ASSESSMENT IN ALZHEIMER’S DISEASE

Assessment of patients as individuals is integral to the planning of care and treatment. Accurate
diagnosis is therefore essential, especially for early intervention in confirmed or suspected
Alzheimer’s disease.

There is no single diagnostic test that can determine if a person has Alzheimer’s disease.
Physicians (often with the help of specialists such as neurologists, neuropsychologists,
geriatricians and geriatric psychiatrists) use a variety of approaches and tools to help make a
diagnosis. Although physicians can almost always determine if a person has dementia, it may be
difficult to identify the exact cause. 

Medical history

During the medical workup, your health care provider will review your medical history,
including psychiatric history and history of cognitive and behavioral changes. He or she will
want to know about any current and past illnesses, as well as any medications you are taking.
The doctor will also ask about key medical conditions affecting other family members, including
whether they may have had Alzheimer's disease or other dementias.

Physical exam and diagnostic tests

During a medical workup, you can expect the physician to:

 Ask about diet, nutrition and use of alcohol.

 Review all medications. (Bring a list or the containers of all medicines currently being
taken, including over-the-counter drugs and supplements.)

 Check blood pressure, temperature and pulse.

 Listen to the heart and lungs.

 Perform other procedures to assess overall health.

 Collect blood or urine samples for laboratory testing.

Neurological exam

During a neurological exam, the physician will closely evaluate the person for problems that
may signal brain disorders other than Alzheimer's. The doctor will look for signs of small or
large strokes, Parkinson's disease, brain tumors, fluid accumulation on the brain, and other
illnesses that may impair memory or thinking.

The physician will test:

  Reflexes.

 Coordination, muscle tone and strength.

 Eye movement.

 Speech.

 Sensation.

The neurological exam may also include a brain imaging study.

Mental status tests

Mental status testing evaluates memory, ability to solve simple problems and other thinking
skills. Such tests give an overall sense of whether a person:

 Is aware of symptoms.

 Knows the date, time, and where he or she is.

 Can remember a short list of words, follow instructions and do simple calculations.

Mini-Mental State Exam (MMSE) and the Mini-Cog test 

The MMSE and Mini-Cog test are two commonly used assessments.

During the MMSE, a health professional asks a patient a series of questions designed to test a
range of everyday mental skills. The maximum MMSE score is 30 points. A score of 20 to 24
suggests mild dementia, 13 to 20 suggests moderate dementia, and less than 12 indicates
severe dementia. On average, the MMSE score of a person with Alzheimer's declines about two
to four points each year.

During the Mini-Cog, a person is asked to complete two tasks:

1. Remember and a few minutes later repeat the names of three common objects.

2. Draw a face of a clock showing all 12 numbers in the right places and a time specified by
the examiner.
The results of this brief test can help a physician determine if further evaluation is needed.

Computerized tests cleared by the FDA

A growing area of research is the development of devices to administer computer-based tests
of thinking, learning and memory, called cognitive tests.

The U.S. Food and Drug Administration (FDA) has cleared several computerized cognitive
testing devices for marketing. These are the Cantab Mobile, Cognigram, Cognivue, Cognision
and Automated Neuropsychological Assessment Metrics (ANAM) devices.

Some physicians use computer-based tests such as these in addition to the MMSE and Mini-
Cog. Computerized tests have several advantages, including giving tests exactly the same way
each time. Using both clinical tests and computer-based tests can give physicians a clearer
understanding of cognitive difficulties experienced by patients.

Mood assessment
In addition to assessing mental status, the doctor will evaluate a person's sense of well-being to
detect depression or other mood disorders that can cause memory problems, loss of interest in
life, and other symptoms that can overlap with dementia.

Genetic testing

Researchers have identified certain genes that increase the risk of developing Alzheimer's and
other rare "deterministic" genes that directly cause Alzheimer's. Although genetic tests are
available for some of these genes, health professionals do not currently recommend routine
genetic testing for Alzheimer's disease.

Brain imaging

A standard medical workup for Alzheimer's disease often includes structural imaging with

magnetic resonance imaging (MRI) or computed tomography (CT). These tests are primarily
used to rule out other conditions that may cause symptoms similar to Alzheimer's but require
different treatment. Structural imaging can reveal tumors, evidence of small or large strokes,
damage from severe head trauma, or a build-up of fluid in the brain.
In some circumstances, a doctor may use brain imaging tools to find out if the individual has
high levels of beta-amyloid, a hallmark of Alzheimer’s; normal levels would suggest Alzheimer’s
is not the cause of dementia.

Imaging technologies have revolutionized our understanding of the structure and function of
the living brain. Researchers are studying other brain imaging techniques so they can better
diagnose and track the progress of Alzheimer’s.
These cognitive assessment tools are used to identify individuals who may need additional
evaluation. No one tool is recognized as the best brief assessment to determine if a full
dementia evaluation is needed. However, the expert workgroup identified several instruments
suited for use in primary care based on the following: administration time ≤5 minutes,
validation in a primary care or community setting, psychometric equivalence or superiority to
the Mini-Mental State Exam (MMSE), easy administration by non-physician staff and relatively
free of educational, language and/or cultural bias. For a definitive diagnosis of mild cognitive
impairment or dementia, individuals who fail any of these tests should be evaluated further or
referred to a specialist.

Patient assessment tools:

 The GPCOG is a screening tool for cognitive impairment designed for use in primary care
and is available in multiple languages.
 Mini-Cog - The Mini-Cog is a 3-minute test consisting of a recall test for memory and a
scored clock-drawing test. It can be used effectively after brief training and results are
evaluated by a health provider to determine if a full-diagnostic assessment is needed.

Informant tools (family members and close friends):

 Eight-item Informant Interview to Differentiate Aging and Dementia (AD8) – is an

eight-question interview used to distinguish between normal signs of aging and mild
dementia. This tool assesses individual change and can be administered in the primary
care setting.

 General Practitioner Assessment of Cognition (GPCOG) – is a screening tool for

cognitive impairment designed for use in primary care and is available in multiple
languages.

 Short Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) – the

IQCODE screening tool is an informant questionnaire designed to assess cognitive
decline and dementia. 

DIAGNOSIS IN ALZHEIMER’S DISEASE

Doctors use several methods and tools to help determine whether a person who is having
memory problems has “possible Alzheimer’s dementia” (dementia may be due to another
cause), “probable Alzheimer’s dementia” (no other cause for dementia can be found), or some
other problem.

To diagnose Alzheimer’s, doctors may:

 Ask the person and a family member or friend questions about overall health, use of
prescription and over-the-counter medicines, diet, past medical problems, ability to
carry out daily activities, and changes in behavior and personality
 Conduct tests of memory, problem solving, attention, counting, and language
 Carry out standard medical tests, such as blood and urine tests, to identify other
possible causes of the problem
 Perform brain scans, such as computed tomography (CT), magnetic resonance imaging
(MRI), or positron emission tomography (PET), to rule out other possible causes for
symptoms
These tests may be repeated to give doctors information about how the person’s memory and
other cognitive functions are changing over time. They can also help diagnose other causes of
memory problems, such as stroke, tumor, Parkinson’s disease, sleep disturbances, side effects
of medication, an infection, mild cognitive impairment, or a non-Alzheimer’s dementia,
including vascular dementia. Some of these conditions may be treatable and possibly
reversible. People with memory problems should return to the doctor every 6 to 12 months. It’s
important to note that Alzheimer’s disease can be definitively diagnosed only after death, by
linking clinical measures with an examination of brain tissue in an autopsy. Occasionally,
biomarkers—measures of what is happening inside the living body—are used to diagnose
Alzheimer's.

EVALUATION OF ALZHEIMER’S DISEASE

This involves a careful medical evaluation, including a thorough medical history, mental status
testing, a physical and neurological exam, blood tests and brain imaging exams, including:

 CT imaging of the head: Computed tomography (CT) scanning combines special x-ray
equipment with sophisticated computers to produce multiple images or pictures of the
inside of the body. Physicians use a CT of the brain to look for and rule out other causes
of dementia, such as a brain tumor, subdural hematoma or stroke.
 MRI of the head: Magnetic resonance imaging (MRI) uses a powerful magnetic field,
radio frequency pulses and a computer to produce detailed pictures of organs, soft
tissues, bone and virtually all other internal body structures. MRI can detect brain
abnormalities associated with mild cognitive impairment (MCI) and can be used to
predict which patients with MCI may eventually develop Alzheimer's disease. In the
early stages of Alzheimer's disease, an MRI scan of the brain may be normal. In later
stages, MRI may show a decrease in the size of different areas of the brain (mainly
affecting the temporal and parietal lobes).
 PET and PET/CT of the head: A positron emission tomography (PET) scan is a diagnostic
examination that uses small amounts of radioactive material (called a radiotracer) to
diagnose and determine the severity of a variety of diseases.

A combined PET/CT exam fuses images from a PET and CT scan together to provide
detail on both the anatomy (from the CT scan) and function (from the PET scan) of
organs and tissues. A PET/CT scan can help differentiate Alzheimer's disease from other
types of dementia. Another nuclear medicine test called a single-photon emission
computed tomography (SPECT) scan is also used for this purpose.

Using PET scanning and a new radiotracer called C-11 PIB, scientists have recently
imaged the build-up of beta-amyloid plaques in the living brain. Radiotracers similar to
C-11 PIB are currently being developed for use in the clinical setting.