A new test can spot the signs of dementia earlier.

An estimated 4 million people in the United States have Alzheimer's disease, but many don't know it yet. One reason is that the early signs of the disease are difficult to distinguish from the slight memory lapses people normally experience as they age. If diagnosed early, people can benefit from Alzheimer's drugs and by simply having more time to prepare for an expensive and prolonged illness.

Paul Solomon, a professor of psychology at Williams College in Williamstown, Massachusetts, has developed a new tool for testing people for the early signs of Alzheimer's disease and other forms of dementia. (Alzheimer's disease is the most common form of dementia). Called the 7 Minute Screen, it's a battery of four tests that can be administered in less than 10 minutes (7 minutes and 43 seconds on average) by anyone with an hour of basic training.

In this age of managed care, the short time required for the test is a major selling point. "Doctors don't have seven seconds, much less seven minutes," Solomon points out. Digital Imagery © 2000 PhotoDisc It is important to keep in mind, however, that the 7 Minute Screen does not provide a certain diagnosis of Alzheimer's disease. As a quick screening test, it only identifies people with impairments in memory, reasoning, and other mental tasks that may be due to dementia. To get a true diagnosis, the person must take a longer, more sophisticated physical and mental exam.

In designing the 7 Minute Screen, Solomon made improvements to four pre-existing psychological tests so that they would be more sensitive for detecting dementia. The tests zero in on tasks that are more challenging for people with Alzheimer's disease than for people with normal age-related memory loss. For example, one test asks the patient to recall items from a list of 16 pictures, based in part on hints provided by the tester. People with Alzheimer's even in its early stages still have trouble recalling the items, since they were not stored properly in the first place. This means the test can tell the difference between dementia and age-related memory loss.

Ultimately, Solomon would like to see primary care physicians include an Alzheimer's screening test in routine check-ups for seniors. He says the results of an Alzheimer's screen should be thought of as just like any other medical information a doctor needs to know, like blood pressure or cholesterol level. Regardless of whoever administers the screen, he emphasizes, a physician must carefully explain to the patient that the test only establishes the likelihood of dementia, and is not a certain diagnosis.

Since the 7 Minute Screen is not a complete exam, it is not 100 percent accurate. To date, Solomon has results from the testing of about 1,800 people who have taken the 7 Minute Screen. Overall, about 90 percent of people who score high on the screen are diagnosed with dementia in a follow-up exam. Importantly, Solomon says, one of his most recent studies evaluated the accuracy of the screen in a real-world setting: a doctor's office. The study, in which the 7 Minute Screen was administered to 137 patients in a physician's office, accurately predicted dementia in 91 percent of those tested. The other 9 percent "failed" the screen but were not subsequently diagnosed with dementia. The reasons for this are not thoroughly understood yet, Solomon explains, but a person can fail the screen because of things such as depression or grogginess from medications.

The 7 Minute Screen is not the only Alzheimer's screening tool in the works. Solomon says there are about ten others under development in various research labs. But the 7 Minute Screen is one of the first in the field thanks in part to financial support from the Janssen Research Foundation in Titusville, New Jersey. Janssen is a pharmaceutical firm currently developing a new Alzheimer's drug called galantamine. To help doctors identify people who might benefit from Alzheimer's drugs, Janssen is distributing the screen to physicians free of charge.

Janssen has already given away 6,700 kits in the United States, and receives more than 500 new requests per month. Solomon's work on the screen is part of a much larger effort to develop ways to detect Alzheimer's early. Some researchers, for instance, hope to use brain scanning technology such as magnetic resonance imaging (MRI) to identify subtle damage to the brain before impairments in thinking show up. Other approaches look for gene abnormalities that some studies have linked to Alzheimer's.

The variety of Alzheimer's tests on the horizon makes it important to thoroughly evaluate the 7 Minute Screen, according Dr. Zaven Khachaturian, former head of the Neurobiology of Aging research program at the National Institutes of Health and now an independent consultant on Alzheimer's research with KRA, Inc. in Maryland. "Clearly a screen has a value," Khachaturian says. "But the user needs to know how well it works." He likens the process of evaluating a new medical test to performance testing on new cars. Consumers need to know about gas mileage and acceleration to make an informed choice. Similarly, physicians need to know how well an Alzheimer's screen performs under various conditions. For example, one screen may turn out to catch Alzheimer's earlier in people under 65; another may perform better in people over 70. "The important thing is to have the very best for the patients," Khachaturian says. "It may turn out that it will be a combination of tests. But they all need to run through the same process before they can be accepted by the medical community." Solomon agrees. "The more the merrier," he says. "If they use ours, that's great. The key thing is to get people screened."

Indeed, once dementia takes hold, brain cells and the memories they encode begin to die, and are lost forever. The ultimate hope, of course, is to find a way to prevent Alzheimer's disease altogether. But if the day comes that we learn how to at least halt the progression of dementia, early detection will be critical to minimizing the cruel and costly impact of the illness on individuals, families and society.

OVERVIEW OF DIANOSIS ANDTREATMENT OF DEMENTIA

Disorders that cause dementia include conditions that impair the vascular (blood vessels) or neurologic (nerve) structures of the brain. Some causes of dementia are treatable. These include normal pressure hydrocephalus, brain tumors, and dementia due to metabolic causes and infections. Unfortunately, most disorders associated with dementia are progressive, irreversible, and degenerative.

The two major degenerative causes of dementia are Alzheimer's disease and vascular dementia (loss of brain function due to a series of small strokes). The two conditions often occur together, and vascular dementia may speed the progression of Alzheimer's disease. Neither condition can be diagnosed definitively until autopsy.

Dementia may be diagnosed when two or more brain functions are impaired. These functions include language, memory, visual-spatial perception, emotional behavior or personality, and cognitive skills (such as calculation, abstract thinking, or judgment). Dementia usually appears first as forgetfulness. Other symptoms may be apparent only with neurologic examination or cognitive testing.

Dementia progresses slowly from decreased problem solving and language skills to difficulty with ordinary daily activities to severe memory loss and complete disorientation with withdrawal from social interaction.

Symptoms

· Progressive memory loss

· Inability to concentrate

· Decrease in problem-solving skills and judgment capability

· Confusion, severe

· Hallucinations and delusions

· Altered sensation or perception

· Impaired recognition (agnosia)

• Impaired recognition of familiar objects or persons
• Impaired recognition through the senses

· Altered sleep patterns

• Insomnia
• Need for increased sleep
• Disturbance or change in sleep-wake cycle

· Motor system impairment

• Impaired skilled motor function (apraxia)
  • Inability to reproduce geometric figures
  • Inability to mimic hand positions
  • Inability to dress self
• Gait changes
• Inappropriate movements
• Other motor system impairment

· Disorientation

• Person, place, time disorientation
• Visual-spatial disorientation
• Inability to interpret environmental cues

· Specific disorders of problem-solving or learning

• Inability to generalize
• Loss of abstract thinking
• Impaired calculating ability
• Inability to learn

· Memory deficit

• Short-term memory problems (can't remember new things)
• Long-term memory problems (can't remember past)

· Absent or impaired language ability (aphasia)

• Inability to comprehend speech
• Inability to read
• Inability to write
• Inability to speak, without muscle paralysis
• Inability to form words
• Inability to name objects
• Poor enunciation
• Inappropriate speech; use of jargon or wrong words
• Inability to repeat a phrase
• Persistent repetition of phrases
• Other language impairment

· Personality changes

• Irritability
• Poor temper control
• Anxiety
• Depression
• Indecisiveness
• Self-centeredness
• Inflexibility
• No observable mood (flat affect)
• Inappropriate mood or behavior
• Withdrawal from social interaction
• Inability to function or interact in social or personal situations
• Inability to maintain employment
• Decreased ability to care for oneself
• Decreased interest in daily living activities

· Lack of spontaneity

Additional symptoms that may be associated with this disease are as follows:

· Swallowing problems

· Incontinence

Signs and tests

A neurologic examination may reveal abnormalities. Early signs of dementia include mild problems with memory or attention. Over time, the following cognitive difficulties may appear:

· Language problems

· Disorientation

· Personality changes

· Visual or spatial problems

· Slow thinking

· Impaired skilled motor function (apraxia)

· Impaired recognition (agnosia)

· Difficulty with planning and organizing

· Weakness

· Incontinence

· Falling

The extent of damage and cause of dementia may be indicated by tests and procedures that include, but are not limited to, the following:

· Serum electrolytes

· Blood chemistry (chem-20)

· Serum calcium

· Glucose test

· Thyroid stimulating hormone level

· Thyroid function tests

· Liver function tests

· Blood ammonia levels

· B-12 level

· Drug or alcohol levels (toxicology screen)

· Urinalysis

· Blood gas analysis

· EEG (electroencephalograph)

· Head CT

· MRI of head

· CSF (cerebrospinal fluid) analysis

Treatment

The goal of treatment is to control the symptoms of dementia. Treatment varies with the specific disorder. Hospitalization may be needed for a short time. The underlying causes should be identified and treated, this includes treating reversible organic lesions such as tumors.

Stopping or changing medications that worsen confusion or that are not essential to the care of the person may improve cognitive function. Medications that contribute to confusion include anticholinergics, analgesics, cimetidine, central nervous system depressants, lidocaine, and others.

Disorders that contribute to confusion should also be treated. These include heart failure, decreased oxygen (hypoxia), thyroid disorders, anemia, nutritional disorders, infections, and psychiatric conditions such as depression. Correction of co-existing medical and psychiatric disorders often greatly improves mental functioning.

Medications may be needed to control aggressive or agitated behaviors that are dangerous to the person with dementia or to others. These are usually given in very low doses and adjusted as necessary.

Possible medications for this use include the following:

· Anti-psychotics, given at night

· Serotonin-affecting drugs (trazodone, buspirone)

· Dopamine blockers (haloperidol, Risperidal, olanzapine, clozapine)

· Cholinesterase inhibitors [donepezil (aricept), rivastigmine (exelon), or the newly approved galantamine (reminyl) for Alzheimer's-type dementia]

· Fluoxetine, imipramine, or Celexa to help stabilize mood

· Stimulant drugs (such as methylphenidate) to increase activity and spontaneity

· Vitamin E

Sensory function should be evaluated regularly and hearing aids, glasses, or cataract surgery should be provided as needed.

Formal psychiatric treatment such as psychotherapy or group therapy is seldom helpful because it may overload the limited cognitive resources in the person with dementia.

LONG-TERM TREATMENT:

Providing a safe environment, controlling aggressive or agitated behavior, and meeting the physiologic needs of a person with dementia may require monitoring and assistance in the home or in an institutionalized setting. Possible options include in-home care, boarding homes, adult day care, and convalescent homes.

Visiting nurses or aides, volunteer services, homemakers, adult protective services, and other community resources may help in caring for the person with dementia. In some communities, support groups may be available (see elder care - support group), and family counseling can help family members cope with home care.

In any care setting, there should be familiar objects and people. Lights can be left on at night to reduce disorientation. The activity schedule should be simple. Behavior modification may help some people to control unacceptable or dangerous behavior. This consists of rewarding appropriate behaviors and ignoring inappropriate ones (within the bounds of safety). Reality orientation, with repeated reinforcement of environmental and other cues, may also help reduce disorientation.

Legal advice may be appropriate early in the course of the disorder, before the person with dementia becomes too incapacitated to make decisions. Advance directives, power of attorney, and other legal actions may make it easier to decide about the care of the person with dementia.

Expectations (prognosis)

The outcome varies. Acute disorders that cause delirium may coexist with chronic disorders causing dementia. Chronic brain syndromes are often progressive and usually result in decreased quality of life and decreased life span.

Complications

Complications depend on the cause of the dementia, but they may include the following:

· Loss of ability to function or care for self

· Loss of ability to interact

· Increased infections anywhere in the body

· Reduced life span

· Abuse by an overstressed caregiver

· Side effects of medications used to treat the disorder

Calling your health care provider

· Call your health care provider if dementia develops or a sudden change in mental status occurs.

· Call your health care provider if the condition of a person with dementia deteriorates and you are unable to cope with caring for that person in the home.

Prevention

Most causes of dementia are not preventable. The risk of vascular dementia, which is caused by a series of small strokes, can be reduced by quitting smoking and controlling high blood pressure and diabetes. Eating a low-fat diet and exercising regularly may also reduce the risk of vascular dementia. Vascular dementia may also play a role in the progression of Alzheimer's disease.