A number of other tests that measure the degree of dementia (usually carrying the names of their originators: Roth, Pfeiffer, Blessed, Mattis) rely essentially on the points mentioned previously and a brief assessment of the patient’s ability to accomplish the activities of daily living, which is lost in the later stages of disease. For serial measurement specifically for those with Alzheimer disease, a number of systems have been devised as reviewed in Chap. 38. Among the most commonly used is the Alzheimer Disease Assessment Scale-Cognitive (ADAS-Cog). It is more comprehensive than the others and takes longer to administer.
Probably the Wechsler Adult Intelligence Scale (WAIS) is also accurate in detecting dementia. In this test, an index of deterioration is provided by the discrepancy between the vocabulary, picture-completion, and object-assembly tests as a group (these correlate well with premorbid intelligence and are relatively insensitive to dementing brain disease) and other measures of general performance, namely arithmetic, block design, digit-span, and digit-symbol tests. The Wechsler Memory Scale estimates the degree of memory failure and can be used to distinguish the amnesic state from a more general dementia (discrepancy of more than 25 points between the WAIS and the memory scale). Questions that measure spatial and temporal orientation and memory are the key items in most of these abbreviated scales of dementia. All of the aforementioned clinical and psychologic tests, and several others as well, measure the same aspects of behavior and intellectual function. The WAIS, MOCA, and the MMSE of Folstein and associates are the most widely used clinically in our experience and serve the clinician well.
Dementia is a clinical state of the most serious nature. The physician can see the patient serially over a period of weeks, during which the appropriate laboratory tests (blood, cerebrospinal fluid analysis, and CT, MRI and functional imaging as discussed in Chap. 38) can be carried out. The management of demented patients in the hospital may be relatively simple if they are quiet and cooperative. If the disorder of mental function is severe, it is helpful if a nurse, attendant, or member of the family can stay with the patient at all times.
The primary responsibility of the physician is to diagnose the treatable forms of dementia and to institute appropriate therapy. If it is established that the patient has an untreatable dementing brain disease and the diagnosis is sufficiently certain, a responsible member of the family should be informed of the medical facts and prognosis and assisted in the initiation of social and support services. In the past, it was considered that patients themselves need be told only that they have a condition for which they are to be given rest and treatment. Most physicians (and patients) find this too patronizing; certainly, in the current social environment, patients ask directly if they have Alzheimer disease. To this query, we usually respond that they may, but that more time is required to be certain. Some intelligent patients have insisted on knowing the details and implications of this statement, and we have felt obliged to give as much useful information as required by them.
Reassurance that the physician will be available to help the patient and family manage the situation is of utmost value. Crises should be preempted by regular contact with a general physician. If the dementia is slight and circumstances are suitable, patients should remain at home for the first years, continuing to engage in those accustomed activities of which they are capable. They should be spared responsibility and guarded against injury that might result from imprudent action, such as leaving a stove turned on or driving and getting lost—or worse. If they are still at work, plans for occupational retirement should be carried out. In more advanced stages of the disease, when mental and physical enfeeblement become pronounced, a skilled nursing facility or supervised home care should be arranged.
In the advanced stages of dementia, as reviewed by Mitchell, feeding tubes are probably not a wise choice and hospice and palliative care may be employed to good benefit.