Introduction:

My name is Frank Nicolosi, thank you very much for inviting me today.(Feb. 25, 2008)

In Today’s lecture of Mental Capacity/Competency I would like to approach this in the way that we all can learn from each other. Since this group is relatively small, I think we can leave the floor open to questions, comments, insights to go along with my actual presentation. I believe this will help keep the flow going well and be the most enjoyable way to tackle this very interesting and challenging topic.

Ok, now I have my ‘lecture handouts’. I refer to them as such, as I would like your to follow my talk with these notes. These notes are the abbreviated version, but the entire ‘lecture notes’ can be found on my website: www.illinoismediationlaw.com . (Go to my website, look under lecture and you will find the entire lecture notes available). Please feel free to scribble any notes on them, as the handouts of course are yours to keep and it is my hope that you can use these in the future as good references for ‘Mental Competency’ issues. (the handouts follow my lecture, but also listed are my references and other information that I feel can be very helpful to all of us in the future.

First of all an over view of what we will cover:

I. Brief IntroductionII. Mental Competency for Lawyers/JudgesIII. Mental Competency for Physicians and Health Care WorkersIV. Summary

I. Introduction:As we all know Mental Competency, or ‘Mental Incompetency’ is a very hot topic in both law and medicine. Lawyers can be faced sometimes often with having to make decisions on a client’s competency. Such areas including wills, estates, guardianships are just some of these areas.Judges also can at times be faced with deciding a plaintiff’s or a defendant’s ‘mental competency’.

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As a physician, health care worker we are often also faced with problems of ‘is this patient mentally competent to live alone, take care of him or her self, take his/her own medicines, etc. Also, such decisions as , can this person competently decide on if a procedure should be done, or can he/she decide what plan of treatment would be suitable for them and would they be able to follow such plan?

Ok, now to the ‘legal aspect’ of competency:

II. Legal CompetencyWhen preparing this lecture/dialogue, I felt that it would be very helpful to at least ‘touch base’ on some principles that I thought are crucial to ‘legal mental competency’. Although, again my focus is medical competency, as attorneys it is my hope that you will be able to gather and keep some ‘Take Home Points’ that can be used in your every day and not so every days of your practice.

First of all, since legal competency issues can cover many areas of law, (if not technically all areas), as some have been mentioned above, I would like to direct our energies first on: Guardianships. Guardianships, as we know, a Guardianship is needed when a person is unable to make and communicate responsible decisions regarding his personal care or finances due to a mental, physical or developmental disability.

The extent to which a guardian is allowed to make decisions for a ward is determined by the court based on a thorough clinical evaluation and report.

Two basic types of guardianship are "person guardianship" and "estate guardianship ". (as we know….) “guardian of the person" is appointed by the court when a disabled individual cannot make or communicate responsible decisions regarding his personal care. This guardian will make decisions about medical treatment, residential placement, social services and other needs.

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The court appoints a "guardian of the estate" when a disabled person is unable to make or communicate responsible decisions regarding the management of his estate or finances. The guardian will, subject to court supervision, make decisions about the ward's funds and the safeguarding of the ward's income or other assets.

Excellent Handbook (Must Get) :

ASSESSMENT of Older AdultsWITH DIMINISHED CAPACITY:

http://www.abanet.org/aging/publications/publicationslistorder.shtml#capacity

A Handbook for LawyersAssessment of Older Adults with Diminished Capacity: A Handbook for Lawyers

------American Bar Association Commission on Law and Aging and American Psychological Association. With the coming demographic avalanche as the Boomers reach their 60s and the over-80 population swells, lawyers face a growing challenge: older clients with problems in decision-making capacity. While most older adults will not have impaired capacity, some will. Obvious dementias impair decision-making capacity-but what about older adults with an early stage of dementia or with mild central nervous system damage? Such clients may have subtle decisional problems and questionable judgments troubling to a lawyer. Assessment of Older Adults with Diminished Capacity: A Handbook for Lawyers offers ideas for effective practices and makes suggestions for attorneys who wish to balance the competing goals of autonomy and protection as they confront the difficult challenges of working with older adults with diminished capacity. 80 pp. 2005. ISBN 1-59031-497-2/ Product Code: 4280025. $25. L

Judicial Determination of Capacity of Older Adults in Guardianship Proceedings

-------American Bar Association Commission on Law and Aging, American Psychological Association, and National College of Probate Judges. This book contains practical tools to equip a wide audience of judges to conduct

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any form of guardianship proceeding more effectively, improve communication with healthcare professionals, creatively use less-restrictive alternatives and limited guardianships, and accommodate disabilities of older adults in ways that will enhance capacity. Specifically, the handbook 1) outlines the “six pillars of capacity assessment,” essential to a full and accurate assessment of capacity; and 2) gives a practical explanation of the “five key steps in judicial determination of capacity.” The handbook provides a layered information approach that enables you to go as far as you need to on any aspect of capacity assessment. Links to expanded information, work sheets, model forms, and fact sheets are available at no charge on the Web site of the ABA Commission on Law and Aging at http://www.abanet.org/aging/. 41 pp. 2006. ISBN 978-1-59031-764-8/Product Code: 4280026. $25. J.

From The Handbook of Lawyers:

1. What are legal standards of diminished

capacity?

2. What are clinical models of capacity?

3. What signs of diminished capacity should a

lawyer be observing?

4. Capacity Worksheet for Lawyers (pp. 23 - 26)

This capacity worksheet helps you identify andorganize:

1. Observational signs of diminished capacity.2. Mitigating factors affecting capacity.3.Transaction-specific elements of legal capacity.4. Task-specific factors in evaluating capacity.5. Preliminary conclusions about client capacity.6. What mitigating factors should a lawyer take into account?

7. Should a lawyer use formal clinical assessmentinstruments? (Ch. IV, pp. 21 - 22). It is generallynot appropriate for lawyers to use formal clinical

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assessment instruments such as the Mini-MentalStatus Examination (MMSE), as they are not trainedin using and interpreting these tests, the information yielded is limited, and the results may be misleading.

Unavoidable capacity determinations:

1. Does the client have the capacity to contractfor my services?2. Does the client have the capacity to completethe legal transaction?

Lawyers need a conceptually sound andconsistent process for answering these questions.

***Lawyers need to be familiar with three facets ofdiminished capacity:

1. Standards of capacity for specific legaltransactions.2. Approaches to capacity in state guardianshipand conservatorship laws.3. Ethical guidelines for assessing client capacity.

Another source to at look at:

Science, common sense, and the determination of mental capacity.By Frolik, LawrencePsychology, Public Policy, and Law. Vol 5(1), Mar 1999, 41-58.AbstractIn 1993, when the Supreme Court decided Daubert and created the modern standard for the admissibility of scientific evidence, it almost certainly did not consider its possible effect on evidentiary hearings in probate courts even though such courts routinely admit expert testimony in will contests and guardianship hearings. Probate courts also admit

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testimony of lay witnesses who express their opinion as to the mental capacity of the individual in question. Yet both expert and lay witnesses are only "fact bringers" and not "fact interpreters" because the ultimate question of capacity is legal, not factual. Because the determination of legal capacity is made by the judge or jury, the role of experts in capacity trials is not fundamentally different than that of lay persons. The limited role of the expert suggests that probate courts should allow great latitude in the admission of expert testimony because the fact finders must ultimately rely on their own amorphous sense of "legal capacity." (PsycINFO Database Record (c) 2008 APA, all rights reserved)

(I would be happy to e-mail this above full article to anyone who e-mails me)

III. Mental Competency for Physicians and Health Care Workers

Several of many good Articles on Mental Capacity:

Competency Evaluations Start With Five Senses: Ken Hausman, Psychiatric News, May 16, 2003

http://pn.psychiatryonline.org/cgi/content/full/38/10/34

A forensic psychiatrist who is often called on to conduct mental competency evaluations of elderly individuals advises colleagues on the dos and don’ts of such assessments. Carla Rodgers, M.D.

Rodgers urges psychiatrists who conduct competency evaluations to rely on their senses of sight, smell, touch, and hearing to fill in a substantial number of the competency evaluation blanks.

She also advised psychiatrists to pay attention to an evaluee’s facial expression, grooming such as nail care, and clothing. Clothing that is disheveled or rife with food stains could be signs of a loss of mental competence

As for hearing, she urged psychiatrist evaluators to listen for wheezing and hoarseness and, though it may seem basic, whether the person can hear what the psychiatrist is saying, which includes "checking to make sure hearing aids are actually turned on."

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Rodgers also urged psychiatrist evaluators to obtain as much collateral data as possible. These should come from the evaluee’s medical charts and laboratory reports, hospital and nursing-home staff or other caregivers, family members, the attending physician, and other consultants.

Throughout a competency evaluation the psychiatrist should keep in mind the specific type of competency at issue.

If, for example, competency to make a will is being assessed, key issues evaluators need to assess center on whether the elderly person knows who his or her natural heirs are and the nature and extent of the estate involved.

Evaluating a person’s competence to make medical decisions, in contrast, requires that the individual know what is wrong with him or her and who is doing the treating, as well as understand the proposed treatment in general terms and the risks and benefits of that treatment compared with receiving no treatment, Rodgers explained.

And do not overlook an exploration of the family’s motives in requesting a competency evaluation, she cautioned. Do family members have reason for wanting their oddly behaving relative to be declared incompetent?

capacity." (PsycINFO Database Record (c) 2008 APA, all rights reserved)

UPtoDate website:

http://www.uptodate.com

Evaluation of cognitive impairment and dementia

Authors Marie-Florence Shadlen, MDEric B Larson, MD, MPH

Section Editors Steven T DeKosky, MD, FAANKenneth E Schmader, MD

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INTRODUCTION — Dementia is a disorder that is

characterized by impairment of memory and at least

one other cognitive domain (aphasia, apraxia,

agnosia, executive function). These must represent a

decline from previous level of function and be severe

enough to interfere with daily function and

independence [1].

Alzheimer disease (AD) is the most common form of

dementia in the elderly, accounting for 60 to 80 percent of

cases, and it is estimated to affect more than 4 million

Americans [2-5].

DEFINITION OF DEMENTIA — Although a number of

definitions exist for dementia, the DSM-IV definition is

widely accepted and includes the following [1]:

Evidence from the history and mental status

examination that indicates major impairment in

learning and memory as well as at least one of the

following:

      -  Impairment in handling complex tasks

      -  Impairment in reasoning ability

      -  Impaired spatial ability and orientation

      -  Impaired language

The cognitive symptoms must significantly interfere

with the individual's work performance, usual social

activities, or relationships with other people

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This must represent a significant decline from a

previous level of functioning

The disturbances are of insidious onset and are

progressive, based on evidence from the history or

serial mental-status examinations

The disturbances are not occurring exclusively during

the course of delirium

The disturbances are not better accounted for by a

major psychiatric diagnosis

The disturbances are not better accounted for by a

systemic disease or another brain disease

In a practice guideline published by the American Academy

of Neurology (AAN), the DSM-IIIR definition of dementia

(identical to the DSM-IV definition) was reported to have

good to very good reliability and was recommended for

routine use [8].

IDENTIFICATION OF DEMENTIA — Detecting dementia

is a problem in routine, day-to-day medical practice

[9]. One study found that the diagnosis was missed in 21

percent of demented or delirious patients on a general

medical ward, while 20 percent of nondemented patients

were misjudged as demented [10]. Nonetheless, the clinical

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diagnosis of dementia is reasonably accurate for those with

experience in the evaluation of this disorder (show table 1)

[11].

Table I

Sensitivity and specificity of diagnostic tests for dementia

Diagnostic test Sensitivity, percent

Specificity, percent

Mini-Mental State Exam*

87 82

Short Portable Mental Status Questionnaire* Any dementia 82 92 Mild dementia 55 96 NINCDS criteria 92 65DSM-IV criteria 76 80Clinical judgment 85 82

Diagnosis of dementia.Diagnosis of Alzheimer disease.

*Most patients with dementia do not present with a

complaint of memory loss; it is often a spouse or other

informant who brings the problem to the physician's

attention. Self-reported memory loss does not appear to

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correlate with the subsequent development of dementia,

while informant-reported memory loss is a much better

predictor of the current presence and future development of

dementia [12,13]. Nevertheless, family members are often

delayed in recognizing the signs of dementia, many of which

are inaccurately ascribed to "aging."

The normal cognitive decline associated with aging consists

primarily of mild changes in memory and the rate of

information processing, which are not progressive and do

not affect daily function. In a study of 161 community-

dwelling, cognitively normal individuals ages 62 to 100

years, learning or acquisition performance declined

uniformly with increasing age [14]. In contrast, delayed

recall or forgetting remained relatively stable. Similarly, a

second report found that aging was associated with a decline

in the acquisition and early retrieval of new information but

not in memory retention [15].

Patients with dementia may have difficulty with one

or more of the following [16]:

Learning and retaining new information (eg, trouble

remembering events)

Handling complex tasks (eg, balancing a checkbook)

Reasoning (eg, unable to cope with unexpected events)

Spatial ability and orientation (eg, getting lost in

familiar places)

Language (eg, word finding)

Behavior

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Patients and informants are often uncertain about the onset

of symptoms since the appearance of dementia is insidious.

The physician can usually date the onset of dementia by

identifying when the patient stopped driving or managing

finances. Useful questions for the patient and informant are,

"When did you first notice the memory loss?" and "How has

the memory loss progressed since then?"

The diagnosis of dementia must be distinguished

from delirium and depression (show table 2) [17].

Table 2

Differential diagnosis of memory loss Symptom Usual cause Examples Gradual onset of short-term memory loss and functional impairment in more than one domain:

Dementia

Alzheimer disease, Parkinson dementia, Lewy body dementia, Pick's disease, alcohol-related dementia, Creutzfeld-Jacobs disease

I. Executive function (finances, shopping, cooking, laundry, transportation) II. Basic activities of daily living (feeding, dressing, bathing, toileting, transfers) Stepwise, sudden deterioration in cognition; episodes of confusion,

Cerebrovascular disease

Vascular dementia, multi-infarct dementia, Binswanger's

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aphasia, slurred speech, focal weakness

dementia (subcortical dementia)

Acute cognitive impairment with clouded sensorium; difficulty with attention; may have hypersomnolence

Delirium

Hypo- or hyperglycemia, hypo- or hypernatremia, hypoxemia, anemia, intermittent cerebral ischemia, thyrotoxicosis, myxedema, alcohol withdrawal, sepsis, drugs (especially cholinergics, benzodiazepines, etc)

Complains of memory loss, decreased concentration, impaired judgment, feels worse in morning and hopeless

Depression

Minor depression, dysthymic disorder, major depression, pathologic grief reaction

(See "Diagnosis of delirium and confusional states" and see

"Depression: Clinical manifestations and diagnosis"):

Delirium is usually acute in onset and is

associated with a clouding of the sensorium.

Patients with delirium may have fluctuations in their

level of consciousness and have difficulty with attention

and concentration. Delirium and dementia can overlap,

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making the distinction difficult and sometimes

impossible.

Patients with depression are more likely to

complain about memory loss than those with

dementia; the latter are frequently brought to

physicians by their families, while depressed

patients often present by themselves. Patients

with depression may have signs of psychomotor

slowing and produce a poor effort on testing, while

those with dementia often try hard but respond with

incorrect answers. Depression and dementia may occur

in the same patient.

The US Preventive Services Task Force has concluded that

there is insufficient evidence to recommend for or against

routine screening for dementia in older adults [18,19]. The

USPSTF clinical practice guideline for screening for dementia,

as well as other USPSTF guidelines, can be accessed through

the website for the Agency for Healthcare Research and

Quality at www.ahrq.gov/clinic/uspstfix.htm.

Mild cognitive impairment — Mild cognitive impairment

(MCI) is generally defined by the presence of memory

difficulty and objective memory impairment but preserved

ability to function in daily life. Patients with MCI appear to be

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at increased risk of dementia. This topic is discussed

separately. (See "Mild cognitive impairment").

Dementia syndromes — The major dementia

syndromes include [20-22]: (see "Dementia

syndromes")

Alzheimer disease (AD)

Dementia with Lewy bodies (DLB)

Frontotemporal dementia (FTD)

Vascular (multi-infarct) dementia (VaD)

Parkinson disease with dementia (PDD)

Less common disorders such as progressive supranuclear

palsy (PSP) can also be associated with dementia. Non-

neurodegenerative dementias may be reversible, if the

underlying cause can be identified and adequately treated

[23].

Most elderly patients with chronic dementia have AD

(approximately 60 to 80 percent). The vascular

dementias account for 10 to 20 percent, and PD for 5

percent. The prevalence of VaD is relatively high in blacks,

hypertensive persons, and patients with diabetes; some of

the reversible dementias (eg, metabolic dementias) tend to

occur in younger individuals. DLB may be as prevalent as

VaD in older cohorts of patients [24]. FTD is much less

common than AD, VaD, or DLB.

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Alcohol-related dementia, medication side effects (eg,

antihistamine use), depression, and other central nervous

system illnesses are responsible for the remainder of the

chronic dementias.

Dementia frequently has more than one cause, particularly

as the condition progresses. In addition, medical illnesses

exacerbating poor cognition are common in patients with

dementia. The bedside evaluation combined with historical

information from a reliable informant provides most of the

information needed to ascertain the cause of dementia [17].

However, even with the addition of information from imaging

studies, clinical criteria for VaD have relatively poor

sensitivity [25].

DIAGNOSTIC APPROACH — The initial appointment in

a patient with suspected dementia should focus upon

the history. Preferably, family members are available to

give an adequate history of cognitive and behavioral

changes [21]. A drug history is particularly important; use of

drugs that impair cognition (eg, analgesics, anticholinergics,

psychotropic medications, and sedative-hypnotics) should be

sought.

A full dementia evaluation can probably not be

completed in a routine 30-minute visit; adequate time

should be arranged as a follow-up appointment. The initial

step at the follow-up visit is an assessment of cognitive

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function. This should be followed by a complete physical

examination, including neurologic examination. The

subsequent work-up may include laboratory and imaging

studies (show algorithm 1) [26,27].

The DSM-IV criteria for the diagnosis of dementia are

shown in Table three (show table 3).

A full dementia evaluation can probably not be completed in

a routine 30-minute visit; adequate time should be arranged

as a follow-up appointment. The initial step at the follow-up

visit is an assessment of cognitive function. This should be

followed by a complete physical examination, including

neurologic examination. The subsequent work-up may

include laboratory and imaging studies (show algorithm 1)

[26,27]. The DSM-IV criteria for the diagnosis of dementia

are shown in Table three (show table 3).

Algorithm 1 :

Diagnosis of dementia

17

Adapted from Corey-Bloom, J, Thal, LJ, Galasko, D, et al, Neurology 1995; 45:211.

Table 3:

©2009 UpToDate®

DSM-IV criteria for dementia

1. Memory impairment

2. At least one of the following:

Aphasia

Apraxia

Agnosia

Disturbance in executive functioning

3. The disturbance in 1 and 2 significantly interferes with work, social activities, or relationships

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4. Disturbance does not occur exclusively during delirium

Additional criteria for dementia type:

Dementia of the Alzheimer type:

Gradual onset and continuing cognitive decline

Not caused by identifiable medical, psychiatric, or neurologic condition

Vascular dementia:

Focal neurological signs or laboratory evidence of cerebrovascular condition

Dementia due to other medical conditions:

Evidence from history, physical exam, or laboratory findings of a specific medical condition causing cognitive deficits (HIV disease, head trauma, Parkinson disease, Huntington's chorea, Pick's disease, Creutzfeld-Jacob)

Adapted from American Psychiatric Association Diagnostic and Statistical Manual, 4th ed, APA Press, Washington DC, 1994.

Cognitive testing — Agreement between the history

and the mental status examination is strongly

suggestive of the diagnosis of dementia. When the

history suggests cognitive impairment but the mental status

examination is normal, possible explanations include mild

dementia, high intelligence or education, depression, or

rarely, misrepresentation on the part of the informants [28].

Conversely, when the mental status examination suggests

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cognitive impairment but the family and patient deny any

problems, possible explanations include an acute confusional

state, very low intelligence or education, or inadequate

recognition by the family [28]. Neuropsychological

assessment (psychometric testing) may be useful in difficult

situations; re-evaluation at a later time is often helpful.

Mini-Mental State Examination — The Mini-Mental

State Exam (MMSE) is the most widely used cognitive

test for dementia in US clinical practice [29,30]. The

examination takes approximately seven minutes to

complete. It tests a broad range of cognitive

functions including orientation, recall, attention,

calculation, language manipulation, and

constructional praxis.

The MMSE includes the following tasks [29]:

What is the date: (year)(season)(date)(day)(month) - 5

points

Where are we: (state)(county)(town)(hospital)(floor) - 5

points

Name three objects: Ask the patient all three after you

have said them. Give one point for each correct answer.

Then repeat them until he/she learns all three. Count

trials and record. The first repetition determines the

score, but if the patient cannot learn the words after six

trials then recall cannot be meaningfully tested.

Maximum score - 3 points.

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Serial 7s, beginning with 100 and counting backward:

one point for each correct; stop after five answers.

Alternatively, spell WORLD backwards: one point for

each letter in correct order. Maximum score - 5 points.

Ask for the three objects repeated above: one point for

each correct. Maximum score - 3 points.

Show and ask patient to name a pencil and wrist watch

- 2 points.

Repeat the following, "No ifs, ands, or buts." Allow only

one trial - 1 point.

Follow a three stage command, "Take a paper in your

right hand, fold it in half, and put it on the floor." Score

one point for each task executed. Maximum score - 3

points.

On a blank piece of paper write "close your eyes;" ask

the patient to read and do what it says - 1 point.

Give the patient a blank piece of paper and ask him/her

to write a sentence. The sentence must contain a noun

and verb and be sensible - 1 point.

Ask the patient to copy a design (eg, intersecting

pentagons). All 10 angles must be present and two

must intersect - 1 point.

A total maximal score on the MMSE is 30 points. A score of

less than 24 points is suggestive of dementia or delirium.

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Using a cutoff of 24 points, the MMSE had a sensitivity of 87

percent and a specificity of 82 percent in a large population

based sample (show table 1) [31]. However, the test is not

sensitive for mild dementia, and scores may be influenced

by age and education, as well as language, motor, and visual

impairments [32]. In one study, for example, the median

MMSE score was 29 for individuals with at least nine years of

schooling, 26 for those with five to eight years of schooling,

and 22 for those with four years of schooling or less [31].

The use of higher cutoff scores on the MMSE improves

sensitivity but lowers specificity. For research purposes,

some investigators use a cutoff score of 26 or 27 in

symptomatic populations in order to miss few true cases,

while lower cutoffs would be necessary in populations where

the expected prevalence is low [33]. Age-specific norms also

have been established [31]; some groups have developed

tools that incorporate age, gender, and education level

(show figure 1) [34,35].

The MMSE also has utility in assessing competency in

decision making. Studies suggest that high scores, ≥23, and

low scores, <19, can be highly predictive in discriminating

competency from incompetency. Intermediate scores

warrant more detailed competency evaluation [36,37].

The MMSE has limitations for assessing progressive cognitive

decline in individual patients over time. Changes of two

points or less are of uncertain clinical significance as they

22

may represent measurement error, regression to the mean,

or a practice effect [38].

Clinical Dementia Rating — The Clinical Dementia Rating

(CDR) was designed to assess severity of Alzheimers disease

in longitudinal studies and clinical trials [39]. This

assessment is also increasingly used in clinical decision

making as well, such as driving. (See "Safety and societal

issues related to dementia", section on Driving).

In a semi-structured interview with the patient and

caregiver, impairments in six domains (memory, orientation,

judgment and problem solving, community affairs, home and

hobbies, personal care) are assessed as none, questionable,

mild, moderate, and severe (0,0.5,1,2, and 3) [39]. A

caregiver who knows the patient well is necessary for an

accurate and valid assessment by the CDR. The global CDR

score is assigned based on performance in each domain,

placing particular weight on the memory score. A detailed

description of the CDR is available [39], and an algorithm for

scoring is available at www.biostat.wustl.edu/adrc/.

While time-consuming to administer, the test has established

validity and inter-rater reliability [40,41], and may be useful

in following disease progression over time.

Other brief cognitive assessments — Ideal tests for

mental status screening should be brief and have good

performance in populations with different cultural, linguistic,

and educational backgrounds.

23

Mini-Cog. The "Mini-Cog" test consists of a clock

drawing task (CDT) and an uncued recall of three

unrelated words [42]. The CDT is considered

normal if all numbers are present in the correct

sequence and the hands display the correct time

in a readable way. Scoring is based on a simple

decision tree with the following three rules:

Subjects recalling none of the words are classified as

demented

Subjects recalling all three words are classified as non-

demented

Subjects with intermediate (one to two) word recall are

classified based on the CDT (abnormal = demented;

normal = non-demented)

The advantages of the Mini-Cog include : high

sensitivity for predicting dementia status, short testing time

relative to the MMSE, ease of administration, and diagnostic

value not limited by the subject's education or language

[42].

Informant interview — A brief, eight-item

questionnaire for informants appears to be sensitive for

detecting dementia and cognitive impairment [44].

Informants are asked whether the patient has exhibited

any increase in the following deficits or behaviors:

      -  Problems with judgment

      -  Reduced interest in hobbies/activities

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      -  Repeats questions, stories, or statements

      -  Trouble learning how to use a tool or appliance

      -  Forgetting the correct month or year

      -  Difficulty handling financial affairs (bill-paying, taxes)

      -  Difficulty remembering appointments

      -  Consistent problems with thinking and/or memory

Short portable mental status questionnaire. The

short portable mental status questionnaire is

another popular test of cognitive function [45]. It

can be performed in approximately five minutes.

This test contains items that test orientation, attention,

immediate recall, arithmetic, abstraction, construction,

information, and delayed (approximately three

minutes) recall. It is reasonably sensitive and specific

for the diagnosis of moderate to severe dementia, but

similar to the MMSE, it is relatively insensitive in cases

of mild dementia (show table 1).

Clock drawing. Asking the patient to draw a clock

with a specific time is a quick examination that

appears to correlate well with the MMSE score,

although it has not undergone as rigorous an evaluation

as the MMSE [46]. It is not a sensitive test for

identifying very mild dementia [47,48].

Neuropsychologic testing — Neuropsychologic testing

usually involves extensive evaluation of multiple

cognitive domains (eg, attention, orientation, executive

25

function, verbal memory, spatial memory, language,

calculations, mental flexibility and conceptualization).

In a 2001 parctice parameter, the AAN reviewed a number of

studies of neuropsychological testing for dementia; some

were well designed observational controlled studies [49-53],

and others were case series [54-56]. Most studies

demonstrated a relatively high sensitivity (range 80 to 98

percent) and specificity (from 44 to 98 percent) for detection

of dementia.

The AAN concluded that neuropsychologic batteries are

useful in identifying patients with dementia, particularly

when administered to those at higher risk by virtue of

memory impairment [49]. Neuropsychologic instruments

that emphasize memory function were considered most

useful. Five subtests (Animal naming, Modified Boston

Naming Test, MMSE, Constructional Praxis, and Word List

Memory) were identified to be a valid, reliable measure of

cognition in normal aging and AD. An aggregate total score

accurately differentiated normals from those with MCI and

AD [57]. However, it is important to recognize that scores

can also be influenced by education and age and apply only

to individuals whose primary language is English [58].

While different causes of dementia can preferentially affect

different cognitive domains, neuropsychologic testing has

limited utility for differentiating among causes of dementia

as there are substantial overlaps in test performance [ 59 ].

26

Follow-up testing may provide more helpful information than

a single study, particularly when results are equivocal, in

that evidence of decline can predict future decline [60]. (See

"Mild cognitive impairment", section on Neuropsychological

testing).

Physical examination — A thorough general physical

examination to rule out an atypical presentation of a

medical illness should be combined with a neurologic

examination. The latter should focus upon focal neurologic

deficits that may be consistent with prior strokes, signs of

Parkinson disease (PD) (eg, cogwheel rigidity and tremors),

gait, and eye movements. In comparison, patients with

Alzheimer disease (AD) generally have no motor deficits at

presentation. This examination, along with the medical and

neurologic history, will allow tailoring of laboratory tests.

Laboratory testing — The American Academy of

Neurology (AAN) recommends screening for B12

deficiency and hypothyroidism in patients with

dementia [8]. (See "Neurologic manifestations of

hypothyroidism" section on Screening for hypothyroidism in

cognitive impairment). There are no clear data to support or

refute ordering "routine" laboratory studies such as a

complete blood count, electrolytes, glucose, and renal and

liver function tests. Screening for neurosyphilis is not

recommended unless there is a high clinical suspicion.

The cost-effectiveness of obtaining multiple laboratory

studies in all patients is questioned because the yield is low

27

[63]. The prevalence of reversible dementia has fallen since

1972. In a 1994 study, this was less than one percent, and in

a 2006 community-based series, none of the 560 patients

with dementia screened had a treatable metabolic cause

[63,64]. Some tests can be tailored to patients with a

compatible history (eg, red blood cell folate in a patient with

ethanol dependence, or ionized serum calcium in a patient

with multiple myeloma, prostate cancer, or breast cancer).

Patients with an atypical syndrome, eg, rapidly progressive

dementia, may benefit from a more extensive evaluation

(show table 4) [65].

The value of genetic testing for AD in patients with

dementia is controversial. The apolipoprotein E

epsilon 4 allele has been considered for use as a

diagnostic test. As previously mentioned, however, many

patients who are homozygotes for this allele will not develop

AD [66]; thus, application of this test to large populations

would lead to the overdiagnosis of AD, a practice with

obvious potentially damaging consequences. For these

reasons, genetic testing for the apolipoprotein E epsilon 4

allele is not currently recommended [67], nor is genetic

testing for other potential causes of dementia [8].

While some studies suggest that increased levels of tau

protein and decreased levels of beta-amyloid protein ending

at amino acid 42 in cerebrospinal fluid or plasma may have

predictive value for AD in nondemented patients and in

patients with MCI, and may also distinguish AD from other

28

forms of dementia [68-77], a role for these measurements in

clinical practice has not been established [78-81].

Neuroimaging — The use of neuroimaging in patients with

dementia is controversial. A number of guidelines on the

clinical evaluation of dementia have been published, many

of which do not recommend imaging studies routinely, but

include clinical prediction rules to identify patients who

might have reversible causes of dementia that can be

diagnosed with imaging studies (eg, subdural hematoma,

normal pressure hydrocephalus, treatable cancer) [8,64,82-

88]. The prediction rules vary, including factors such as

young age (<60), focal signs, short duration of symptoms

(less than two years), among others. However, the

sensitivity and specificity of these prediction rules is low

[89]. The AAN recommends structural neuroimaging with

either a noncontrast head CT or MRI in the routine initial

evaluation of all patients with dementia [8].

MRI findings in AD include both generalized and focal

atrophy as well as white matter lesions [90]. In general,

these findings are nonspecific. course of the disease,

thereby guiding treatment decisions [91,96,97].

Demented patients with atherosclerotic risk factors may

harbor silent cerebrovascular disease. Neuroimaging in

these cases may lead to more aggressive management of

the patient's hypertension, diabetes, lipid disorders, and

smoking cessation, and may prompt one to prescribe aspirin.

29

A head CT scan is important for patients with acute onset of

cognitive impairment and rapid neurologic deterioration.

Neuroimaging is also indicated when there are historical

features or findings on physical examination suggestive of a

subdural hematoma, thrombotic stroke, or cerebral

hemorrhage, as well as in individuals with rapidly

progressive dementia [65].

AD and other neurodegenerative diseases can cause serious

alterations in brain metabolism, providing the rationale for

the use of positron emission tomography (PET) to assist in

the diagnosis of dementia. In one of the largest studies of

PET for this purpose to date, PET studies in 146 patients

presenting with cognitive symptoms of dementia were

sensitive indicators of the presence of AD and of

neurodegenerative disease in general [ 98 ]. A negative PET

scan indicated that pathologic progression of cognitive

impairment was unlikely to occur over the next three years.

The clinical application of PET scanning remains to be

determined [ 99 ].

Brain biopsy —  Brain biopsy has a very limited role in the

diagnosis of dementia; the diagnostic yield is low, and the

test is invasive with a significant risk of serious

complications. Typically, it is reserved for younger patients

and those with atypical clinical presentations in which a

treatable cause of dementia (eg, inflammatory disorders

30

such as vasculitis or multiple sclerosis) is considered

plausible. in only 11 percent [106].

SUMMARY AND

RECOMMENDATIONS — Recommendations for the

evaluation of cognitive impairment and dementia are

derived from our clinical experience as well as from the

American Academy of Neurology (AAN) practice guidelines

[8,49].

The initial step in the evaluation of a patient with

suspected dementia should focus upon the history.

Family members or other informants who know the

patient well are invaluable resources for providing an

adequate history of cognitive and behavioral changes.

Adequate time should be arranged for a full assessment

of cognitive function, followed by a complete physical

examination, including neurologic examination.

The Mini-Mental State Exam is a useful screening test

for dementia; a score of less than 24 points is

suggestive of dementia or delirium.

Neuropsychologic testing batteries are useful in

identifying patients with dementia, particularly when

administered to those who may be at increased risk of

cognitive impairment.

31

Screening for B12 deficiency and hypothyroidism is

recommended for patients being evaluated for

dementia.

Screening for depression in patients with dementia is

recommended because depression is a common

treatable comorbidity that may also masquerade as

dementia.

Genetic testing for the apolipoprotein E epsilon 4 allele

is not currently recommended, nor is genetic testing for

other potential causes of dementia.

Structural neuroimaging with either a noncontrast head

CT or MRI is recommended in the routine initial

evaluation of all patients with dementia.

Use of UpToDate is subject to the Subscription and

License Agreement.

References:

1) www.uptodate.com

2) ASSESSMENT of Older Adults WITH DIMINISHED CAPACITY: (A Handbook for Lawyers) http://www.abanet.org/aging/publications/publicationslistorder.shtml#capacity

3) Science, common sense, and the determination of mental capacity. By Frolik, Lawrence Psychology, Public Policy, and Law. Vol 5(1), Mar 1999, 41-58.

32

(I can( e-mail) send this to anyone wanting the entire 18 page article)

4) American Psychiatric Association Diagnostic and Statistical Manual, 4th ed, APA Press, Washington DC, 1994 5)Jacobson: Psychiatric Secrets, 2nd ed. Second Edition

James L. Jacobson, MD Associate Professor, Department of Psychiatry, University of Vermont

Medical School, Burlington, Vermont Alan M. Jacobson, MD Professor, Department of Psychiatry, Harvard Medical School Senior Vice President, Strategic Initiatives, Joslin Diabetes Center, Boston, Massachusetts

6) Early Diagnosis of Dementia, American Family Physician.February 15, 2001 http://www.aafp.org/afp/AFPprinter/20010215/703.html?print=yes

7) Competency Evaluations Start With Five Senses: Ken Hausman, Psychiatric News, May 16, 2003

http://pn.psychiatryonline.org/cgi/content/full/38/10/34

8) Assessing Mental Capacity in Older Adults, APA online

Volume 35, No. 9 October 2004

http://www.apa.org/monitor/oct04/capacity.html

9) American Family Physician: Dementia What are the Common Signs? March 1,2003

10) Office of State Guardian Frequently Asked Questions, Illinois Guardianship and Advocacy Commision,

33

http://gac.state.il.us/osg/osgcont.html

11)Initial Evaluation of the Patient with Supected Dementia,

American Family Physician, May 1, 2005

http://www.aafp.org/afp/20050501/1745.html

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