Neuropsychological Assessment of Dementia
Neuropsychological Assessment of Dementia
ASSESSMENT TO
DIAGNOSE DEMENTIA
Fenny L. Yudiarto
NEUROPSYCHOLOGICAL
ASSESSMENT (NA)
DIAGNOSTIC
PATIENT CARE & PLANNING
REHABILITATION &
TREATMENT EVALUATION
RESEARCH
(Lezak MD. Neuropsychological Assessment. 3rd. ed. New York: Oxford Univ. Press. 1995)
TESTS IN NA
DIAGNOSE
DIAGNOSE ?? Management
Management ??
COMMON SYMPTOMS of DEMENTIA
Determine etiology
CRITERIA A FOR CLINICAL DIAGNOSIS OF
ALZHEIMER DISEASE (AD)
Probable AD
Criteria for clinical diagnosis pf probable AD:
• Dementia established by clinical examination, documented by mental status testing, and confirmed by
neuropsychologic tests
• Deficits in two or more areas of cognition
• Progressive worsening of memory and other cognitive functions
• No disturbance of consciousness
• Onset between ages 40 and 90
• Absence of systemic or other brain diseases that could account for dementia
Diagnosis of probable AD is supported by:
• Progressive deterioration of specific cognitive function such as language (aphasia), motor skills (apraxia),
and perception (agnosia)
• Impaired activities of daily living and altered patterns of behavior
• Family history of similar disorders, particularly if confirmed neuropathologically
• Laboratory results of:
– Normal lumbar puncture as evaluated by standard techniques
– Normal pattern or nonspecific changes in EEG, such as increased slow-wave activity
– Evidence of progressive cerebral atrophy on CT by serial observation
Features consistent with diagnosis of probable AD:
• Plateaus in the course of progression of the illness
• Associated symptoms of depression, insomnia, incontinence, delusions, illusions, hallucinations, catastrophic verbal,
emotional, or physical outbursts, sexual disorders, and weight loss.
• Other neurologic abnormalities, especially with more advanced disease and including motor signs such as increased muscle
tone, myoclonus, or gait disorder
• Seizures in advanced disease
• CT normal for age
Features that make diagnosis of probable AD unlikely:
• Sudden onset
• Focal neurologic findings
• Seizures or gait disturbances early in the course of the illness
Possible AD
Criteria for clinical diagnosis of possible AD:
• Atypical onset, presentation, or clinical course of dementia in the absence of other neurologic, psychiatric, or systemic causes
• Presence of a second systemic or brain disorder sufficient to produce dementia but nor considered to be the cause of the
dementia
• Single, gradually progressive, severe cognitive deficit identified in the absence of other identifiable cause
Definite AD
Criteria for diagnosis of definite AD:
• Clinical criteria for probable AD
• Histopathologic evidence obtained from a biopsy or autopsy
Neoplasms Trauma
• Gliomas • Craniocerebral trauma
• Meningiomas • Acute and chronic subdural
• Metastatic tumors, carcinoma, hematoma
lymphoma, leukemia Toxins
• Remote effects of carcinomas • Alcoholism
• Heavy metals (lead, manganese,
Metabolic Disorders mercury, arsenic)
• Thyroid disease • Organic poisons, including solvents
(hyper- and hypothyroidism) and insecticides)
• Hypoglycemia Infection
• Hypernatremia and hyponatremia • Bacterial meningitis and encephalitis
• Hypercalcemia • Parasitic meningitis and encephalitis
• Renal failure • Fungal meningitis and encephalitis
• Hepatic failure • Cryptococcal meningitis
• Cushing’s disease • Viral meningitis and encephalitis
• Addison’s disease • Brain abscess
• Hypopituitarism • Neurosyphilis: meningovascular,
• Wilson’s disease tabes dorsalis, general paresis
• Primary AIDS encephalopathy
Autoimmune Disorders Nutritional Disorders
• Central nervous system vasculitis, • Thiamine deficiency (Wernicke’s
temporal arteritis encephalopathy and Wernicke-
• Disseminated lupus erythematosus Korsakoff syndrome)
• Multiple sclerosis • Vitamin B12 deficiency (pernicious
anemia)
• Folate deficiency
Drugs • Vitamin B6 deficiency (pellagra)
• Antidepressants Psychiatric Disorders
• Antianxiety agents • Depression
• Hypnotics • Schizophrenia
• Sedatives • Mania
• Antiarrhythmics • Other psychoses
• Antihypertensives
Other Disorders
• Anticonvulsants • Normal-pressure hydrocephalus
• Cardiac medications, including • Whipple’s disease
digitalis • Sarcoidosis
• Drugs with anticholinergic effects • Sleep apnea
Modified from: Terry RD. Aging and the Brain. New York, NY: Lippincott-Raven
Publishers; 1988:17-82.
IRREVERSIBLE CAUSES OF DEMENTIAS
Modified from: Terry RD. Aging and the Brain. New York, NY: Lippincott-Raven
Publishers; 1988:17-82.
SIMILARITIES AND DIFFERENCES IN THE
CLINICAL PRESENTATIONS OF DEPRESSION
AND EARLY ALZHEIMER’S DISEASE
Feature Depression Presenting as Classic Alzheimer’s Disease
Memory Difficulties without Depression
Age of onset Common below and above Rare below age 60
age 60
Onset Subacute or insidious Insidious
Course of symptoms Some fluctuations Progressive decline
Memory complaints Almost always aware Sometimes aware, often
untroubled by memory
Affective state Sad or stoic Sad, stoic, or cheerful
Sleep-wake cycle Often disturbed Sometimes disturbed
Language/praxis symptoms Uncommon unless Uncommon in mild stages,
and signs depression is severe but common in moderate
and severe stages
Memory testing Performs better than self- Performs worse than self-
expectation expectation
Response to cholinesterase Improvement in cognitive Modest improvement in
inhibitor therapy status not expected cognitive status can occur
Response to antidepressant Significant improvement Mild improvement in mood
therapy likely or behavior may occur
HOW TO DIAGNOSE ALZHEIMER ?
V. Language
Spontaneous speech
I-V FRONTAL LOBE SCORE (FLS)
CT/MRI Normal or regional atrophy Normal or ventricular dilatation Ventricular dilatation and sulcal
and sulcal enlargement enlargement
PET/SPECT Normal or bilateral posterior Bilateral parietal and frontal Bilateral, parietal, and frontal
parietal hypometabolism/ hypometabolism/hypoperfusio hypometabolism/hypoperfusion
hyperfusion n
Abbreviations: AD, Alzheimer’s disease; EEG, electroencephalogram; CT, computed tomography; MRI, magnetic
resonance imaging; PET, positron emission tomography; SPECT, single photon emission computed tomography.
Modified from: Cummings JL, Benson DF. Dementia: A Clinical Approach. Boston, Mass: Butterworth-Heinemann: 1992.