca­tion is avail­able at www.tuftsnemc.org/ psych/mmse.asp.)

Kather­ine did okay on her MMSE. She scored a respectable 26 out of a pos­si­ble 30. No big red flag there for most doc­tors, who don’t worry until they see a total score below 24. But the score actu­ally con­cerned her doc­tor, who hap­pened to know that for her years of edu­ca­tion and age, nor­mal for Kather­ine would be closer to a 28.

Doc­tors some­times neglect to home in on how the test taker did on each set of ques­tions. For exam­ple, for­get­ting today’s date is less impor­tant than miss­ing other assess­ment ques­tions. Before leav­ing the doctor’s office, find out your (or your relative’s) total MMSE score and what items were missed.

Kather­ine ended up tak­ing the MMSE many times over the years. Her scores declined slowly because, as the tests revealed, she had MCI (mild cog­ni­tive impair­ment). But after three years, she, too,was diag­nosed with Alzheimer’s and her decline accelerated.

It’s Time …

Prob­a­bly the sec­ond most pop­u­lar test to screen for demen­tia is the clock-drawing test, which requires patients to draw a clock show­ing a spe­cific time. The test is a good way to screen for over­all men­tal abil­i­ties, and it can reveal prob­lems that the patient has been able to hide dur­ing day-to-day activ­i­ties. Kather­ine did great on the test, which was lucky for her daugh­ter, whose own lit­tle girl was just mas­ter­ing the skill of telling time. It’s upset­ting for fam­ily mem­bers to see a par­ent or spouse fail at a task most kids mas­ter in grade school.

Most gen­eral prac­ti­tion­ers con­sider talk­ing with the patient, order­ing some blood tests and a brain scan, and giv­ing the MMSE and clock-drawing test suf­fi­cient for diag­nos­ing demen­tia. It might be suf­fi­cient for some­one with obvi­ous signs of Alzheimer’s. But it could miss the early-stage Alzheimer’s or MCI. For­tu­nately for Kather­ine and her fam­ily, her doc­tor did more.

ASSESSING LANGUAGE SKILLS

A diag­no­sis of Alzheimer’s requires being impaired in mem­ory and one other men­tal func­tion, such as lan­guage or atten­tion. Lan­guage prob­lems usu­ally indi­cate that Alzheimer’s is some­what pro­gressed or that the prob­lem is another type of demen­tia that strikes the lan­guage cen­ters of the brain first.

To assess lan­guage, beyond just lis­ten­ing to how the per­son for­mu­lates and under­stands words, a doc­tor will ask the patient to name com­mon objects, such as chair, shoe, or elbow. More sen­si­tive tests of lan­guage skills involve ask­ing the patient to name, for exam­ple, all the four-legged ani­mals he or she can think of as quickly as pos­si­ble, or to repeat com­plex phrases, such as “Nel­son Rock­e­feller had a Lin­coln Con­ti­nen­tal.” Kather­ine took one sec­tion of a lan­guage test called the Boston Nam­ing Test that required her to name uncom­mon objects depicted in line draw­ings. She got only twen­tysix out of thirty right, which is slightly worrisome.

The Delayed Recall Test

One of the most sen­si­tive tests to dis­tin­guish nor­mal aging from Alzheimer’s is the delayed recall test, which tests a person’s mem­ory for a story or list of ten to six­teen words heard thirty min­utes ear­lier. It’s usu­ally given as part of a larger mem­ory test that also assesses imme­di­ate recall. Katherine’s MCI came out of the shad­ows here. She was in the bot­tom nine­teenth per­centile on these recall tests.

One delayed recall test, called the Buscke Selec­tive Remind­ing test, helps dis­tin­guish Alzheimer’s from nor­mal aging, because the tester is allowed to give clues to jog the test taker’s mem­ory. A prompt usu­ally does not help if Alzheimer’s is at the wheel, but it does help if the mem­ory mal­func­tion is due to depres­sion or atten­tion grabbers.

There are other tests, too. To assess atten­tion, doc­tors see how well the patient can fol­low direc­tions. They also ask the patient to spell words for­ward and back­ward or to sub­tract num­bers for­ward and back­ward (for exam­ple, sub­tract by 7s start­ing at 100). There are com­put­er­ized tests of atten­tion as well, which are becom­ing increas­ingly pop­u­lar in pri­vate prac­tices and research centers.

Daily Living

The activ­i­ties once taken for granted, from using the phone to fix­ing din­ner, go from rou­tine to frus­trat­ing to impos­si­ble as Alzheimer’s storms the brain. Katherine’s doc­tor used a Func­tional Activ­i­ties Ques­tion­naire (FAQ) to rate her abil­ity to per­form sev­eral com­mon daily activ­i­ties. The ques­tion­naire assigns one point if a per­son has trou­ble with the activ­ity but can do it alone, two points if he or she needs assis­tance, and three points if he or she is depen­dent on some­one else to do it. The high­est score, 30, indi­cates impair­ment in all activ­i­ties; a score below 9 is nor­mal. Kather­ine scored a 5, because she needs some help bal­anc­ing her check­book and assem­bling tax records.

DEPRESSION, DEMENTIA, OR BOTH?

Depres­sion is a must-check con­di­tion for every per­son com­plain­ing of impaired think­ing. Depres­sion and Alzheimer’s have an insid­i­ous rela­tion­ship: Depres­sion masks Alzheimer’s, is mis­taken for Alzheimer’s, wors­ens Alzheimer’s, may pre­cede the onset of Alzheimer’s, and can be caused by Alzheimer’s. To screen for depres­sion, the doc­tor may start by just ask­ing a few impor­tant questions:

1. Are you able to have fun or expe­ri­ence plea­sure dur­ing a nor­mal day?
2. Are you sleep­ing well?
3. Are you in pain?
4. Is every­thing okay with home and fam­ily life?
5. Have you lost weight unin­ten­tion­ally? Are you overeat­ing?
Katherine’s answers were: 1. not really; 2. not really; 3. not really; 4. I don’t have much of a home life;
5. I wish.

Her doc­tor decided to give her the Geri­atric Depres­sion Scale— Short Form, which asks fif­teen ques­tions to probe for depres­sion. A score greater than 5 war­rants fur­ther assess­ment and a score greater than 10 indi­cates clin­i­cal depres­sion. Kather­ine scored 11.After ask­ing a few more ques­tions and review­ing her med­ical record, the doc­tor pre­scribed an anti­de­pres­sant. He also rec­om­mended that her fam­ily get her more involved in phys­i­cal and social activ­i­ties, includ­ing walk­ing. Three months later, her depres­sion eased. Her mem­ory prob­lems per­sisted, but she was think­ing more clearly and her atten­tion and con­cen­tra­tion improved. Also, she regained a good por­tion of her for­mer desire to see her friends.

Doc­tors often give the rel­a­tive of the per­son with Alzheimer’s the brief Neu­ropsy­chi­atric Inven­tory (NPI) to assess changes in the patient’s sleep­ing and eat­ing habits, appetite, depres­sion, eupho­ria, irri­tabil­ity, hal­lu­ci­na­tions, para­noia, impul­siv­ity, and night­time behaviors.

The fam­ily mem­ber also describes how much each of these behav­iors is dis­rupt­ing the family.To fill out the sur­vey, fam­ily mem­bers can rely on their mem­ory or keep a weekly diary of changes they notice in the per­son with Alzheimer’s.The NPI can help a doctor:

• Be more thor­ough. Unusual symp­toms, such as extreme eupho­ria or impul­siv­ity, may point to frontal lobe demen­tia, for example.
• Deter­mine if the per­son needs psy­chi­atric drugs, such as antidepressants
• Iden­tify the stage of Alzheimer’s—more severe behav­ior prob­lems usu­ally indi­cate more advanced dementia
• Mon­i­tor improve­ments fol­low­ing the start of new med­ica­tions (such as Ari­cept or Namenda)

This scale is par­tic­u­larly use­ful if one is being treated by a non­spe­cial­ist, since most gen­eral prac­ti­tion­ers often lack the time or expe­ri­ence to assess behav­ioral prob­lems in detail. Doc­tors use the NPI when first assess­ing a patient and again at sub­se­quent appoint­ments to mon­i­tor change. Roughly one-third of peo­ple with MCI and two thirds of peo­ple with mild to mod­er­ate Alzheimer’s have a behav­ioral change.

Com­put­er­ized Neu­ropsy­cho­log­i­cal Tests

For peo­ple with mild mem­ory loss, com­put­er­ized tests of all aspects of men­tal func­tion­ing, includ­ing mem­ory, are par­tic­u­larly use­ful though not widely used. Unlike paper-and-pencil tests, com­put­er­ized assess­ments can eas­ily be made more dif­fi­cult to chal­lenge patients who are only slightly impaired or who are highly able test tak­ers. Com­put­er­ized tests are becom­ing very fea­si­ble to admin­is­ter, as more patients (though not all) are becom­ing more tech­nol­ogy savvy and com­fort­able with a key­board. You prob­a­bly have to go to a spe­cial­ist to take them, how­ever, as they are not read­ily avail­able elsewhere.

…(to con­tinue read­ing, check out  The Alzheimer’s Action Plan: The Experts’ Guide to the Best Diag­no­sis and Treat­ment for Mem­ory Prob­lems).

—

Dr. Murali Doraiswamy is the Head of the Divi­sion of Bio­log­i­cal Psy­chi­a­try at Duke University’s School of Med­i­cine, and co-author of The Alzheimer’s Action Plan: The Experts’ Guide to the Best Diag­no­sis and Treat­ment for Mem­ory Prob­lems, just released in paper­back. The first arti­cle in this 2-part series focused on Alzheimer’s Early and Accu­rate Diag­no­sis: Nor­mal Aging vs. Alzheimer’s Disease.