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CONVENOR
MEMBERS
It has been three years since the publication of Practical manual of dementia
and cognitive disorders in older adults - diagnosis and assessment by the
Hong Kong Geriatrics Society, Brain Health Special Interest Group. With
rapid advances in knowledge about dementia, the Group felt an imperative
to produce an updated second edition. We were uncertain whether naming
it as the second edition would be appropriate as observant readers may
have noticed that the title of this manual has been changed to Practical
manual of neurocognitive disorders in older adults. With the issuance of
DSM-5 in 2013, the reason for using the term neurocognitive disorder to
replace dementia and cognitive disorders is obvious. Nevertheless, we
have not deliberately refrained from using the term dementia. Therefore
it will continuously appear in many parts of this manual. Despite inherent
negative implications of the term, its generic and literal meaning has its own
merit and significance for communication among health professionals and
academia in the field of dementia.
Apart from adding the most current criteria like DSM-5 and NIA-AA criteria,
we have updated many other criteria for various types of dementia. However,
we still retain some classical criteria like the Hachinski ischaemic score for
vascular dementia and the Petersen criteria for mild cognitive impairment.
Not only because of their historical significance in the advancement of
dementia knowledge, but also as fundamental milestones to facilitate
readers understanding of the conceptual evolution of certain types of
neurocognitive disorders.
second edition. It is no longer possible or necessary to keep it pocket- We would like to acknowledge Dr Wang Ki, consultant radiologist of Prince
sized as doctors already have too many belongings to keep in their white of Wales Hospital, for his writing on chapter Neuroimaging in dementia, and
coats, including commonly a smart phone. An additional App version may Mr. Charles Chiu, Chairman of Guardianship Board, HKSAR, for his writing
be what we should aim for in the future editions. For the present edition, we on chapter Enduring power of attorney, guardianship order and advance
believe it will serve as a useful desk reference in your office or clinic. directive, and Ms. Menda Chau, occupational therapist of Wong Chuk Hang
Hospital, for contributing to Chapter Non-pharmacological management of
Apart from thanking the members of Brain Health Special Interest Group, behavioural and psychological symptoms of dementia.
who have contributed to information gathering, peer discussion, editing
and writing, I must give special thanks to two invited authors. Dr Wang
Ki, consultant radiologist of Prince of Wales Hospital, who has written the
chapter Neuroimaging in dementia and Mr. Charles Chiu, Chairman of
Guardianship Board, HKSAR, who contributed to the chapter Enduring
power of attorney, guardianship order and advance directive.
June 2014
CONTENT
2.7 Clinical dementia rating (CDR) 118 Section 6: First time assessment of neurocognitive 178
2.8 Functional assessment staging (FAST) 121 disorder in older adults
2.9 Global deterioration scale (GDS) 126 6.1 Practical guide for first time assessment 179
2.10 Geriatric depression scale (GDS) 128
2.11 Cornell Scale for Depression in Dementia (CSDD) 130
2.12 Disability Assessment for Dementia (DAD) 134
2.13 Neuropsychiatric inventory (NPI) 139
2.14 Zarit burden interview (ZBI) 140
The incidence and prevalence of dementia in older adults are increasing of neurocognitive disorders. The importance of non-pharmacological
rapidly. Not only does the disease carry significant impact on morbidity management can never be over-emphasized. Section 5 discusses late stage
and mortality, but it also creates heavy burdens on caregivers and health dementia including both end-of-life management and medico-legal facts of
expenditure. As clinicians, we increasingly encounter older patients who advance planning. The last section, section 6, is a proposed schema for the
present with cognitive complaints or those who are incidentally discovered first time assessment of neurocognitive disorder in a memory clinic setting.
to have cognitive impairment. The diagnosis of dementia relies solely on
clinical approach. To date, no high technology can replace the diagnostic We wish this manual will serve as a convenient desk reference for geriatricians,
accuracy of a well-trained clinician. A handy reference will definitely facilitate psychiatrists, neurologists and trainees of these specialties; or for any
an accurate diagnosis and a proper assessment in a demented older adult. clinician who encounter older demented persons in their clinical practice.
It is always advisable not to make a diagnosis of dementia causally in Lastly, we hope that the inclusion of Chinese versions of cognitive tests,
acute settings as many secondary causes can complicate our assessment. which are culture and language dependent, may benefit older patients and
Therefore, we advise you to use this manual primarily in clinic, extended care medical practitioners in mainland China, or in any other Chinese speaking
or long-term care settings but with wisdom and caution in acute settings. community worldwide.
10 11
SECTION 1
Diagnostic criteria of neurocognitive disorders
Reference
1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.
Arlington, VA, American Psychiatric Association, 2013.
13
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Diagnostic criteria of neurocognitive disorders
14 15
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Diagnostic criteria of neurocognitive disorders
an additional objective assessment. Also note that major NCD due to AD 1.1.2 NIA-AA criteria for all-cause dementia 2011
requires 2 domains, one of which needs to be memory. Therefore, it still
adheres to the convention. In addition, the DSM-5 criteria due to different
subtypes also adopt probable and possible classification in line with world When cognitive or behavioral (neuropsychiatric) symptoms that:
expert panel criteria. This is another major difference from DSM-IV. 1. Interfere with ability to function at work or at usual activities; and
2. Represent a decline from previous levels of functioning and performing;
The * are more important for older adults and can be referred to the different
and
section of this manual with the page numbers in brackets. As remarked in the
DSM-5 manual, older adults are commonly complicated by comorbidities, 3. Are not explained by delirium or major psychiatric disorder;
which make subtyping difficult.
4. Cognitive impairment is detected and diagnosed through a combination
of (1) history taking from patient and a knowledgeable informant and
Specifiers (2) an objective cognitive assessment, either a bedside mental status
After subtyping, we can assign specifiers, which are similar to behavioural examination or neuropsychological testing.
and psychological symptoms of dementia, and they are listed below: 5. The cognitive or behavioral impairment involves a minimum of two of the
Delusions following domains :
Hallucinations a. Impaired ability to acquired and remember new information
Mood disturbance b. Impaired reasoning, handling of complex tasks and poor judgment
Agitation
c. Impaired visuospatial abilities
Combative behaviours
Sleep disturbance d. Impaired language functions
This is a good list for history taking and mental examination. It helps to identify
non-cognitive problems in dementia that needs either pharmacological or
non-pharmacological intervention.
18 19
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Diagnostic criteria of neurocognitive disorders
1.2.2 DSM-IV criteria for dementia of the 1.2.3 NIA-AA criteria for dementia due to
Alzheimers type 1994 Alzheimers Disease 2011
A. The development of multiple cognitive deficits manifested both NIA-AA criteria for probable AD dementia
1. memory impairment 1. Meet criteria for dementia by NIA-AA
2. one (or more) of the following cognitive disturbances : 2. Insidious onset
aphasia 3. Clear-cut history of worsening of cognition by report or observation
apraxia 4. The initial and most prominent cognitive deficits are evident on history
agnosia and examination in one of the following categories :
B. The cognitive deficits in Criteria A1 and A2 each cause significant b. Non-amnestic presentations:
impairment in social or occupational functioning and represent a Language presentation
significant decline from a previous level of functioning
Visuospatial presentation
C. The course is characterised by gradual onset and continuing cognitive
decline Executive dysfunction
D. The cognitive deficits in criteria A1 and A2 are not due to any of the 5. The diagnosis of probable AD dementia should not be applied when
following: there is evidence of :
other central nervous system conditions that cause progressive a. substantial concomitant cerebrovascular disease
deficits in memory and cognition b. core features of Dementia with Lewy bodies
systemic conditions that are known to cause dementia c. prominent features of behavioral variant frontotemporal dementia
substance-induced conditions d. prominent features of semantic variant primary progressive aphasia
E. The deficits do not occur exclusively during the course of a delirium or non-fluent/agrammatic variant primary progressive aphasia
F. The disturbance is not better accounted for by another mental disorder e. another concurrent, active neurological disease, or a non-
neurological medical comorbidity or use of medication that could
have a substantial effect on cognition
Reference
1. American Psychiatric Association: Diagnostic and statistical Manual of Mental Disorders, Fourth Edition, Text
Note : All patients who met criteria for probable AD by 1984 NINCDS-ADRDA
Revision. Washington, D.C., American Psychiatric Association, 2000.
criteria would meet the NIA-AA criteria for probable AD.
20 21
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Diagnostic criteria of neurocognitive disorders
NIA-AA criteria for possible AD dementia NIA-AA AD dementia criteria incorporating biomarkers
Meets the core clinical criteria for AD dementia, but either of : Neuronal injury
Biomarker (CSF tau, FDG-
1. Atypical course Diagnostic probability of PET, structural
a sudden onset of cognitive impairment or demonstrates insufficient category AD etiology A (PET or CSF) MRI)
historical detail or objective cognitive documentation of progressive Probable AD dementia
decline.
Unavailable, Unavailable,
2. Aetiologically mixed presentation Based on clinical
Uninformative conflicting, or conflicting, or
criteria
indeterminate indeterminate
concomitant cerebrovascular disease; or
Unavailable or
features of dementia with Lewy bodies; or Intermediate
indeterminate
Positive
With three level
evidence for another neurological disease or a non-neurological of evidence of AD Unavailable or
Intermediate Positive
medical comorbidity or medication use that could have a substantial pathophysiological indeterminate
process
effect on cognition
High Positive Positive
Note : A diagnosis of possible AD by 1984 NINCDS-ADRDA criteria would not Possible AD dementia
necessarily meet the NIA-AA criteria for possible AD dementia.
Unavailable, Unavailable,
Based on clinical
Uninformative conflicting, or conflicting, or
criteria
Dementia unlikely to be due to AD indeterminate indeterminate
1. Does not meet criteria for AD dementia. With evidence of AD High but does not
pathophysiological rule out second Positive Positive
2. a. Regardless of meeting clinical criteria for probable or possible process etiology
AD dementia, there is sufficient evidence for an alternative diagnosis.
Dementia-unlikely
Lowest Negative Negative
b. Regardless of meeting clinical criteria for possible AD dementia, due to AD
both amyloid beta and neuronal injury biomarkers are negative.
Abbrevations : AD, Alzheimers disease; A, amyloid-beta; PET, positron emission tomography; CSF,
cerebrospinal fluid; FDG, 18fluorodeoxyglucose; MRI, magnetic resonance imaging.
22 23
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Diagnostic criteria of neurocognitive disorders
6. Two major categories of Alzheimers biomarkers: Stage 3. Amyloidosis + neurodegeneration + subtle cognitive decline
a. Biomarkers of amyloid beta (A) accumulation evidence of subtle change from baseline level of cognition
which are reductions in CSF A42 and increase amyloid retention poor performance on more challenging cognitive tests
on PET. does not yet meet criteria for mild cognitive impairment
is regarded as initial event in AD-P.
b. Biomarkers of neuronal degeneration or injury
which are elevated CSF tau (both total and phosphorylated tau);
decreased fluorodeoxyglucose 18F (FDG) uptake on PET with
temporoparietal pattern of hypometabolism; atrophy on structural
MRI in a characteristic pattern involving the medial, basal, and
lateral temporal lobes, and medial and lateral parietal cortices.
presence of these biomarkers in addition to biomarkers of A
accumulation may increase the likelihood of clinical decline to
MCI within several years.
References
7. It is postulated that evidence of subtle cognitive decline detected by 1. Jack CR Jr, Albert MS, Knopman DS, McKhann GM, Sperling RA, Carrillo MC, et al. Introduction to the
more sensitive cognitive measures, together with biomarkers evidence of recommendations from the National Institute on Aging-Alzheimers Association workgroups on diagnostic guidelines
for Alzheimers disease. Alzheimers Dement 2011;7;257-62.
A accumulation and neuronal injury, indicate the last stage of preclinical 2. Mckhann GM, Knopman DS, Chertkow H, Hyman BT, Jack CR Jr, Kawas CH, et al. The diagnosis of dementia due
AD and are approaching MCI. to Alzheimers disease: recommendations from the National Institute on Aging-Alzheimers Association workgroups
on diagnostic guidelines for Alzheimers disease. Alzheimers Dement 2011;7:263-9.
3. Sperling RA, Aisen PS, Beckett LA, Bennett DA, Craft S, Fagan AM, et al. Toward defining the preclinical stages of
Alzheimers disease: recommendations from the National Institute on Aging-Alzheimers Association workgroups on
diagnostic guidelines for Alzheimers disease. Alzheimers Dement 2011;7:280-92.
24 25
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Diagnostic criteria of neurocognitive disorders
Practical notes on Alzheimers Disease and Dementia The original criteria rest on the notion that AD is a clinical-pathological entity.
However, with the emerging concept that AD pathophysiological change
Making the diagnosis of dementia due to Alzheimers disease occurs decades before the clinical overt symptoms, AD is regarded as a
It is a clinical diagnosis by exclusion of some potential causes. There is no continuous spectrum from preclinical/presymptomatic, to pre-dementia/mild
single reliable diagnostic investigation or imaging to rule in the disease. It cognitive impairment (MCI), and finally to clinically overt dementia. This allows
relies on the history from patients and caregivers to establish the diagnosis. the new criteria and guideline to define three stages of disease progression
Therefore, it is always advisable to take history from reliable caregivers. It is over time (preclinical AD, MCI due to AD and dementia due to AD). The
not recommended to assess the patient in acute settings with presence of new criteria and guideline regarding AD dementia and MCI due to AD are
confounding medical and environmental factors. intended to guide diagnosis in the clinical setting. On the other hand, the
recommendation of preclinical AD is intended purely for research purpose.
Alzheimers Disease vs. Alzheimers Dementia and NIN-AA criteria
Biomarkers are parameters that can be measured in the body to reliably
It is worthwhile to note that a number of elderly people suffer from Alzheimers
indicate the pathophysiological process of a disease. Five mostly widely
disease (AD) but not Alzheimers dementia yet. The latter signifies that the
studied biomarkers of AD are incorporated into the new diagnostic criteria.
patient has to exhibit features of dementia while the former signifies presence
They are divided into two categories : (1) the biomarkers of amyloid beta (A)
of Alzheimers pathology such as amyloid plaques or tau proteins in the brain
accumulation, which are PET evidence of A deposition and low CSF A42,
only. Early AD may be picked up by the advances in technology, e.g., the
and (2) the biomarkers of neuronal degeneration or injury, which are elevated
ratio of biomarkers such as low amyloid beta and high phosphorylated tau
CSF tau (both total and phosphorylated tau), decreased 18fluorodeoxyglucose
level in the cerebrospinal fluid, or new neuroimaging techniques. This may
(FDG) uptake on PET in temporoparietal cortex; and disproportionate
allow detection of preclinical stage of AD, in the hope to prevent patients from
atrophy on structural magnetic resonance imaging in medial, basal, and
evolving into the stage of clinical Alzheimers dementia by earlier treatment.
lateral temporal lobe, and medial and lateral parietal cortices. Integration of
NIA-AA has developed criteria based on this conceptual framework about
biomarkers into the new guideline is mainly for research purpose, in which the
the pathophysiological evolution of AD. It encompasses preclinical stages of
use of biomarkers is paramount in the detection of pre-clinical AD, whereas,
AD (solely for research purpose), mild cognitive impairment due to AD and
it is complimentary in the diagnosis of MCI and dementia due to AD, as they
finally AD dementia.
are based primarily on clinical ground.
With advances in the understanding and detection of AD pathophysiology,
DSM-5 vs. NIA-AA criteria in AD
a new criteria and guideline for the diagnosis of AD was published by the
National Institute on Aging-Alzheimers Association (NIA-AA) in 2011 after Both criteria incorporate quantifiable cognitive test as an integral part of the
revising the 1984 criteria for clinical diagnosis of AD by the National Institute diagnosis. NIA-AA does not specifically demand a reference value but DSM-5
of Neurological and Communicative Disorders and Stroke (NINCDS) and the differentiate mild and major NCD by different cut-offs. NIA-AA criteria start
Alzheimers Disease and Related Disorders Association (ADRDA). with meeting the criteria for dementia while DSM-5 starts with meeting the
criteria for major or mild NCD. Both contain probable and possible AD. NIA-
The new criteria and guideline has two notable differences from the original AA criteria contain the preclinical stage of AD which incorporated biomarkers
NINCDS-ADRDA criteria, namely (1) three stages of disease are defined, and for research application, whereas DSM-5 does not cover the preclinical stage
the (2) incorporation of biomarker tests. of AD. MCI due to AD in NIA-AA is equivalent to DSM-5 mild NCD due to AD.
26 27
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Diagnostic criteria of neurocognitive disorders
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Diagnostic criteria of neurocognitive disorders
1.3.2 DSM-IV criteria for vascular dementia 1994 1.3.3 American Heart Association (AHA) / American
Stroke Association (ASA) criteria for vascular
cognitive impairment 2011
A. The development of multiple cognitive deficits manifested by both:
1. Memory impairment (impaired ability to learn new information or to
recall previously learned information) Diagnostic Criteria for Vascular Cognitive Impairment
2. One or more of the following cognitive disturbances: 1. The term vascular cognitive impairment (VCI) characterizes all forms
of cognitive deficits from vascular dementia (VaD) to mild cognitive
aphasia impairment (MCI) of vascular origin.
apraxia 2. These criteria cannot be used for subjects who have an active diagnosis
agnosia of drug or alcohol abuse/dependence. Subjects must be free of any type
of substance for at least 3 months.
disturbance in executive functioning
3. These criteria cannot be used for subjects with delirium.
B. The cognitive deficits in criteria A1 and A2 each cause significant
impairment in social or occupational functioning and represent a
Probable VaD
significant decline from a previous level of functioning.
1. Meet criteria for dementia
C. Focal neurological signs and symptoms (e.g., exaggeration of deep
It should be based on a decline in cognitive function from a prior
tendon reflexes, extensor plantar response, pseudobulbar palsy,
baseline and a deficit in performance in 2 cogntive domains that are
gait abnormalities, weakness of an extremity) or laboratory evidence
of sufficient severity to affect the subjects activities of daily living.
indicative of cerebrovascular disease (e.g., multiple infarctions involving
cortex and underlying white matter) that are judged to be etiologically It must be based on cognitive testing, and a minimum of 4 cognitive
related to the disturbance. domains should be assessed : executive/attention, memory,
language, and visuospatial functions.
D. The deficits do not occur exclusively during the course of a delirium. The deficits in activities of daily living are independent of the motor/
sensory sequelae of the vascular event.
2. There is cognitive impairment and imaging evidence of cerebrovascular
disease and
there is a clear temporal relationship between a vascular event and
the onset of cognitive deficits, or
there is a clear relationship in the severity and pattern of cognitive
Reference impairment and the presence of diffuse, subcortical
1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text
Revision. Washington, D.C., American Psychiatric Association, 2000. cerebrovascular disease pathology.
30 31
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Diagnostic criteria of neurocognitive disorders
Reference
1. Gorelick PB, Scuteri A, Black SE, DeCarli C, Greenberg SM, Iadecola C, et al. Vascular contributions to
cognitive impairment and dementia: a statement for healthcare professionals from the American Heart
Association/American Stroke Association. Stroke 2011;42(9):2672 - 713.
32 33
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Diagnostic criteria of neurocognitive disorders
Cerebrovascular disease
Focal signs consistent with stroke, and
Neuroimaging evidence of relevant CVD including multiple large vessel
infarcts or a single strategically placed infarct (angular gyrus, thalamus,
basal forebrain, or PCA or ACA territories), as well as multiple basal
ganglia and white matter lacunes, or extensive periventricular white
matter lesions.
Reference
1. Romn GC, Tatemichi TK, Erkinjuntti T, Cummings JL, Masdeu JC, Garcia JA, et al. Vascular dementia:
diagnostic criteria for research studies: Report of the NINDS-AIREN International Workshop*. Neurology
1993;43(2):250-60.
34 35
SECTION 1
Diagnostic criteria of neurocognitive disorders
References
1. Hackinski VC, Iliff LD, Zihka E, Du Boulay GH, McAllisterVL, Marshall J, et al. Cerebral blood flow in dementia.
Arch Neurol 1975;32(9):632-7.
2. Mayer-Gross W, Slater E, Roth M: Clinical Psychiatry, 3rd ed. Baillier, Tindall & Carssell, London, 1969.
36 37
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Diagnostic criteria of neurocognitive disorders
Reference
1. Langa KM, Foster NL, Larson EB. Mixed dementia: emerging concepts and therapeutic implications. JAMA
2004;292(23):2901-8.
38 39
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Diagnostic criteria of neurocognitive disorders
1.4 Mild cognitive impairment (MCI) 1.4.1 DSM-5 criteria for mild neurocognitive disorder 2013
In this part, diagnostic criteria of MCI or its equivalent are extracted from
the original full spectrum criteria from different sources, including DSM-5,
Mild Neurocognitive Disorder
NIA-AA and AHA-ASA. Therefore, reference to other sections in this manual
is required for the complete criteria of that particular disease. The classical Diagnostic Criteria
Petersen criteria have been retained to give a complete picture about the A. Evidence of modest cognitive decline from a previous level of
concept of MCI in evolution. performance in one or more cognitive domains (complex attention,
executive function, learning and memory, language, perceptual-motor,
or social cognition) based on:
1. Concern of the individual, a knowledgeable informant, or the clinician
that there has been a mild decline in cognitive function; and
2. A modest impairment in cognitive performance, preferably
documented by standardized neuropsychological testing or, in its
absence, another quantified clinical assessment.
B. The cognitive deficits do not interfere with capacity for independence
in everyday activities (i.e., complex instrumental activities of daily living
such as paying bills or managing medications are preserved, but greater
effort, compensatory strategies, or accommodation may be required.
C. The cognitive deficits do not occur exclusively in the context of a
delirium.
D. The cognitive deficits are not better explained by another mental disorder
(e.g., major depressive disorder, schizophrenia).
Reference
1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.
Arlington, VA, American Psychiatric Association, 2013.
40 41
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Diagnostic criteria of neurocognitive disorders
1.4.2 DSM-5 criteria for mild neurocognitive disorder 1.4.3 DSM-5 criteria for mild vascular neurocognitive
due to AD 2013 disorder 2013
Mild Neurocognitive Disorder Due to Alzheimers Disease Mild Vascular Neurocognitive Disorder
Diagnostic Criteria Diagnostic Criteria
A. The criteria are met for mild neurocognitive disorder. A. The criteria are met for mild neurocognitive disorder.
B. There is insidious onset and gradual progression of impairment in one or B. The clinical features are consistent with a vascular etiology, suggested
more cognitive domains (for major neurocognitive disorder, at least two by either of the following:
domains must be impaired).
1. Onset of the cognitive deficits is temporally related to one or more
C. Criteria are met for either probable or possible Alzheimers disease as cerebrovascular events.
follows:
2. Evidence of decline is prominent in complex attention (including
Probable Alzheimers disease is diagnosed if there is evidence of processing speed) and frontal-executive function.
a causative Alzheimers disease genetic mutation from either genetic
C. There is evidence of the presence of cerebrovascular disease form
testing or family history.
history, physical examination, and/or neuroimaging considered sufficient
Possible Alzheimers disease is diagnosed if there is no evidence of to account for the neurocognitive deficits.
a causative Alzheimers disease genetic mutation from either genetic
D. The symptoms are not better explained by another brain disease or
testing or family history, and all three of the following are present:
systemic disorder.
1. Clear evidence of decline in memory and learning.
Probable vascular neurocognitive disorder is diagnosed if one of the
2. Steadily progressive, gradual decline in cognition, without extended following is present; otherwise possible vascular neurocognitive disorder
plateaus. should be diagnosed:
3. No evidence of mixed etiology (i.e., absence of other neurodegenerative 1. Clinical criteria are supported by neuroimaging evidence of significant
or cerebrovascular disease, or another neurological or systemic parenchymal injury attributed to cerebrovascular disease (neuroimaging-
disease or condition likely contributing to cognitive decline). supported).
D. The disturbance is not better explained by cerebrovascular disease, 2. The neurocognitive syndrome is temporally related to one or more
another neurodegenerative disease, the effects of a substance, or documented cerebrovascular events.
another mental, neurological, or systemic disorder.
3. Both clinical and genetic (e.g., cerebral autosomal dominant arteriopathy
Reference
with subcortical infarcts and leukoencephalopathy) evidence of
1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.
Arlington, VA, American Psychiatric Association, 2013. cerebrovascular disease is present.
42 43
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Diagnostic criteria of neurocognitive disorders
Reference
1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.
Arlington, VA, American Psychiatric Association, 2013.
44 45
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Diagnostic criteria of neurocognitive disorders
Reference
1. Albert MS, DeKosky ST, Dickson D, Dubois B, Feldman HH, Fox NC, et al. The diagnosis of mild cognitive
impairment due to Alzheimers disease: recommendations from the National Institute on Aging-Alzheimers
Association workgroups on diagnostic guidelines for Alzheimers disease. Alzheimers Dement 2011;7:270-9.
46 47
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Diagnostic criteria of neurocognitive disorders
Cognitive Complaint
MCI
Reference Reference
1. Gorelick PB, Scuteri A, Black SE, DeCarli C, Greenberg SM, Iadecola C, et al. Vascular contributions to 1. Winblad B, Palmer K, Kivipelto M, Jelic V, Fratiglion L, Wahlund L-O, et al. Mild cognitive impairment-beyond
cognitive impairment and dementia: a statement for healthcare professionals from the American Heart controversies, towards a consensus: report of the International Working Group on Mild Cognitive Impairment.
Association/American Stroke Association. Stroke 2011;42(9):2672 - 2713. J Intern Med 2004;256(3):240-6.
48 49
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Diagnostic criteria of neurocognitive disorders
1.4.7 Petersen criteria for mild cognitive impairment 1999 Practical notes on MCI
The concept of MCI has been developed since 1999 with the classical
Presence of a subjective memory complaint Petersen criteria for MCI. The diagnosis is made when there is a cognitive
impairment for their age and education, and that the deficit does not interfere
Preserved general intellectual functioning significantly with their daily activities. It is often considered to be the boundary
Demonstration of a memory impairment by cognitive testing or transitional stage between normal aging and dementia, although some
may remain stable and some may even revert back to normal (e.g., those due
Intact ability to perform activities of daily living
to depression or medical conditions). The annual conversion rate of amnestic
Absence of dementia MCI to Alzheimers dementia is approximately 5-10%. The 2004 International
Working Group on MCI criteria included the component of increasing
difficulty in performing everyday tasks without the loss of autonomy, like
changes in the areas of dressing, use of telephone, money and household
appliances. In addition, it also included cognitive deficits other than memory
and sub-classified MCI into amnestic or non-amnestic, and single or multiple
domain types. This direction has been followed on in the updated criteria
from DSM-5, NIA-AA and AHA-ASA, wherein MCI is broadly defined rather
than specifically tied up with only memory deficit or AD.
Reference
1. Petersen RC, Smith GE, Waring SC, Ivnik RJ, Tangalos EG, Kokmen E. Mild cognitive impairment: clinical
characterization and outcome. Arch Neurol 1999;56(3):303-8.
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1.5.2 DSM-5 criteria for neurocognitive disorder due to 1.5.3 Parkinsons disease dementia criteria 2007
Parkinsons disease 2013
D. The neurocognitive disorder is not attributable to another medical Impaired attention - which may fluctuate over time
condition and is not better explained by another mental disorder. Impaired executive function - Impairment in complex thought
Major or mild neurocognitive disorder probably due to Parkinsons processes such as in initiating an action, planning, or organization
disease should be diagnosed if 1 and 2 are both met. Major or mild Impaired visuo-spatial ability - Marked deficits in the processing
neurocognitive disorder possibly due to Parkinsons disease should be of visual-spatial material
diagnosed if 1 or 2 is met:
Impaired free recall memory - which improved with cueing
1. There is no evidence of mixed etiology (i.e., absence of other
neurodegenerative or cerebrovascular disease or another neurological, At least one behavioral symptoms
mental, or systemic disease or condition likely contributing to cognitive Apathy - Decreased spontaneity, motivation, effortful behavior
to cognitive decline).
Changes in personality and mood - Can include depression and
2. The Parkinsons disease clearly precedes the onset of the neurocognitive anxiety
disorder.
Hallucinations - Usually complex and visual
Delusions - Usually paranoid delusions, such as infidelity or
perceived unknown guests in the home
Excessive daytime sleepiness
Reference
1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.
Arlington, VA, American Psychiatric Association, 2013.
54 55
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Reference
1. McKeith IG, Dickson DW, Lowe J, Emre M, OBrien JT, Feldman H, et al. Diagnosis and management of
dementia with Lewy bodies: third report of DLB Consortium. Neurology 2005;65(12):1863-72.
58 59
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Diagnostic criteria of neurocognitive disorders
References
1. Hoops S, Nazem S, Siderowf D, Duda JE, Xie SX, Stern MB, et al. Validity of the MoCA and MMSE in the detection
of MCI and dementia in Parkinson disease. Neurology 2009;73(21):173845.
2. Emre M, Aarsland D, Brown R, Burn DJ, Duyckaerts C, Mizuno Y, et al. Clinical diagnostic criteria for dementia
associated with Parkinsons disease. Movement disorders 2007;22(12):1689-707.
3. McKeith IG, Dickson DW, Lowe J, Emre M, OBrien JT, Feldman H, et al. Diagnosis and management of dementia
with Lewy bodies: third report of DLB Consortium. Neurology 2005;65(12):1863-72.
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B. The disturbance has insidious onset and gradual progression. Possible frontotemporal neurocognitive disorder is diagnosed if there
is no evidence of a genetic mutation, and neuroimaging has not been
C. Either (1) or (2): preformed.
1. Behavioral variant:
a. Three or more of the following behavioral symptoms:
i. Behavioral disinhibition.
ii. Apathy or inertia.
iii. Loss of sympathy or empathy.
iv. Perseverative, stereotyped or compulsive/ritualistic behavior.
v. Hyperorality and dietary changes.
b. Prominent decline in social cognition and /or executive abilities.
2. Language variant:
a. Prominent decline in language ability, in the form of speech
production, word finding, object naming, grammar, or word
comprehension.
D. Relative sparing of learning and memory and perceptual-motor function.
E. The disturbance is not better explained by cerebrovascular disease,
Reference
another neurodegenerative disease, the effects of a substance, or
1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.
another mental, neurological, or systemic disorder. Arlington, VA, American Psychiatric Association, 2013.
62 63
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Diagnostic criteria of neurocognitive disorders
64 65
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Diagnostic criteria of neurocognitive disorders
Reference
1. Rascovsky K, Hodges JR, Knopman D, Mendez MF, Kramer JH, Neuhaus J, et al. Sensitivity of revised
diagnostic criteria for the behavioral variant of frontotemproal dementia. Brain 2011;134(9):2456-77.
66 67
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1. Most prominent clinical feature is difficulty with language 2. Effortful, halting speech with inconsistent speech sound errors and
distortions (apraxia of speech)
2. These deficits are the principal cause of impaired daily living activities
At least 2 of 3 of the following other features must be present:
3. Aphasia should be the most prominent deficit at symptoms onset
and for the initial phases of the disease 1. Impaired comprehension of syntactically complex sentences
Exclusion: criteria 1-4 must be answered negatively for a PPA diagnosis 2. Spared single-word comprehension
1. Pattern of deficits is better accounted for by other nondegenerative 3. Spared object knowledge
nervous system or medical disorders II. Imaging-supported nonfluent/agrammatic variant diagnosis
2. Cognitive disturbance is better accounted for by a psychiatric Both of the following criteria must be present:
diagnosis
1. Clinical diagnosis of nonfluent/agrammatic variant PPA
3.
Prominent initial episodic memory, visual memory, and
2. Imaging must show one or more of the following results:
visuoperceptual impairments
a. Predominant left posterior fronto-insular atrophy on MRI or
4. Prominent, initial behavioural disturbance
b. Predominant left posterior fronto-insular hypoperfusion or
hypometabolism on SPECT or PET
III. Nonfluent/agrammatic variant PPA with definite pathology
Clinical diagnosis (criterion 1 below) and either criterion 2 or 3 must be
present:
1. Clinical diagnosis of nonfluent/agrammatic variant PPA
2. Histopathologic evidence of a specific neurodegenerative pathology
3. Presence of a known pathogenic mutation
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3. Diagnostic criteria for the semantic variant PPA 4. Diagnostic criteria for logopenic variant PPA
I. Clinical diagnosis of semantic variant PPA I. Clinical diagnosis of logopenic variant PPA
Both of the following core features must be present: Both of the following core features must be present:
1. Impaired confrontation naming 1. Impaired single-word retrieval in spontaneous speech and naming
2. Impaired single-word comprehension 2. Impaired repetition of sentences and phrases
At least 3 of the following other diagnostic features must be present: At least 3 of the following other features must be present:
1. Impaired object knowledge, particularly for low-frequency or low- 1. Speech (phonologic) errors in spontaneous speech and naming
familiarity items 2. Spared single-word comprehension and object knowledge
2. Surface dyslexia or dysgraphia 3. Spared motor speech
3. Spared repetition 4. Absence of frank agrammatism
4. Spared speech production (grammar and motor speech) II. Imaging-supported logopenic variant diagnosis
II. Imaging-supported semantic variant PPA diagnosis Both criteria must be present:
Both of the following criteria must be present: 1. Clinical diagnosis of logopenic variant PPA
1. Clinical diagnosis of semantic variant PPA 2. Imaging must show at least one of the following results:
a. Predominant left posterior perisylvian or parietal atrophy on MRI
2. Imaging must show one or more of the following results:
b. Predominant left posterior perisyvian or parietal hypoperfusion of
a. Predominant anterior temporal lobe atrophy
hypometabolism on SPECT or PET
b. Predominant anterior temporal hypoperfusion or hypometabolism
III. Logopenic variant PPA with definite pathology
on SPECT or PET
Clinical diagnosis (criterion 1 below) and either criterion 2 or 3 must be
III. Semantic variant PPA with definite pathology present:
Clinical diagnosis (criterion 1 below) and either criterion 2 or 3 must be 1. Clinical diagnosis of logopenic variant PPA
present:
2. Histopathologic evidence of a specific neurodegenerative pathology
1. Clinical diagnosis of semantic variant PPA
3. Presence of a known pathogenic mutation
2. Histopathologic evidence of a specific neurodegenerative pathology
Reference
3. Presence of known pathogenic mutation 1. Gorno-Tempini ML, Hills AE, Weintraub S, Kertesz A, Mendez M, Cappa SF, et al. Classification of primary
progressive aphasia and its variants. Neurology 2011;76(11):1006-14.
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Cores diagnostic features must be all present for diagnosis Mental rigidity and inflexibility
Supportive diagnostic features are not necessary conditions for diagnosis Distractibility and impersistence
but they add substantial weight to the clinical diagnosis Hyperorality and dietary changes
Supportive features are common to all clinical syndromes of Perseverative and stereotyped behaviour
frontotemporal lobar degeneration (FTD), progressive nonfluent aphasia
Utilization behaviour
and semantic dementia. These features support but not necessary for
diagnosis B. Speech and language
Diagnostic exclusion features must be absent Altered speech output
Relative diagnostic exclusion features are against but do not firmly Aspontaneity and economy of speech
exclude diagnosis Press of speech
Character change and disordered social conduct are the dominant features Echolalia
initially and throughout the disease course. Instrumental functions of Perseveration
perception, spatial skills, praxis, and memory are intact or relatively well
Mutism
preserved.
C. Physical signs
Core diagnostic features Primitives reflexes
Insidious onset and gradual progression Incontinence
Early decline in social interpersonal conduct Akinesia, rigidity, and tremor
Early impairment in regulation of personal conduct Low and liable blood pressure
Early emotional blunting
Early loss of insight
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Supportive features
Onset before 65 years: positive family history of similar disorder in first-
degree relatives
Bulbar palsy, muscular weakness and wasting, fasciculations
74 75
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76 77
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78 79
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1.7 Delirium
1.7.1 DSM-5 criteria for delirium 2013 Specify cause:
Substance intoxication delirium
Substance withdrawal delirium
A. A disturbance in attention (i.e., reduced ability to direct, focus,
Medication-induced delirium
sustain, and shift attention) and awareness (reduced orientation to the Delirium due to another medical condition
environment). Delirium due to multiple aetiologies
B. The disturbance develops over a short period of time (usually hours to a
Specify onset and duration:
few days), represents a change from baseline attention and awareness,
Acute: Lasting a few hours or days
and tends to fluctuate in severity during the course of a day.
Persistent: Lasting weeks or months
C. An additional disturbance in cognition (e.g., memory deficit,
disorientation, language, visuospatial ability, or perception). Specify type:
Hyperactive
D. The disturbances in Criteria A and C are not better explained by another Hypoactive
preexisting established, or evolving neurocognitive disorder and do not Mixed level of activity
occur in the context of a severely reduced level of arousal, such as
coma.
E. There is evidence from history, physical examination, or laboratory
findings that the disturbance is a direct physiological consequence of
another medical condition, substance intoxication or withdrawal (i.e.,
due to a drug of abuse or to medications), or exposure to a toxin, or is
due to multiple etiologies.
Reference
1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.
Arlington, VA, American Psychiatric Association, 2013.
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1.7.2 Confusion Assessment Method 1990 Practical notes on DSM-5 criteria and the Confusion
Assessment Method (CAM) for delirium
The presence of features (1), (2), and either (3 or 4). Delirium is common in older adults with or without underlying dementia,
and is an emergency condition. In DSM-5, the exclusion of delirium is a
1. Acute onset and fluctuating course prerequisite for the diagnosis of any form of NCD. DSM-5 has timely added
2. Inattention in the clinically relevant aetiological and descriptive specifiers to establish
a comprehensive framework for the diagnosis of delirium. This can assist
3. Disorganized thinking
clinicians in the management of older delirious patients. Medication-induced
4. Altered level of consciousness delirium, delirium due to another medical condition and delirium due to
multiple aetiologies are common underlying causes of delirium in old age. It
is worth noting that persistent delirium, on contrary to the conventional acute
and short-lived delirium, can last for months. In reality, persistent delirium
frequently occurs in older adults, yet this and the hypoactive form of delirium
remain highly under-recognized in clinical practice. If the DSM-5 diagnostic
criteria for delirium are being observed closely, these deficits hopefully can
be alleviated in the future. Despite the comprehensiveness of the DSM-5
delirium diagnostic criteria, the classical CAM items are still a practical guide
in the detection of delirium for their inherent beauty of simplicity.
Reference
1. Inouye SK, Van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment
method: A new method for detection of delirium. Annals of internal medicine 1990;113(12):941-8.
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Reference
1. Chu LW, Pei LKW, Ho MH, Chan PT. Validation of the abbreviated Mental Test (Hong Kong version in the elderly
medical patient. HKMJ 1995;1:207-11.
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Abbreviated Mental Test (Original Hodkinsons Version) Practical notes on the Abbreviated Mental Test (AMT)
Test item Scoring instructions* The AMT is a screening test, and not a test to monitor progress or drug
response. Although a lower score is supposed to reflect lower cognitive
Age Score for exact age only function, the test was not designed for this purpose and hence should
not be interpreted as such.
Date of birth Score for correct date and month
(year not required) The AMT can tell us whether the individual is at risk of cognitive
impairment, but not its severity.
Year Score for current year only
Reference
1. Hodkinson HM. Evaluation of a mental test score for assessment of mental impairment in the elderly. Age Aging
1972;1(4):223-8.
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1
8. Daily problems with thinking and/or memory AD8
0
TOTAL AD8 SCORE 2009
88 89
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References
1. Galvin JE, Roe CM, Powlishta KK, Coats MA, Muich SJ, Grant E, et al. The AD8 A brief informant interview to detect
dementia. Neurology 2005;65(4):559-64.
2. Li T, Wang HL, Yang YH, Galvin JE, Morris JC, Yu X. The reliability and validity of Chinese version of AD8. Zhonghua
nei ke za zhi [Chinese Journal of Internal Medicine] 2012;51(10):777-80.
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1 = correct if clock looks grossly normal with placement of correct Graphical Diffculties Stimulus Bound Conceptual Deficits Spatial/Planning Perseveration
Response Deficits
time
0 = incorrect
Hong Kong version as screening test in the elderly with low
educational levels (sensitivity 83%, specificity 79% ) (ref 2). It is a
2-part composite CDT with
Adapted from reference 3.
a. clock drawing scored with 0-10 points (Figure 2). Cut off points
3/4. 1. Graphical errors - hands and numbers imprecise and clumsy, but still appear
recognizable as a clock.
b. reading and setting the time on a toy clock.
Impaired fine motor control and planning from disrupted frontostriatal circuits in, e.g.,
vascular dementia
2. Stimulus-bound response errors - drawing is dominated by a single stimulus, usually
related to the time-setting instruction.
E.g., instructed to Set time to 11:10, patient fail to recode the 10 min into setting the
minute hand at 2.
3. Conceptual deficits - misrepresentations of the clock and time (e.g., does not look
like a clock, hands do not communicate a time, hands are absent, time written on
the clock). Impaired access to knowledge store of factual and conceptual knowledge,
i.e. semantic memory of meaning/features of a clock, a function of lateral temporal
lobes which is affected earlier in Alzheimers disease (AD) than vascular dementia (VaD),
Parkinsons disease dementia (PDD) or frontotemporal dementia (FTD).
4. Spatial and/or planning deficits - planning difficulties with irregular spacing between
numbers, left hemi-neglect, numbers written outside clock-face or counter-clockwise
direction. Impaired parietal lobe function, greater in PDD, DLB, VaD, AD than in FTD.
5. Perseveration - recurrence of activity without an appropriate stimulus, e.g., drawing
more than 2 hands, repeating same numbers, or writing more beyond 12. These errors
are common in AD and may be localized to the prefrontal area of the frontal lobe.
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Instructions :
6 Abnormal clock-face drawing with inaccurate time
Fill inside a pre-drawn circle of 2.5 diameter the numbers of a clock with arms
denotation (e.g. reversal of numbers, perseveration
indicating the 3 oclock position. beyond twelve, misplaced numbers, drawing only
to one side, omitting most numbers)
Scoring Criteria for Clock Drawing Test (CDT)
Score Criteria Example 7 A recognizable attempt to draw a clock face but
with no clear denotation of time
0 Correct denotation of time with normal spacing
(e.g. one arm omitted, circle the numbers or 2. Lam LCW, Chiu FK, Ng KO, Chan C, Chan WF, Li SW, Wong M. Clock-face drawing, reading and setting tests in the
screening of dementia in Chinese elderly adults. The Journal of Gerontology Series B: Psychological Sciences and
lines of clock face instead of drawing arms) Social Sciences 1998;53(6):353-7.
3. Eknoyan D, Hurley R, Taber K. The clock drawing task: Common errors and functional neuroanatomy. J
Neuropsychiatry Clin Neurosci 2012;24(5):260-5.
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Cautions
Do not make a diagnosis of dementia based on the MMSE score alone.
Remember the MMSE is only a screening test, and dementia is a very
serious, irreversible and devastating disease. The analogy is that we do
not make a diagnosis of cancer just based on a lung shadow on the
CXR. It could be a wrong score, it could be mild cognitive impairment or
depression, or even a noisy environment during the test.
Try not to make a diagnosis of dementia based on the MMSE performed
during or immediately after a hospitalization or acute illness. The
performance could be affected by physical discomfort, low mood,
medication effects, strange environment, and lost of contact with the
real, usual world.
The usual decline rate on the MMSE for AD patients in observational
studies (without treatment) in the West is 3-4 points per year. In Hong
Kong, however, the decline was noted to be slower, about 2 points
per year. This difference should be taken into consideration when drug
response is being considered.
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5 5 Serial 7 substraction [ ] 93 [ ] 86 [ ] 79 [ ] 72 [ ] 65
B 2B 2 starting at 100 4 or 5 correct subtractions : 3pt , 2 or 3 correct; 2pts, 1 correct; 1pt, 0 correct 0 pt _____ / 3
1 1
Begin Begin
LANGUAGE
D D 4 4
3 3 Repeat : I only know that John is the one to help today. [ ]
_____ / 2
C C The cat always hid under the couch when dogs were in the room. [ ]
[ ] [ ]
Fluency/ Name maximum number of words in one minute that begin with the letter F
[ ] (N 11 words) _____ / 1
Draw CLOCK (Ten past eleven) (3 points)
ABSTRACTION
Similarity between e.g. banana - orange = fruit [ ] train - bicycle [ ] watch ruler _____ / 2
DELAYED RECALL
Point for
Has to recall words FACE VELVET CHURCH DAISY RED
_____ / 5 UNCUED
Cotour [ ] Number [ ] Hands [ ] WITH NO CUE [ ] [ ] [ ] [ ] [ ] recall only
ORIENTATION
[ ] Date [ ] Month [ ] Year [ ] Day [ ] Place [ ] City _____ / 6
100 101
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[ ] 2 1 8 5 4
[ ] 7 4 2 _____ / 2
1
2
10 10
[ ] 5 2 1 3 7 4 1 1 8 0 6 2 1 5 1 7 4 5 1 1 1 4 1 7 0 5 1 1 2 _____ / 1
10 10 2 2
2
2 3
9
3
99
100 7 [ ] 93 [ ] 86 [ ] 79 [ ] 72 [ ] 65
4 34
1 9
_____ / 3
3
453232110
8
8 1 4
8 7
6 5 4
8 7 56 5 [ ]
7 6 _____ / 2
5
[ ] [ ] [ ]
7 6
3 [ ] N11 _____ / 1
= [ ] [ ] _____ / 2
[ ] [ ] [ ] _____ / 5
[ ] [ ] [ ] [ ] [ ]
_____ / 5
[ ] [ ] [ ] [ ] [ ] [ ] _____ / 6
61
[ ] [ ] [ ] _____ / 3
22
_____ / 30
Nasreddine MD
Hong Kong version 08 June 2010
5 Translated by Wong A and Mok V
www.mocatest.org
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3.
1. 1
1
1
1 1
2 3 10
1
1 2 3 4 5 6 7 8 9
10 10
0
2.
4.
1 1 (1) (2) (3)
0
104 105
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5.
1
1
7s
301
23
1007
79285
78716492
3
6. 7.
[]
[]
1
1247
106 107
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8. 10.
[] [60 ( )
]
1
601
9.
( )
1
=
=
=
=
108 109
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Nasreddine MD
Hong Kong version 08 June 2010
Translated by Wong A and Mok V
www.mocatest.org
110 111
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Two Successive Commands Following two-part verbal commands 2 Consonant Perseveration Say,gee-key-bee four times. 1
Single Command Following one-part verbal commands 4 Vowel Perseveration Say,boh-bah-bee four times. 1
Visual Matching Identifying visual designs 4 Graphomotor Design 2 Reproduction of semi circle 1
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Construction Memory
Item Task Points Item Task Points
Construction Design 1 Reproduction of vertical lines 1 Orientation Orientation to time, day, date and situation 9
Construction Design 2 Reproduction of diamond in box 1 Verbal Recall - Reading Recall of sentence presented orally 4
Construction Design 3 Reproduction of square and diamond 1 Verbal Recall - Recall of sentence that was generated by the
3
Sentence Invitiation client
Construction Design 4 Reproduction of diamond 1
Verbal Recognition Verbal forced-choice recognition memory 5
Construction Design 5 Reproduction of square 1
Visual Memory Visual forced-choice recognition memory 4
Construction Design 6 Reproduction of recognizable name/signature 1
25 (total)
6 (total)
Conceptualization
Item Task Points
Identities and Oddities Identifying similar and dissimilar 16
Identifying how objects are alike; abstract
Similarities 8
concept formation
Priming Inductive
Generating similar objects 3
Reasoning
Differences Identifying dissimilar verbal objects 3
Similarities - Multiple Identifying how objects are alike in a
8
Choice multiple-choice format
Verbal Recall - Sentence
Generate sentence using man and car 1
Initiation
39 (total)
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Practical Notes on Mattis Dementia Rating Scales The Chinese version of the Mattis Dementia Rating Scale (CDRS) has been
validated by The Chinese University of Hong Kong with cut-off scores to
Dementia Rating Scale (DRS) is an instrument developed to detect and
discriminate normal from AD patients. The optimal cut-off points for CDRS
characterize cognitive impairment. It consists of 36 tasks, measuring 5
subscales and total scores with sensitivities and specificities as follows:
cognitive domains:
Attention Sensitivity/
Cut-off scores
specificity (%)
Initiation/ Perseveration
Adjusted CDRS total* 141 85.0/91.6
Construction
CDRS total ( total =144) 112 80.0/91.6
Conceptualization Attention ( total = 37) 29 22.5/98.8
Memory Initiation/Perseveration ( total =37) 26 85.0/94.0
Construction (total= 6) 3 33.0/88.0
It has been validated for staging demented patients, such that it differentiates
normal controls from mildly demented patients and the mildly from moderately Conceptualization ( total=39) 28/29 65.0/79.5
demented Alzhemiers disease (AD) patients. Memory (total = 25) 18 82.5/92.7
The pattern of scores or the subtest score in the DRS has been found to * Adjusted CDRS total is the CDRS total score adjusted for age and educational level, which is calculated by raw CDRS
total + .421(age)-1.091(education)
be useful in differentiating AD patients from patients with other types of
dementia (e.g., Parkinsons disease dementia, dementia with Lewy bodies,
Huntingtons disease, and progressive supranuclear palsy).
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Impairment
No memory loss or slight inconsistent Consistent slight forgetfulness; partial Moderate memory loss; more Severe memory loss; only Severe memory loss; only
Memory forgetfulness recollection of events; benign marked for recent events; defect highly learned material retained; fragments remain
forgetfulness interferes with everyday activities new material rapidly lost
Fully oriente Fully oriented except for slight Moderate difficulty with time Severe difficult with time Oriented to person only
difficulty with time relationships relationships; oriented for place at relationships; usually
Orientation examination; may have geographic disoriented to time, often to
disorientation elsewhere place
Solves everyday problems & handles Slight impairment in solving problems, Moderate difficulty in handling Severely impaired in handling Unable to make judgments
Judgment
business & financial affairs well; judgment similarities, and differences problems, similanities, and problems, similarities, and or solve problems
& Problem good in relation to past performance differences; social judgment usually differences; soicial juddgment
Solving maintained usually impaired
Independent function at usual level in job, Slight impairment in these activities Unable to function independently No pretense of independent function outside home
shopping, volunteer and social groups at these activities although may
Community still be engaged in some; appears Appears well enough to be Appears too ill to be taken
Affairs normal to casual inspection taken to functions outside a to functions outside a family
family home home
Life at home, hobbies, and intellectual Life at home, hobbies, and intellectual Mild but definite impairment Only simply chores preserved; No significant function in
interests well maintained interests slightly impaired of function at home; more very restricted interests, poorly home
Home and
difficultchores abandoned; more maintained
Hobbies complicated hobbies and interests
abandoned
Fully capable of self-care Needs prompting Requires assistance in Requires much help with
Personal dressing, hygiene, keeping of personal care; frequent
care personal effects incontinence
* Score in each domain are combined to obtain a global CDR score range from 0 (normal) through 3 (severe dementia), which is based on the Washington University CDR - assignment algorithm
(https://www.alz.washington.edu/cdrnacc.html).
References
1. Morris JC. The Clinical Dementia Rating (CDR) : current version and scoring rules. Neurology 1993;43(11):2412-14.
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Practical notes on the CDR (Clinical Dementia Rating scale) 2.8 Functional assessment staging (FAST)
The CDR is often used in drug trials for staging of dementia and requires Stage 1
input from both the patient and the caregiver. It is very comprehensive
and captures deficits in orientation, ADL, IADL and social domains, in No cognitive decline. No subjective complaints of memory deficit. No memory
addition to that in memory. deficit evident on clinical interviews.
Free training for the CDR is available on the web at No objective evidence of memory deficit on clinical interview. No
http://alzheimer.wustl.edu/cdr/default.htm. objective deficits in employment or social situations. Appropriate
concern regarding symptoms.
Reference
1. Morris JC. The Clinical Dementia Rating (CDR) : current version and scoring rules. Neurology 1993;43(11):2412-14.
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Stage 5 (Early Dementia) B. obsessive symptoms, e.g., person may continually repeat simple
cleaning activities;
Moderately severe cognitive decline.
C. anxiety agitation, and even previously nonexistent violent behavior may
Patient can no longer survive without some assistance. Patient is unable
occur;
during interview to recall a major relevant aspect of their current lives, e.g.,
an address or telephone number of many years, the names of close family D. cognitive abulla, i.e., loss of willpower because an individual cannot
members (such as grandchildren), the name of the high school or college carry a thought long enough to determine a purposeful course of action.
from which they graduated. Frequently some disorientation to time (date,
day of week, season, etc.) or to place. An educated person may have Stage 7 (Late Dementia)
difficulty counting back from 40 by 4s or from 20 by 2s. Persons at this stage
retain knowledge of many major facts regarding themselves and others. They Very severe cognitive decline. All verbal abilities are lost.
invariably know their own names and generally know their spouses and Frequently there is no speech at all - only grunting. Incontinent of urine,
childrens names. They require no assistance with toileting and eating, but requires assistance toileting and feeding. Lose basic psychomotor skills,
may have some difficulty choosing the proper clothing to wear. e.g., ability to walk, sitting and head control. The brain appears to no longer
be able to tell the body what to do. Generalized and cortical neurologic signs
Stage 6 (Middle Dementia) and symptoms are frequently present.
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Reference
1. Reisberg B, Ferria SH, de Leon MJ, Crook T. The global deterioration scale for assessment of primary degenerative
dementia. Am J Psychiatry 1982;139:1136-9.
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*Answers in bold indicate depression. Score 1 point for each bolded answer. 2, 3, 4, 6, 8, 9, 10, 12, 14, 15
A total score of 0 to 5 is normal and a total score greater than 5 suggests depression. 1, 5, 7, 11, 13
8
Source : www.cuhk.edu.hk/med/shhcgg/healthyageing/dl/GDS.pdf
Reference Reference
1. Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS) : recent evidence and development of a shorter version. 1. Lee HCB, Chiu HFK, Kwok WY, Leung CM. Chinese Elderly and the GDS short form: a preliminary study. Clinical
Clin Gerontol 1986;5: 165-73. Gerontologist: The Journal of Aging and Mental Health 1993;14(2):37-42.
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17. SELF-DEPRECIATION
5. AGITATION
Self-blame, poor self esteem, feelings of failure
Restiessness, handwringing, hairpulling
18. PESSIMISM
6. RETARDATION
Anticipation of the worst
Slow movements, slow speech, slow reactions
19. MOOD CONGRUENT DELUSIONS
7. MULTIPLE PHYSICAL COMPLAINTS
delusions of poverty, illness, or loss
(Score 0 if Gi symptoms only)
8. LOSS OF INTEREST Each question is rated for severity with 0 point = absent, 1 points = mild or intermittent,
Less involved in usual activities (score only if change occurred acutely i.e.: in less than 1
2 points = severe, or A = unable to evaluate.
month)
Rating should be based on symptoms and signs occurring during the week prior to
C. PHYSICAL SIGNS interview.
9. APPETITE LOSS No score should be given if symptoms results from physical disability or illness.
Eating less than usual A total score >10 indicates probably major depressive episode and a total score >18
indicates definite major depression episode.
10. WEIGHT LOSS
(score 2 if greater than 5 lbs. in 1 month)
Reference
1. Alexopoulos GS, Abrams RC, Young RC, Shamoian CA. Cornell Scale for Depression in Dementia. Biol Psychiatry
1988;23(3):271-84.
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Undertake to wash himself/ herself or to take a bath or a shower. Undertake to prepare a light meal or snack for himself/ herself.
Undertake to brush his/ her teeth or care for his/ her dentures. Adequately plan a light meal or snack (ingredients, cookware).
Decide to care for his/ her hair (wash and comb). Prepare or cook a light meal or a snack safely.
Prepare the water. towels, and soap for washing, taking a bath or a shower. TELEPHONING
Wash and dry completely all parts of his/ her body safely. Attempt to telephone someone at a suitable time.
Brush his/ her teeth or care his/ her dentures appropriately. Find and dial a telephone number correctly.
Care for his/ her hair (wash and comb). Carry out an appropriate telephone conversation.
Choose appropriate clothing (with regard to the occassion, neatness, the weather and Undertake to go out (walk, visit, shop) at an appropriate time.
color combination).
Adequately organize an outing with respect to transportation, keys, destination,
Dress himself/ herself in the appropriate order (undergarments, pants/ dress, shoes). weather, necessary money, shopping list.
Dress himself/ herself completely. Go out and reach a familiar destination without getting lost.
Undress himself/ herself completely. Safely take the adequate mode of transportation (car, bus, taxi).
Use the toilet without accidents Show an interest in his/ her personal affairs such as his/ her finances and written
correspondence.
EATING
Organize his/ her finance to pay his/ her bills (cheques, bankbook, bills).
Decide that he/ she needs to eat.
Adequately organize his/ her corresspondence with respect to stationery, address,
Choose appropriate utensils and seasonings when eating. stamps.
Eat his/ her meals at a normal pace and with appropriate manners. Handle adequately his/ her money (make change).
134 135
SECTION 2
Assessment scales in neurocognitive disorders
Reference
The BI measures independency in 10 basic ADLs, and the Katz
1. Gelinas I, Gauthier L, McIntyre M, Gauthier S. Development of a functional measure for persons with Alzheimers measures independency in 6 basic ADLs.
disease: the disability assessment for dementia. Am J Occup Ther 1999;53:471-81.
136 137
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Assessment scales in neurocognitive disorders
The BI has a score ranging from 1-100, hence is more sensitive to 2.13 Neuropsychiatric inventory (NPI)
changes and is used more often in rehabilitation settings. The Katz
The NPI is one of the most frequently used tools in assessing behavioural
ranges only from 0-6, is less sensitive to changes, but is very simple
psychcological symptoms of dementia (BPSD). It addresses 12 symptoms
to use, and therefore more often used to assess stable nursing home
which varied from psychotic symptoms (hallucinations, delusions), mood
residents.
(anxiety, agitation/ aggression, depression, euphoria, apathy), to behavioural
The DAD measures not only whether the patient is able to perform an symptoms (irritability, disinhibition, aberrant motor behaviour, sleep and
activity, but also his/ her initiative to start an activity, without being nighttime behaviour, and eating problems).
prompted. For example, the DAD asks whether the patient decides to
The full NPI takes about 30 - 45 minutes to complete and is often used in
take a bath or wash her hair on her own, while the BI or Katz only ask
drug studies. In clinical practices however there is often not enough time for
whether she can bathe herself with or without assistance. The lack of
this. Neverthelss, the list of BPSDs in the NPI are very useful reminders for
initiation is a hallmark of dementia. In someone with dementia, being
clinicians during history taking in dementia care. As BPSDs are often highly
able to decide to take a bath without being reminded to is very different
related to caregiver stress, noting the type, severity and frequency of BPSDs,
from doing so only with prompting or coercing.
and the follow-up of their progress after treatment is important in relieving
The DAD addresses other problems common in dementia, e.g. caregiver burden, allowing the patient to be cared at home longer, or causing
judgement. It asks whether the patient can choose appropriate clothing less conflicts in institutions.
for the occasion or weather, in addition to being able to dress properly.
The BI and Katz only assess whether the patient can dress herself or
not. Judgment is an important area in dementia only addressed by the
DAD.
The DAD, being a scale for dementia patients, also addresses memory.
For example, it asks whether the patient can take down or convey
a telephone message. Memory is not assessed by the BI or Katz. In
fact none of the basic ADLs assessed by the BI or Katz required much
memory.
Reference
1. Cummings JL. The Neuropsychiatric Inventory: assessing psychopathology in dementia patients. Neurology
1997;48(Suppl 6): S10-6.
138 139
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Assessment scales in neurocognitive disorders
2.14 Zarit Burden Interview (ZBI) Practical notes on Zarit Burden Interview
Chinese Version of the Zarit Burden Interview The Zarit Burden Interview (ZBI) is a popular caregiver self-report measure
for use in clinical or community settings. It has been specially designed to
reflect the stresses experienced by the caregivers of demented patients.
It originated as a 29-item questionnaire but the revised version containing
22-item is more commonly used. This instrument covers areas of concern
1.
mostly mentioned by caregivers, including caregivers health, psychological
4 3 2 1 0
well-being, social life, finance, and the relationship between the caregiver
2. 4 3 2 1 0
and patient. Each item is a question which the caregiver is asked to endorse
3.
4 3 2 1 0 using a 5-point scale. Response options range from 0 (never) to 4 (nearly
always). It is scored by adding the numbered response of the individual
4. 4 3 2 1 0
items. The total score of the 22 items ranges from 0 to 88 with higher scores
5. 4 3 2 1 0
representing a higher level of caregiver burden. It is suggested that a score
6. 4 3 2 1 0 below 21 indicates little or no burden, 21-40 for mild to moderated burden,
7. 4 3 2 1 0 41-60 for moderate to severe burden, and 61-88 for severe burden. The
8. 4 3 2 1 0 Chinese version of ZBI was validated in Hong Kong in 2005. Overall, ZBI has
9. 4 3 2 1 0
been shown to be a valid and reliable instrument for measuring the burden
10.
of caregiver in studies.
4 3 2 1 0
11. 4 3 2 1 0
12. 4 3 2 1 0
13. 4 3 2 1 0
14.
4 3 2 1 0
15. 4 3 2 1 0
16. 4 3 2 1 0
17. 4 3 2 1 0
18. 4 3 2 1 0
19. . 4 3 2 1 0
20. 4 3 2 1 0 References
1. Zarit SH, Reever KE, Bach-Peterson J. Relatives of the impaired elderly: correlated of feelings of burden. Gerontologist
21. 4 3 2 1 0 1980;20(6):649-55.
22. 4 3 2 1 0 2. Rankin ED, Haut MW, Keefover RW, Franzen MD. The establishment of clinical cutoffs in measuring caregiver burden
in dementia. Gerontologist 1994;34(6):828-32.
/ 88 3. Chan TSF; Lam LCM; Chiu HFK (2005). Validation of the Chinese Version of the Zarit Burden Interview. Hong Kong
Journal Psychiatry 2005;15(1):9-13.
140 141
SECTION 3
Investigation
3.1 Neuroimaging
Indications for Neuroimaging in Dementia
When clinical diagnosis is in doubt, e.g., Alzheimers disease vs dementia
with Lewy bodies, depression vs pseudo-dementia
When organic disease is suspected, e.g., recent onset of signs and
symptoms, history of head injury, acute delirium
When result of neuroimaging affects clinical management
SECTION 3
Investigation
143
SECTION 3
Investigation
Baseline Investigation
Brain region Significance
CT brain (non-contrast) is enough to exclude most of the organic causes,
e.g., small vessel disease, hydrocephalus, infarctions and hemorrhage, Frontal lobes atrophy FTLD, FTD, non-specific atrophy
subdural collection and brain tumour AD (symmetrical),
Temporal lobes atrophy
Coronal and sagittal images should be requested to adequately assess FTD, PPA, CBD (asymmetrical)
pattern of atrophy, e.g. coronal images for hippocampus, sagittal images AD (symmetrical)
for brainstem Hippocampal atrophy
usually not significant in early FTD
MRI brain (non-contrast) is better than CT brain in terms of lesion AD and non-specific age related atrophy
Parietal lobes atrophy
characterization, and MRI is automatically performed in multi-planar less prominent in FTD
format.
Usually not prominent unless in moderate
Serial comparison is essential to find out the dominant lobar atrophy Occipital lobes atrophy or severe stage of dementia, if occurs in
in various dementias or minimal progression in age-related cerebral early stage, DLB is suspected
atrophy
Brainstem atrophy PSP, MSA
Corpus callosum
PPA, CBD
(Normal 5mm thick at post. Genus)
144 145
SECTION 3
Investigation
146 147
SECTION 3
Investigation
148 149
SECTION 3
Investigation
150 151
SECTION 3
Investigation
152 153
SECTION 3
Investigation
Use of CSF Biomarkers in B. Mild Cognitive Impairment (MCI) - Mainly for research purpose
A. AD dementia - To improve the diagnostic accuracy. 1. To establish the underlying aetiology for recruiting patients for new drug
trial
The accuracy of clinical diagnostic criteria for AD dementia is poor, such that
the clinical diagnosis is correct only 63% to 90% of the time. The accuracy is 2. To determine the likelihood of progression to AD dementia within a
even lower in early stages of the disease. The development and application of defined period
revised diagnostic criteria that include biomarkers will substantially improve
the diagnostic accuracy for AD dementia and other dementias. MCI criteria incorporate biomarkers to suggest the probability of AD aetiology
154 155
SECTION 4
Management
SECTION 4
observation of the person with dementia, e.g., wandering, agitation,
disinhibition, catastrophic reactions, complaining and negativism.
b. Specific psychological symptoms: Usually and mainly assessed
Management through interviews with persons with dementia and their relatives,
e.g., delusion, hallucination, misidentification, depression, apathy
and anxiety
Assessment / Intervention:
In the third edition of the Occupational Therapy Clinical Guideline for People
with Dementia (2011), some assessment tools for BPSD are recommended:
1. Chinese version of the Cohen-Mansfield Agitation Inventory (CMAI)
The CMAI was developed for use in assessing different agitated
behaviours in individuals with dementia in institutions or in the community.
The agitated behaviours include wandering, aggression, inappropriate
vocalization, sexual disinhibition and negativism. It takes 10-15 minutes
to administer.
2. Chinese version of the Neuropsychiatry Inventory (CNPI)
The CNPI is a brief interview assessing 10 domains: delusions,
hallucinations, dysphonia, anxiety, agitation/aggression, euphoria,
disinhibition, irritability/liability, apathy, and aberrant motor behaviour.
It may help to distinguish among different causes of dementia, record
severity and frequency separately. It takes 10 -15 minutes to administer.
157
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Management
3. Clifton Assessment Procedures of the Elderly (CAPE) Apart from the formal assessment tools, the TECH approach developed by
Sharon Kratiuk-wall (1996) is also recommended. It provides a systematic
The CAPE is used to evaluate the presence and severity of impairment
and structured way to determine the triggering factors of BPSD by asking 4
in mental and behavioural functioning. It comprises of two components:
key questions. Those questions are broken down into four headings: Task,
the Cognitive Assessment Scale (CAS) and the Behaviour Rating Scale
Environment, Communication and Health status, as follows:
(BRS). The CAS is consisted of 12 questions covering information/
orientation subtests. The BRS covers physical disability, apathy, Task Environmental Communication Health Status
communication difficulties and social disturbance. Higher scores
indicate a greater severity of behaviour problems. It takes 15-30 minutes Too many Provide safety Is there a need to: Is the behavior
to administer. choices? (limit and security? related to
ability to process (Physical and Focus on
information) emotional) the feelings Cognitive
underlying a deficit?
Task too Too much / too persons words?
complex? little stimulation? Aging e.g.
Reduce hearing,
Too many steps? Too much / too complexity of the sight, change
little space? communication? of sleeping
Difficulty in pattern?
recognition or Appear Place emphasis
familiarity? (e.g. unfamiliar? on non-verbal Medication?
object) communication?
Appear Fatigue?
Is the task reminiscent of Be calmer,
reminiscent of past unpleasant quieter, less Hunger or thirst?
past pleasant experience? demanding Constipation?
/ unpleasant
experiences? Optimum for Minimize Pain or
function? e.g. distraction? discomfort?
temperature,
lighting, seating
etc.
Structure
to allow
participation?
Provide cues for
activity?
Under each key question, not only the possible causes considered to be
triggers to the persons behaviour are analyzed, but a framework to tackle
the BPSD is also provided.
For both professional group therapy and individual therapy, it is generally
agreed that non-pharmacological interventions (NPIs) should be considered
158 159
SECTION 4
Management
as the first-line management of most BPSD. Although a number of NPIs Montessori materials consist of learning games suited to a patients abilities
(see table) are now available for persons with dementia, it should be noted and interests, examples are memory games, household utensils, books
that there are several areas of overlap between these therapies and, in and so on. The aim of the Montessori Method for dementia is to provide
fact, each approach is rarely used in isolation. Client-centered and tailored opportunities for the patient to enjoy life by engaging in daily roles, routines
therapy guided by the patients background, interests, cultural, religious and and activities of daily living that are created and presented based on his/her
life factors to the person with dementia are the most important concept in needs, strengths, skills, abilities and interests, and delivered in a supportive
treating ones BPSDs. environment purposefully and meaningfully. The rationale is that undesirable
behaviour would be significantly decreased when the patients unmeet needs
Categories for Non-Pharmacological Interventions for BPSD are met.
National and international guidelines often recommend NPIs as the first
Sensory Enhancement / Cognitive / emotion- line of treatment for BPSD. However, there is evidence that antipsychotic
Behavior Therapy
Relaxation oriented interventions
medications can also be used effectively when the BPSD poses significant
e.g. Massage and e.g. Reminiscence e.g. Differential risks of harm to the patient or others, or when the aggressive symptoms
touch Therapy reinforcement are persistent, recurrent or severe enough to cause significant suffering and
Music therapy Validation Therapy Stimulus control distress.
Snoezelen Habit training
Multisensory
Art therapy
Aroma therapy
e.g. Recreational e.g. Montessori e.g. Staff education 1. Lebowitz BD. Behavioral and Psychological Symptoms of Dementia: A Clinical and Research Update. International
Psychogeriatrics 2000;12(S1):19-21.
activities Methods for Staff support 2. Occupational Therapy Clinical Guideline for People with Dementia (Third Edition, April 2011), Working Group on
Outdoor walks dementia (MMD)TM
Training programs Psychogeriatrics of Coordinating Committee in Occupational Therapy, Hong Kong Hospital Authority.
Physical activities for family 3. Choy CNP, Lam LCW, Chan WC, Li SW, Chiu HFK. Agitation in Chinese elderly: validation of the Chinese version of
caregivers the Cohen-Mansfield Agitation Inventory. International Psychogeriatrics 2001;13(3):325-35.
4. Leung VPY, Lam LC, Chiu HF, Cummins JL, Chen QL. Validation study of the Chinese version of the neuropsychiatry
inventory (CNPI). International Journal of Geriatric Psychiatry 2001;16(8):789-93.
Environmental Social contact:
Cognitive therapy 5. Pattie AH, Gilleard CJ. Clifton assessment procedure for the elderly manual. Windsor: NFER Nelson, 1979.
Modifications Real or Simulated
6. Krattiuk-Wall S, Quirke S, Heal C, Shanley C. The TECH Approach to Dementia Care: a resource kit for people with
challenging behaviours in a residential care setting: task, environment, communication, health. Concord, N.S.W.:
e.g. Reality orientation e.g. Wandering areas e.g. Individual social Centre for Education and Research on Aging; 1996.
Natural / enhanced contact
7. British Columbia Minstry of Health. Best Practice Guideline for Accommodating and Managing Behavioral and
environments Pet therapy Psychological Symptoms of Dementia in Residential Care. 2011.
Reduced Simulated 8. Ballard CG, OBrien J, James I, Swann A. Dementia: management of behavioural and psychological symptoms.
Nordic Journal of Psychiatry 2003;57(2): 159-60.
stimulation interactions /
family videos 9. Lin LC, Yang MH, Kao CC, Wu SC, Tang SH, Lin JG. Using Acupressure and Montessori-based activities to decrease
Light therapy agitation for residents with dementia: a cross-over trial. Journal of the American Geriatrics Society 2009;57(6):1022-
29.
160 161
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Management
4.2 Treatment guideline and practical tips in using Rivastigmine (Exelon, Exelon Patch)
cholinesterase inhibitors and NMDA antagonist Oral rivastigmine is indicated for the treatment of mild to moderate dementia
Although patients and caregivers have high expectations of drug treatment of the Alzheimer type. Initial oral dosing recommendation is 1.5 mg twice a
for dementia, clinicians should always emphasize non-pharmacological day, with a maximum dose of 6mg twice a day (12mg/day). Rivastigmine is
measures to enhance the coping skills for patients and caregivers at all times a potent, selective inhibitor of brain AChE and butylcholinesterase (BuChE).
and through all stages of the disease. Rivastigmine is considered a pseudo-irreversible inhibitor of AChE. While
the precise mechanism of rivastigmines action is unknown, it is postulated
Cognitive enhancers on mild cognitive impairment (MCI) to exert its therapeutic effect by enhancing cholinergic function. This is
accomplished by increasing the concentration of acetylcholine through
It is not uncommon that physicians are asked by the families of MCI patients reversible inhibition of its hydrolysis by cholinesterase. The transdermal
to start these drugs, even though their safety and efficacy in this condition patches 4.6 mg/24 hours and 9.5 mg/ 24 hours are approved for mild to
is uncertain. A systemic review of randomized, placebo-controlled trials moderate AD patients. It has the advantage of causing less gastrointestinal
compared cholinesterase inhibitor or memantine in MCI using outcome side effect, better 24 hours drug profile and is easier to administer to patients.
measurements of cognition, function, behaviour, global status and mortality, Yet, mild dermatitis is not uncommon at the application sites of the patches.
found no significant effects of either on cognition or function. On the contrary, A reliable caregiver has to be committed to remove the old patch before a
higher rates of nausea, diarrhea, vomiting, and headache were observed in new patch is applied every 24 hours.
the treatment group compared with the placebo group.
Galantamine (Reminyl PRC)
Cognitive enhancers on Alzheimers disease dementia
Galantamine is indicated for the treatment of mild to moderate dementia
Cholinesterase inhibitors (ChEIs) are used to enhance the cholinergic function of the Alzheimer type. It enhances central cholinergic function by inhibiting
in Alzheimers disease (AD) patients. ChEIs (donepezil, rivastigmine, and AChE. The dosing recommendation for the immediate-release formulation
galantamine) inhibit acetylcholinesterase (AChE) (specific cholinesterase) at is 4 mg twice daily. The extended-release formulation is given at a dose of
the synapse 8 mg orally once daily. The maintenance dose after dose titration is 16-24
mg/day.
Donepezil (Aricept, Aricept Evess)
Donepezil has shown efficacy in patients with mild to moderate AD, as well Memantine (Ebixa)
as moderate to severe AD. It selectively inhibits AChE and improves the Memantine is the only drug on the market targeted for N -methyl-D-
availability of acetylcholine. Donepezils long half-life provides a long duration aspartate (NMDA) antagonism and has been approved by the US Food and
of drug availability for binding at the receptor sites. Dosing recommendations Drug Administration (FDA) for patients with moderate to severe AD dementia.
for mild to moderate AD are 5-10 mg orally once daily. Aricept Evess is Memantine is also recommended as an option for managing people with
an oral dispersible formula which is easier to administer to patients with moderate AD dementia who are intolerant of or have a contraindication to
swallowing problem. AChE inhibitors. The initial dose for the immediate-release formulation is 5
mg orally once daily, and it can be titrated to a maximum dose of 20 mg/day.
162 163
SECTION 4
Management
Drugs other than cognitive enhancers for Alzheimers disease of the Alzheimer Type) study, a randomized, double-blind trial comparing
dementia the 13.3 mg/24 hours dose patch with the lower 4.6 mg/24 hours dose.
The higher dose patch demonstrated statistically significant improvement in
AD patients who suffer from behavioural and psychological symptoms of
overall cognition and function in severe AD patients at week 24, as assessed
dementia (BPSD) and who fail non-drug treatment may need psychotropic
by measures of cognition and daily function using the Severe Impairment
medications. The BPSD of AD dementia including depression, agitation,
Battery (SIB) and the Alzheimers Disease Cooperative StudyActivities of
aggression, hallucinations, delusions, and sleep disorders, are frequently
Daily LivingSevere Impairment Version (ADCS-ADL-SIV), respectively.
treated with antidepressants, anxiolytics, antiepileptic drugs as mood
stabilizers, and neuroleptics.
In a recent study of once-daily donepezil 23 mg involving 1,467 randomized
When prescribing these drugs, clinicians should assess the individuals patients with moderate to severe AD dementia, a significantly greater
clinical profile and balance the possible benefits against risks of potential cognitive benefit compared with patients taking donepezil 10 mg/day
side effects. Most importantly, a reliable caregiver should be sought to was demonstrated on the SIB after 6 months of treatment. In this study,
monitor the symptoms and facilitate compliance to treatment as necessary. co-primary effectiveness measures were changes in cognition and global
functioning, as assessed using least squares mean changes from baseline
High dose cognitive enhancers for moderate to severe AD on the Severe Impairment Battery (SIB; cognition) and the Clinicians
dementia Interview-Based Impression of Change Plus Caregiver Input scale (CIBIC+;
global function rating) overall change score at week 24. Donepezil 23
In 2012, the US FDA approved a 13.3 mg/24 hours dosage strength of
mg/day was associated with greater benefits in cognition compared with
the rivastigmine transdermal system for patients with mild to moderate AD
donepezil 10 mg/day. Patients with more advanced AD appeared to benefit
dementia who are experiencing a decline in overall function and cognition.
from donepezil 23 mg/day on assessment of global functioning.
The approval of the higher dosage 13.3 mg/24 hours patch was based
on the findings from the 48-week double-blind OPTIMA study. Patients
However, clinicians should be vigilant of side effects in using high dose CEI.
treated with the 13.3 mg/24 hours dose experienced significantly improved
In particular, low body weight patients are commonly intolerant to high dose
overall function compared with those who received the 9.5 mg/24 hour
therapy. Slow and cautious upward titration to the conventional maximum
patch (P < .05), as measured by the Alzheimers Disease Cooperative Study
dose is recommended.
Instrumental Activities of Daily Living (ADCS-IADL) scale at week 48. In the
OPTIMA study , there was also improvement in cognition as measured by
the Alzheimers Disease Assessment Scale-Cognitive (ADAS-Cog) which
was significant at 24 weeks but not at 48 weeks.
164 165
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Management
Initiate treatment at a low dose and titrate upwards within the first 3 months
to the optimal dose. The latter is usually lower than the recommended
dose based on trials done in western populations. If one drug is ineffective,
some clinicians will switch to another class or another drug of the same
class. Despite not being evidence-based, it appears to be a fair approach.
Combination therapy (ChEI together with memantine) is used by some
clinicians but this has not been extensively investigated in clinical trials.
166 167
SECTION 5
Late stage dementia
SECTION 5 Very few early dementia patients would have considered how they would like
to spend the last year of their lives. Often patients and families are engrossed
in the loss of cognition and difficulties in daily activities in the earlier stages,
Late stage dementia without realizing that dementia and its complications lead to upto one-third
of deaths in developed countries. Being unaware and therefore unprepared,
many advanced dementia patients die with much suffering. In order to allow
family caregivers, and certain early patients, to have an informed choice of
end of life decisions, we must familiarize ourselves with some background
knowledge.
169
SECTION 5
Late stage dementia
170 171
SECTION 5
Late stage dementia
Feeding problems often herald the last stage of life in dementia. Common Choking, coughing Upright positioning, chin-down head position, smaller spoon,
symptoms are slow eating, choking or coughing on or after eating, noisy thickened fluids, minced or puree texture
breathing or wet voice, refusal to eat, or progressive weight loss. Eating
problems are often due to dysphagia which is a part of the neurodegenerative Wet voice Prompt to swallow or cough, gentle throat stroking, change
head position
process. Refusal to eat may be due to fear of choking with food, which
the patient cannot communicate to caregivers, or agnosia (when the Refuse eating Modify environment, reduce disturbance in surrounding,
patient cannot recognize food as food), or simply due to anxiety caused improve food appearance or taste, favourite foods, favourite
by unfamiliar surroundings or a change of caregivers. Tube feeding is often caregiver
used to manage feeding problems in advanced dementia. However, there
is little evidence to support that tube feeding can improve survival, prevent Poor appetite / Rule out pathology from mouth to anus (oral ulcers, poor
early satiety dental/oral hygiene, constipation), avoid over-sedation, reduce
aspiration pneumonia and prevent pressure ulcers. Yet there are ample
unnecessary medications (pill burden)
evidence that tube feeding is associated with increased use of restraints and
patient discomfort (including that due to force feeding such as abdominal Weight loss Keep finger foods or favourite snacks at hand, frequent small
bloating, and those due to the presence of the nasogastric tube, such high caloric-dense meals (forget about diet restrictions!)
as nasal / esophageal erosions, frequent tube replacement, reflux and
associated pneumonitis / pneumonia). [5]
172 173
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Late stage dementia
References
1. http://www.goldstandardsframework.org.uk/cd-content/uploads/files/General%20Files/Prognostic%20
Indicator%20Guidance%20October%202011.pdf; last accessed on 24 Dec 2013.
2. Mitchell SL, Teno JM, Kiely DK, Shaffer ML, Jones RN, Prigerson HG, et al. The clinical course of advanced dementia.
N Engl J Med 2009;361(16):1529-38.
3. Warden V, Hurley AC, Volicer L. Development and psychometric evaluation of the Pain Assessment in Advanced
Dementia (PAINAD) scale. J Am Med Dir Assoc 2003;4(1):9-15; available at http://www.amda.com/caring/may2004/
painad.htm
4. Snow AL, Weber JB, OMalley KJ, Cody M, Beck C, Bruera E, et al. NOPPAIN: a nursing assistant-administered pain
assessment instrument for use in dementia. Dement Geriatr Cogn Disord 2004;17(3):240-6.
5. Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia: a review of the evidence.
JAMA 1999;282(14):1365-70.
6. Edvardsson D, Winblad B, Sandman PO. Person-centred care of people with severe Alzheimers disease: current
status and ways forward. Lancet Neurol 2008;7(4):362-367.
174 175
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Late stage dementia
176 177
SECTION 6
First time assessment of neurocognitive disorder in older adults
SECTION 6 History (collect history from someone who knows the patient well)
Referral source
Main carer
First time assessment of Age and sex
Chief complaint
Cognitive deficits
Duration / onset / course / initial symptom (memory first or other cognitive
domain first)
Memory loss
Perceptual problems
Disorientation: time, place, person
Language (naming, speech and communication) difficulty
Executive function
Attention
179
SECTION 6
First time assessment of neurocognitive disorder in older adults
Drug history
Family history of neurocognitive disorder
180 181
SECTION 6
First time assessment of neurocognitive disorder in older adults
Investigations
Renal and liver function, complete blood picture
Blood Glucose, lipid profile
Thyroid function
Serum vitamin B12 and folate level
VDRL (optional)
Neuroimaging
ECG - note AF (vascular dementia) , long QT interval (neuroleptic treatment
precaution), bradycardia
Management
Social aspects
Prognosis information
Financial arrangement
Advance care planning
Enduring power of attorney
Community and Day care resource
Medical aspects
Vascular risk factors control
Non-pharmacological treatment (do not ignore this)
Pharmacological treatment (it may not be the most useful part)
Follow-up
182 183
ACKNOWLEDGEMENT