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If you or a loved one is concerned that dementia may be
present, a
neuropsychological evaluation can be critical to confirming this, specifying
the exact type, and guiding treatment. Dementia is a general term referring to a significant loss of intellectual and
cognitive (thinking) abilities without impairment of perception or
consciousness. There are many different types of dementia, with Alzheimer’s
disease being the most common. Most forms of dementia are progressive and
irreversible (such as Alzheimer’s disease and fronto-temporal dementia) although
some forms are non-progressive (static) and reversible. An example of a static
form of dementia is dementia due to severe traumatic brain injury. An example
of reversible dementia is dementia due to unrecognized thyroid disease or
vitamin deficiency.
Most forms of
dementia begin with memory loss but other cognitive difficulties (naming
problems, getting lost) can also serve as the initial symptoms. Sometimes,
behavioral symptoms are the initial prominent symptom such as the decline in
personal and social conduct that is typical of fronto-temporal dementia.
Usually, a person with these symptoms will initially be evaluated by a primary
care physician. This typically results in sending the patient for blood tests
and a brain MRI (magnetic resonance imaging) to search for reversible causes of
dementia and determine if there are any visible abnormalities in the brain. The
MRI may show tissue loss (atrophy), abnormal areas of tissue (known as
lesions), a mass such as a brain tumor, or other types of abnormalities.
The person may also
be sent to a neurologist, which is a type of physician specializing in the
neurological system. The neurological exam will typically consist of a brief
interview and a physical exam focusing on the cranial nerves, reflex testing, and
sensory-motor functioning. There will usually be some brief testing of thinking
skills. This could merely involve asking the date and/or memory for a few words
but can involve the use of a brief formal screening test of thinking such as
the
Mini-Mental State Examination. These screening measures are broad tests of
thinking skills that are designed to pick up on red flags that may prompt a
referral for more detailed cognitive testing. While screening measures may
detect some difficulties that support a diagnosis of dementia, these tests are
fairly easy, are not meant to replace a comprehensive neuropsychological
evaluation, and are not good at differentiating between types of dementia.
There are several
advantages to a neuropsychological evaluation. First, a neuropsychologist
specializes in understanding the relationship between brain functioning,
thinking, emotions, and behaviors. This is important because there are
psychological conditions that are common in the elderly (e.g., major depressive
disorder) that can mimic a neurologically progressive dementia (e.g.,
Alzheimer’s disease). Thus, an expert in how psychological and neurological
conditions present is very important and neuropsychology offers that level of
expertise.
Second,
neuropsychologists spend hours upon hours with their patients to understand the
history, obtain and thoroughly review relevant medical records, perform a
detailed clinical interview (with the patient and a close informant[if
possible]) and detailed testing. This degree of detail cannot be obtained in a
physician’s office due to significant time constraints.
Third,
neuropsychologists apply specialized procedures to formally estimate the
estimated intellectual status before a suspected dementing condition began.
Additional specialized tests include measures of memory, learning new
information, attention/concentration, expressive and receptive language (e.g.,
naming, vocabulary, command following), IQ, visual-spatial and visual
constructional skills, motor and sensory functioning, information processing
speed, and executive functioning. Executive functioning refers to higher-level
thinking skills such as abstract thinking, multi-tasking, planning, judgment,
problem-solving, and organizational skills. Test performance is compared to
groups of people who are in the same age group as the patient with have no
history of brain damage. Some tests are also compared to groups of normal
controls with the same/similar educational backgrounds and also for gender.
Some tests of personality and emotional functioning can also be administered.
Neuropsychologists
review the objective information from the testing and look for areas of impairment,
the degree (level) of impairment, and patterns of performance. Specific
thinking and sensori-motor skills are controlled by different areas of the brain. The
neuropsychologist then integrates this information with the information
obtained from the clinical interview, medical records review, behavioral
observations, and knowledge of how various neurological and psychological
conditions present. These results can help determine the specific diagnosis,
which leads to specific treatment recommendations as not all dementias are
treated identically. These recommendations not only may include medication
suggestions but also include practical suggestions to improve daily
functioning. Treatment is drastically different if dementia is due to
Alzheimer’s disease, a reversible thyroid condition, malnutrition, or a severe
psychological disorder.
It is also worth
noting that neuropsychological testing may not reveal dementia but instead show
Mild Cognitive Impairment, which is stage between normal aging and dementia. This
is important to know as it also effects treatment and not all of these cases
convert to dementia.
One needs to be
careful in selecting a neuropsychologist and some guidance on how to do so is
offered
here.
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