Neurol. Croat. Vol.

60, 2, 2011

Cognitive assessment in dementia:

initial approach in outpatient clinic
M. Gregorič Kramberger, S. Popović, Z. Pirtošek

ABSTRACT – A diagnosis of dementia should be made only after comprehensive assessment, which inevi-
tably includes history taking, cognitive and mental state examination, physical examination, a review of
medication in order to identify and minimize use of drugs that may adversely affect cognitive functioning,
and other appropriate investigations. Clinical cognitive assessment in those with suspected dementia should
include examination of attention and concentration, orientation, short- and long-term memory, praxis, lan-
guage and executive function. As part of this assessment, formal cognitive testing should be undertaken us-
91

Number 2, 2011
ing a standardized instrument. Formal neuropsychological testing should form part of the assessment in
cases of mild or questionable dementia.

Key words: assessment, cognition, diagnosis, dementia

OVERVIEW found following careful consultation with the pa-

tient and carer. A focused cognitive and physical
Dementia is a clinical state characterized by the examination is useful and the presence of specific
loss of function in at least two cognitive domains. features may aid in diagnosis. Certain investiga-
When making a diagnosis of dementia, features to tions are mandatory and additional tests are rec-
look for include memory impairment and at least ommended if the history and examination indicate
one of the following: aphasia, apraxia, agnosia and/ particular etiologies. It is useful when assessing a
or disturbances in executive functioning. To be sig- patient with cognitive impairment in the clinic to
nificant the impairments should be severe enough consider the following straightforward questions:
to cause problems with social and occupational • Is the patient demented?
functioning and the decline must have occurred
from a previously higher level. It is important to • If so, does the loss of function conform to a
exclude delirium when considering such a diagno- characteristic pattern?
sis. When approaching the patient with a possible
dementia, taking thorough history is crucial. Clues Ljubljana University Medical Center, Department of
to the nature and etiology of the disorder are often Neurology, Ljubljana, Slovenia
 M. Gregorič Kramberger, S. Popović, Z. Pirtošek. Cognitive assessment in dementia Neurol. Croat. Vol. 60, 2, 2011

• Does the pattern of dementia conform to a par- Assessment of the level of consciousness and atten-
ticular pattern? tion processes is crucial as disturbance in these do-
• What is the likely disease process responsible for mains can influence the performance on other
the dementia? tests. Familiarity with the common bedside tests
for each function is important (Hodges, 1994). For
Due understanding of cognitive function and its most purposes, a screening battery such as Fol-
anatomical correlates is necessary in order to as- stein’s Mini-Mental State Examination (MMSE) is
certain which brain areas are affected. We shall a good starting point. It tests orientation, immedi-
illustrate how the history and examination, in- ate and recent memory, concentration, arithmetic
cluding bedside cognitive testing, are used in diag- ability, language and praxis (5). It is easy to admin-
nosis (1). ister and takes only 5-10 minutes. It has reasonable
sensitivity but low specificity, and may be used for
serial evaluations. The score is out of 30, and 27 or
TAKING HISTORY less is indicative of impairment. A score less than
AND EXAMINATION 25 is definitely abnormal. The MMSE may be nor-
OF THE COGNITIVELY IMPAIRED mal in the presence of subtle impairment, and if
this is suspected, detailed evaluation is recom-
PATIENT mended.
It is vital to obtain a history from a relative or close It is useful to combine the MMSE with the Clock
friend in addition to the patient history if they can Drawing Test in which the patient is asked to draw
provide one. It is useful to interview the patient a clock-face and draw in the hands to indicate
and the accompanying person separately. The ab- 11:10. This tests the patient’s constructional abili-
sence of a concerned relative or friend at the ap- ties and, more importantly, planning and organiza-
pointment may lessen the likelihood of dementia tion or frontal lobe function. Examination of the
in a patient complaining of memory problems. In- frontal lobes is central to many neuropsychiatric
terviewing the patient separately enables the coop- disorders and the following clinical tests for this
eration and language skills to be assessed without are suggested:
them being masked by interruptions or assistance
from a third party. It also allows an assessment into 1. Observing behavior: impulse control, motiva-
the degree of insight of the affected individual. tion, affective regulation, relationships.
92 Conversation with the patient may be as important 2. Motor and expressive language.
as any formal cognitive assessment (2). 3. Primitive reflexes: grasp, palmomental, snout,
Number 2, 2011

In brief cognitive assessment, which should be pout, glabellar tab.

done in all cases, the presence of word finding dif- 4. Verbal fluency: letter-saying as many words-not
ficulties, paraphasic errors, and inappropriate be- proper nouns-as possible in one minute begin-
havior should be sought. The assessment must be ning with the letter F or A or S), category (nam-
divided into a number of domains or systems and ing as many objects from one category as you
each of them has to be examined. These are: can in one minute, such as animals).
1. Alertness and arousal 5. Motor sequencing: Luria’s hand sequences (e.g.,
2. Attention and concentration alternating repeatedly between making a fist
and a ring with one hand and then the other-
3. Orientation
fist-ring test, alternating between a fist, palm
4. Memory and cut movement with one hand and then the
5. Language other).
6. Visuospatial and constructive functions 6. Reasoning and conceptualization: similarities,
7. Frontal lobe and fronto-subcortical functions differences, proverbs.
8. Other dominant (left) hemisphere functions: 7. Planning and organization: clock drawing (ask
calculation, praxis, right-left orientation, finger the patient to draw a clock face and put in num-
gnosis bers and hands to indicate 11:10.
9. Other nondominant (right) hemisphere func- With regard to the tests used, it is important to re-
tions: dressing apraxia, neglect phenomena, member that tests are rarely pure, and usually are
agnosias influenced by a number of cognitive functions. For
10. Insight and judgment example, simple tests like ‘serial sevens’ may be in-
Neurol. Croat. Vol. 60, 2, 2011 M. Gregorič Kramberger, S. Popović, Z. Pirtošek. Cognitive assessment in dementia

tests of cognitive function, it is important to exam-

ine the neurological system in any patient with
possible cognitive impairment. Neurological ex-
amination is, however, often normal in the early
stages of many neurodegenerative dementias and
specific abnormalities may point to rarer or poten-
tially treatable causes of dementia. It is important
to assess the patient at rest for any involuntary
movements, including chorea, tremor, dystonia,
and myoclonus (which may be spontaneous or
Fig. 1. Abnormal clock drawing test. stimulus sensitive). The muscles should be ob-
served for fasciculations. The presence or absence
fluenced by impairment of attention, short-term of primitive reflexes (frontal release signs) should
memory, and calculation ability. A battery of tests be determined. Ocular examination should involve
is therefore necessary to determine which function careful assessment of visual acuity, papillary re-
is really disturbed. Failure on one test must be fol- sponses, eye movements, optic discs, and visual
lowed up with other tests before a dysfunction is fields. Assessment of speech and swallowing may
established. All cognitive tests are designed to be reveal the presence of bulbar features. Examination
administered in a particular manner. Significant for pyramidal or extrapyramidal signs is important
departure from a standard administration may and gait should be assessed wherever possible.
render the test invalid. Repetition of the same test Ataxia is unusual in Alzheimer’s disease, dementia
may lead to an improvement in performance be- with Lewy bodies, and frontotemporal dementia;
cause of what is known as ‘practice effect’. For de- its presence should raise the possibility of a differ-
tailed assessment, a referral to a clinical neuropsy- ent cause. The presence or absence of apraxia
chologist is necessary. We should also be aware that should be assessed by asking the patient to perform
bedside testing has the potential of confounding alternating hand movements or copy gestures (4).
the formal assessment of a neuropsychologist if Peripheral neuropathy may be present and when
that were to follow. Therefore, one should use only cooperation allows signs of this should be sought.
the tests that are meaningful for bedside assess-
ment. Examination of other systems is also useful in look-
ing for evidence of multisystem disease. In addi-
tion to neurological examination, patients should 93
RATING SCALES be assessed for signs of immune compromise (pre-

Number 2, 2011
disposing to opportunistic infections such as pro-
The widely used MMSE provides useful informa- gressive multifocal leukoencephalopathy, toxoplas-
tion in grading established dementia but does have mosis or primary cerebral lymphoma possibly in-
limitations, particularly in detecting early disease. dicating HIV/AIDS). Features of systemic disease
It contains a crude test of delayed recall, with only may indicate an underlying neoplasm, vasculitis,
three items being employed and not enough time infection, or a metabolic disorder. Uveitis may in-
allowed between registration and recall. It lacks a dicate sarcoidosis, Behcet’s disease, or multiple
timed test to detect problems with verbal fluency sclerosis. The presence of cardiac disease, hyper-
(3). The Addenbrooke’s cognitive assessment has tension, or a previous transient ischemic attack or
been developed to address the deficiencies of the stroke may suggest cerebrovascular disease. Armed
MMSE (7). It also has the advantage of being brief with the above theoretical knowledge regarding
enough to allow the clinician to use it within the memory and its subdivisions along with how to
time constraints of a new patient appointment. It elicit information from history taking and exami-
should be noted that even the Addenbrooke’s cog- nation, we can now return to trying to achieve a
nitive assessment is no match for formal neuropsy- diagnosis in a patient with possible dementia (6).
chological assessment. Such services are, however,
patchy, and in some services are non-existent, so
the clinician must remain competent at assessing CONCLUSION
cognition.
It is impractical to examine everything in cognitive
The focused examination of the patient with de- assessment, and as in most other areas of neurolo-
mentia is central in cognitive assessment. Aside gy, the history remains pre-eminent in guiding
from the mental state examination and specific subsequent examination. The central role of an in-
 M. Gregorič Kramberger, S. Popović, Z. Pirtošek. Cognitive assessment in dementia Neurol. Croat. Vol. 60, 2, 2011

formant, and the ability to immediately test the hy- 4. Kipps CM, Hodges JR. Cognitive assessment for
potheses generated during history taking, distin- clinicians. J Neurol Neurosurg Psychiatry 2005;
guish this means of neurological assessment. In 76(Suppl I):i22-30.
some patients, it is not possible to reach a firm di- 5. Folstein MF, Folstein SE, McHugh PR. „Mini
agnosis after a single cognitive assessment, even mental state“. A practical method for grading the
when combined with a formal neuropsychological cognitive state of patients for the clinician. J Psy-
report. This is particularly true for the mild stages chiatr Res 1975;12:189-98.
of neurodegenerative diseases, and reflects the rel-
ative insensitivity of both clinical and imaging as- 6. Neary D, Snowden JS. Sorting out the dementias.
sessment to early pathology. Longitudinal follow Pract Neurol 2002;2:328-39.
up and repeated assessment in such cases is invalu- 7. Mioshi E, Dawson K, Mitcthell J, Arnold R, Hodg-
able, and should not be forgotten. es JR. The Addenbrooke’s cognitive examination
revised (ACE-R): a brief cognitive test battery for
dementia screening. Int J Geriatr Psychiatry 2006;
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1. Heilman KM, Valenstein E, eds. Clinical neuro-
psychology, 4th ed. Oxford: Oxford University
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Address for Correspondence: Asist. Prof. Milica
2. Hodges JR. Cognitive assessment for clinicians.
Gregorič Kramberger, MD, Ljubljana University Me-
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ed. Oxford: Oxford University Press, 2004. milica.krambeger@gmail.com

94 Procjena kognitivnog stanja kod demencije:

prvi pristup u ambulanti
Number 2, 2011

SAŽETAK - Dijagnozu demencije trebalo bi postaviti tek nakon sveobuhvatnog pregleda koji neminovno
uključuje povijest bolesti (anamnezu), ispitivanje kognitivnog i mentalnog stanja, fizikalni pregled, osvrt na
terapiju u cilju identificiranja i smanjena upotrebe lijekova koji bi mogli negativno utjecati na kognitivno
funkcioniranje i druge odgovarajuće pretrage. Ako se sumnja na demenciju, klinički kognitivni pregled bi
trebao obuhvatiti ispitivanje pažnje i koncentracije, orijentacije, kratkoročnog i dugoročnog pamćenja, prak-
sije, jezičnih i egzekutivnih funkcija. U okviru te procjene trebalo bi poduzeti formalno kognitivno testiranje
korištenjem standardiziranih instrumenata. U slučajevima blagih demencija ili kada se demencija dovodi u
pitanje u procjenu bi trebalo uvrstiti formalno neuropsihološko testiranje.

Ključne riječi: kognitivno stanje, demencija, dijagnoza, procjena