Mild cognitive impairment (MCI) is considered as a set of symptoms preceding the onset of dementia, and at the same time as a clinical syndrome corresponding to its early stages.
Diagnostic alertness
Patients with mild cognitive impairment should be observed very carefully because of the high risk of developing dementia within 3-5 years. This is an important period associated with making therapeutic decisions.
It is very important to assess the depth of dementia of the patient. The so-called DSM-IV criteria depending on the depth of cognitive impairment and disturbances of basic vital activity. Below is the classification of DSM-IV dementia depth.
Mild symptoms
An impairment of cognitive functions causes dysfunctions in everyday life, but to a degree that allows the patient to be considerably independent. However, it limited the performance of complex activities. Patients have difficulties with performing more complex activities of everyday life, such as managing their money properly, preparing more complicated meals and complying with complicated medical recommendations.
Moderate symptoms
Cognitive impairment causes the patient is unable to make purchases or use money. He is able to deal only with simple household chores. The range of activities that can not be carried out is constantly growing. The patient has serious difficulties in preparing even simple meals, taking care of their own cleanliness, etc.
Deep symptoms
Substantial or complete limitation of thought processes.
Patients of institutions for the chronically ill require feeding and constant help in hygienic activities. They usually wear diaper pants permanently.
The caretakers' observations are important for the diagnosis
People who often meet with the patient may notice a change in their personality: greater irritability, nervousness, loss of existing interests, change of habits. In moderate and severe dementia, psychotic symptoms may appear (visual and auditory hallucinations, delusions, mistaken recognition of people and events). Their occurrence is usually accompanied by behavioral disorders (aggression, wandering, cry, reversal of circadian rhythms). In the deep phase of dementia, the patient ceases to perform even self-service activities. It requires help with eating, washing, using the toilet and ultimately becomes completely dependent on the care of others.
And so the daughter describes the dementia of her father:
My father was a farmer. He was rather taciturn, always calm, honest and hard-working. He would go to bed at the appointed time and would get up at the appointed time in the morning. He undertook all the undertakings planned on the farm together with his mother. The most important thing for him was to do the job on time and always do it exactly. After my mother's death, he continued to work, but I noticed that he had become subdued, as if life had ceased to interest him. And when he handed over the son to his son after a few years, he began to "rest." He always said that after so many years of work he would not worry about anything, he would have a retirement and a peaceful life. I believe that after this decision his life really became too peaceful, he spent all day thinking about it. I had the impression that it was sinking somewhere deep inside me and becoming absent. It was only when I asked him for something that he behaved as if he woke up. I tried to draw him into conversation; he answered and then thought again. During the day he often fell asleep, and waking up I had the impression that he did not know where he was, only after a while consciousness was coming back. I knew that a disease was beginning and I talked about it.I know that he knew something was wrong with him, that he forgot what was in the morning and remembers the times of his youth.
In addition, the symptoms of the disease were headaches. While combing, he had to do it gently, because the skin on the top of his head was painful. My father became a poor man, his movements were slow, he had difficulty dressing up and it annoyed him very much. He told me that he could see that the walls were moving, that the furniture was moving, and when he spoke, his eyes were as if he were blind. My translations, that it was a disease, he accepted not always as real and necessarily persuaded me that these furniture are definitely moving. In such situations, he was overcome by fear, which led to the fact that he wanted to run as far as possible from this place. The only help was a quiet translation, that everything was fine, that it would pass immediately, and after a while he calmed down, and consequently fell into a nap. My father's illness lasted four years and in the course of time required more and more care.
In my private practice as a psychiatrist, I usually deal with dementia caused by:
dementia, Alzheimer's disease or senile dementia, mild dementia. In addition, I meet the so-called
delinquent syndromes of old people, dementia caused by depression, states of reduced mental performance after taking (in inadequate doses) psychotropic drugs, dementia caused by somatic diseases with a more severe course, etc.
Difficulties in determining the cause of senile dementia
While the diagnosis of dementia can be a relatively simple task, it is difficult to determine its cause. The thorough interview is of fundamental importance for making the correct diagnosis. Remember, however, that the patient giving this interview is already a person with marked problems with memory, impaired criticism, sometimes with tendencies to confabulation, which significantly reduces the credibility of the facts given. That is why it is so important to collect an interview from an elderly person's guardian.
In a clinical trial, the following are important:
• Interview from the patient and his caregiver. We determine the duration of the disease, its onset, course, symptoms accompanying cognitive functions, etc.
• A clinical trial to determine the existence and severity of somatic diseases, which can significantly increase the symptoms of dementia.
• Laboratory tests.
• Performing tests and filling scales.
• Neuropsychological examination.
• Neurological examination.
• Psychiatric examination (assessment of the possibility of the coexistence of depression and its depth).
• Neuroimaging. Exclusion of potentially curable organic diseases of the central nervous system. Confirmation of the appearance of atrophic changes at a specific location, determining their degree, visualization.
Inefficiency of screening tests
An American organization called Preventive Services Task Force (USPSTF) has announced updated guidelines for assessing screening for symptom recognition and the underlying causes of dementia. A group of experts concluded that the current state of knowledge does not allow unambiguous recommendations for routine screening in this area. There is evidence of the effectiveness of some drugs in suppressing the progression of Alzheimer's disease, but there is no convincing evidence of the effectiveness of such treatment in people qualified for therapy based on screening conducted in primary care settings. It is not certain how credible the diagnosis is in this way.
Test diagnosis of cognitive disorders and dementia
One of the most commonly used tests in the assessment of cognitive disorders is the Mini Mental State Examination (MMSE). However, the results of this test should be related to the age and education of the patient. Otherwise it may lead to false positives. The Functional Activities Questionnaire (FAQ) allows you to correctly assess deficits in the daily functioning of the patient. Both MMSE and FAQ allow to diagnose dementia with comparable sensitivity and specificity.
Early detection of cognitive impairment enables the implementation of proper treatment.
However, there are no convincing data justifying the need to introduce large-scale screening tests in primary care, for people who do not show signs of cognitive deficits or dementia.The assessment of cognitive functions should be carried out when suspicion of their impairment is based on observation, history, family relationships and carers. Despite the increasing prevalence of dementia, diagnosis of this disorder still causes diagnostic difficulties in the daily practice of physicians.
Doctor of Medicine Janusz Krzyżowski
Psychiatrist
Private office tel. 22 833 18 68
00-774Warszawa, Dolna 4 lok. 15
