What types of assessment tools are available to evaluate for Alzheimer’s disease (AD)?

Adequate assessment of Alzheimer’s disease (AD) plays a critical role in proper diagnosis and treatment of patients who have AD. Researchers emphasize the importance of assessment measures being both reliable and valid. Currently, most researchers and practitioners use a variety of methods for assessing patients who have AD that incorporate information from both the caregiver and the patient.

The four categories that need to be assessed (and periodically reassessed) with a patient who has AD include: daily function, cognition, comorbid medical conditions, and behavioral disturbances. Because of these differing aspects, no single test can be used to diagnose all areas of AD. Specialists can accurately identify the disease 9 out of 10 times by using a variety of different tests and evaluations.

The criterion that is most often used can be found in the medical handbook called Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (referred to as DSM-IV). Assessing the person’s current health status is an important step in evaluation of AD. Examinations may include: a physical examination, neurological examination, brain imaging (CT or MRI), blood or urine tests, and an electrocardiogram.

A physical exam can help determine medical illnesses that may contribute to cognitive impairment (i.e. congestive heart failure or hypothyroidism). A neurological examination is useful in identifying signs of Parkinson’s disease, strokes, tumors, or other medical conditions that may impair memory and thinking, along with physical functioning. Brain imaging such as computerized tomography (CT) or magnetic resonance imaging (MRI) can help detect strokes, tumors, hydrocephalus, or other abnormalities. If the patient has AD, there may be shrinkage in structures of the brain (i.e. hippocampus), and brain imaging can be useful in determining it. Blood and urine tests can thyroid problems, anemia, medication levels, infections and other factors. An electrocardiogram is especially useful in checking for vascular dementia, because it records electric impulses as the heart pumps blood.

The stages of Alzheimer’s may range depending on which scale is chosen to rate the severity. One way of determining the severity of AD is by administering the Functional Assessment Staging (FAST) scale. This scale helps professionals and caregivers chart the decline of people with AD. Normally this test is administered by the caregiver; however the patient is often encouraged to participate, especially in the earlier stages. The FAST scale breaks down the stages into 7 steps which include: (1) no functional decline, (2) personal awareness of some functional decline, (3) noticeable deficits in demanding situations such as work (mild symptoms), (4) requires assistance in complicated tasks such as accounting (mild symptoms), (5) needs assistance choosing proper attire (mild symptoms), (6) urinary and/or fecal incontinence, needs assistance with Activities of Daily Living (ADLs) (moderate symptoms), and (7) speech abilities declines to minimal vocabulary, and progressive loss of the ability to walk, smile, or even sit-up (severe symptoms). By the last stage, most people become bedridden and often die of sepsis or pneumonia. Although there are modifications between the types of scales, they all eventually breakdown the severity by three subtypes: mild, moderate, and severe dementia.

Daily Function Assessments

There are also a variety of ways to measure daily function. An assessment of daily function is critical to determine the level of care for the patient. The Daily Activities Questionnaire (DAQ) is another type of assessment device designed specifically for AD patients. This scale involves input from family, nursing staff, and an occupational therapist. Twelve areas of functioning are assessed, including activities of daily living (ADLs), such as capabilities of bathing, phone use, shopping, and cooking. This scale helps determine the level of care for the patient. Although no studies were found to use this measurement, it was said to be accurate.

A functional scale for AD patients is the Direct Assessment of Functional Status (DAFS). It measures the following: time orientation, communication, transportation, financial matters, shopping, eating, and grooming. Reported and performance-based assessments of daily function in dementia measure different aspects of patient’s performance and can be viewed as complementary. DAFS is a valid tool for the assessment of dementia severity, capturing cognitive and physical aspects of disability. A study done by Zanetti, Frisoni, Rozzini, Bianchetti, and Trabucchi (1998) found this scale to be sensitive to dementia severity and provides ADditional information when compared with established cognitive and physical assessment tools. The reliability of these measures was high, and validity was demonstrated with established measures of functional status, despite the lacking of more recent studies that use this method.

Cognition Assessments

The most common way to test for dementia in North America is the Mini-Mental State Examination (MMSE). This test can determine which cognitive functions may be affected and how severely a clinician should assess the person’s mental status. The assessment may include: testing a persons sense of time and place, ability to understand, speak, and remember, ability to perform daily activities (i.e. operate basic appliances), and possibly even simple calculations, spelling words backwards, and drawing a simple object (Petersen, 2002). Limitations of the MMSE may include a reduced sensitivity for right-hemisphere dysfunction and difficulty detecting mild dementia. Furthermore, the MMSE may overestimate deficits in individuals with less than 9 years of education (Cummings et al., 2002). As a social worker, the MMSE would be the preferred method for patients with AD because of its world-wide recognition for being reliable and accurate.

Comorbid Medical Conditions

Patients with AD often have comorbid medical conditions such as cardiovascular disease, pulmonary disease, infection, arthritis, renal insufficiency, arthritis, and diminution of vision and hearing on top of alreADy having a diagnosis of AD. Managing these conditions must take into account the current stage of dementia. A physician should evaluate the patient’s capacity to participate in treatment decisions and, as necessary, involve the caregiver in helping make informed choices.

Anxiety and depression are also common among people with AD. Often it is shown by excessive concern over upcoming events or by wandering, yelling, or aggression. Feelings of anxiety can occur because of numerous factors. Some of the most common forms are due to illness, abuse, loss of a loved one, or cognitive decline. Feelings of depression often appear through tearfulness, thoughts of worthlessness, and concerns over being a burden to family and/or caregivers. Few studies mentioned the affects of comorbidity with AD. One study found that depression and anxiety are relatively common for AD patients (Teri, Gibbons, Logdon, McCurry, Kukull, McCormick, Bowen, & Larson, 1999). Their study found that 70 percent of patients experience some sort of anxiety due to dementia. Because of the changes of functional status, dementia patients often experience depression. Due to differences in treatment, it is important to separate depression from other disruptions in behavior. Unfortunately, the caregiver plays a large role in assisting with the diagnosis and assessing the effectiveness of therapy. Behavioral disturbances of some sort eventually occur in nearly all patients with the disease.

The approach to managing comorbid medical conditions must take into account the stage of the dementia and its effects on care planning, communication methods, benefits and risks of treatments, and adherence to treatment. Especially in the early stages of AD, a patient may be lucid and able to choose whether they want to be treated for these conditions or not. Medicines often used to treat depression are those with minimal anticholinergic side effects. Serotonin reuptake inhibitors, such as citalopram (Celexa) and sertraline (Zoloft[tag]), appear to be effective and have few side effects, and are often the treatment of choice for depression.

Behavioral Disturbance

Psychiatric and neuropsychological assessments can also help determine if a person has AD. Psychiatric assessments[/tag] can often determine if the person is depressed or has a condition that may mimic dementia or accompany AD. It could also assist in identifying patterns in cognitive functions that are clues to the actual illness. Neuropsychological tests evaluate memory, ability to reason, problem-solving ability, language competency and coordination between vision and muscular moment.

In addition to the general types of clinical assessments, there are also scales to measure behavioral disturbances in AD patients. The Sandoz Clinical Assessment Geriatric (SCAG) is one of the earliest clinician-rated instruments used to evaluate global psychiatric symptoms in older adults. It includes 18 cardinal signs and symptoms of dementia, which include more than affective behavioral symptoms rated by the clinician. Over the years, it has been shown to be reliable and valid. However, the assessment does have its limitations because it does not measure agitation or psychosis. No recent studies were found that used this assessment scale.

Another form of behavioral assessment is the Behavioral Pathology in AD (BEHAVE-AD) rating scale. This scale was designed specifically for patients diagnosed with AD. The BEHAVE-AD employs a 4-point scale to assess 25 specific symptoms that are listed under seven symptom categories. The categories include paranoid and delusions (items 1-7), hallucinations (8-12), activity disturbance (13-15), aggression (16-18), sleep disturbance (19), mood (20-21), and anxiety (22-25). The purpose of BEHAVE-AD is to measure behaviors that are clinically relevant to the caregivers of AD patients, and that are potentially remediable by medications. The BEHAVE-AD has been proven to be a valid assessment tool for studying behavioral disturbances, and is used globally in countries such as China (CBEHAVE-AD). This test is often used in correlation to the MMSE when testing patients with AD. Because of its accuracy it is the most recommended way to test behavioral disturbances.

Despite the many closely accurate examinations, a diagnosis of AD with absolute certainty requires an examination of the brain tissue. Most of the time this procedure is done after a person dies by autopsy. An autopsy of a person with AD normally reveals the characteristic plaques and tangles in the brain. This information is very useful for research purposes. Autopsy results support the clinical diagnosis in 86 to 90 percent of cases. Although an autopsy can confirm a diagnosis of AD, it is important not to discredit other assessment procedures that in most cases have accurate results. However, it is important to make sure that the type of assessment chosen has accuracy and validity, so the best treatment options can be provided.

References & further information on AD:

Alzheimer Insights Online (1999). [An overview of rating scales used in dementia research]. An International Educational Newsletter, 2(3). Retrieved from http://www.alzheimer-insights.com/insights/vol2no3/vol2no3.htm.

Clark, E., Lipe A., & Bilbrey M. (1998). Use of music to decrease aggressive behavior in people with dementia. Journal of Gerontological Nursing, 7, 8-10.

Cummings J.L., & Askin-Edgar S. (2000). Evidence for psychotropic effects of acetylcholinesterase inhibitors. CNS Drugs, 13:385-95

Cummings, J.L., Frank, J.C., Cherry, D., Kohatsu, N., Kemp, B., Hewett, L., & Mittman, B. (2002). Guidelines for managing AD: Part I. and II. American Family Physician, 65(11), 2525-2534, 2262-2272.

Fazio, S. Chavin, M. & Clair, A. (1999). Activity based Alzheimer care: A national training program. American Journal of AD, 149-155.

Gandy, S. (2003). Deal me in: playing cards and boards games, reADing, dancing, may reduce dementia risk. Retrieved on February 12, 2006 from http://www.alz.org/news/03q2/reducingrisk.asp.

Jensen, S. (2003). Multiple pathways to self: a multi-sensory art experience. Art Therapy, 14, 178-186.

Kennedy, R. (October 31, 2005). The Pablo Picasso Alzheimer’s therapy. New York Times Newspaper. Retrieved on February 19, 2006 from click here for website.

Koss, E. (2002) Use it or Lose it? Retrieved on January 23, 2006 from click here for website.

Lyketsos C., Sheppard JM, Steele C.D., Kopunek S., Steinberg M., & Baker A.S., (2000). Randomized, placebo-controlled, double-blind clinical trial of sertraline in the treatment of depression complicating AD: initial results from the Depression in AD Study. American Journal Psychiatry, 157, 1686-9.

McCarthy, H.J., Roth, D.L, Goode, K., Owen, J., Harrell, L., Donovan, K., Haley, W. (2000). Longitudinal course of behavioral problems during AD: linear versus curvilinear patterns of decline. Journal of Gerontology, 55(4), 200-206.

Newman, B.M & Newman, P.R. (2005). Development through life: A psychosocial approach (9th ed.). Belmont, CA: Wadsworth/Thomson.

Ott, B. &. Cahn-Weiner, D.A. (2001, November/December). Gender Differences in AD. Geriatric Times, 2(6). Retrieved on April 9, 2006 from http://www.geriatrictimes.com/g011123.html.

Petersen, R. (2002). Mayo Clinic on AD. Mayo Clinic Health Information, Rochester, Minnesota, 60-65.

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