Evaluation of dementia

activities of daily living intact, functional activities preserved with minimal impairment particularly on complex instrumental activities of daily living[84]Feldman HH, Jacova C, Mild cognitive impairment, Am J Geriatr Psychiatry. 2005 Aug;13(8):645-55. http://www.ncbi.nlm.nih.gov/pubmed/16085780?tool=bestpractice.com

Folstein MMSE score <24

rapid onset, short duration, disturbance of consciousness that often waxes and wanes between agitation and lethargy, hallucinations, visual illusions, possible history of infection, metabolic disturbance, or pharmacologic toxicity[29]Burns A, Gallagley A, Byrne J. Delirium. J Neurol Neurosurg Psychiatry. 2004 Mar;75(3):362-7. http://www.ncbi.nlm.nih.gov/pubmed/14966146?tool=bestpractice.com [85]Ross GW, Bowen JD. The diagnosis and differential diagnosis of dementia. Med Clin N Am. 2002 May;86(3):455-76. http://www.ncbi.nlm.nih.gov/pubmed/12168555?tool=bestpractice.com

fever, tachycardia, blood pressure changes, fluctuating level of cognitive impairment at different hours of the day, inattention, disorganized thinking, low oxygen saturation[29]Burns A, Gallagley A, Byrne J. Delirium. J Neurol Neurosurg Psychiatry. 2004 Mar;75(3):362-7. http://www.ncbi.nlm.nih.gov/pubmed/14966146?tool=bestpractice.com [41]Fleming KC, Adams AC, Petersen RC. Dementia: diagnosis and evaluation. Mayo Clin Proc. 1995 Nov;70(11):1093-107. http://www.ncbi.nlm.nih.gov/pubmed/7475341?tool=bestpractice.com

persistent dysphoric mood, anhedonia (loss of interest in usual activities), impaired recall with relative sparing of recognition memory, poor concentration, sleep and appetite disturbances, energy loss, psychomotor retardation, feelings of worthlessness and guilt, recurrent thoughts of death[65]Huff FJ, Belle SH, Shim YK, et al. Prevalence and prognostic value of neurologic abnormalities in Alzheimer's disease. Dementia. 1990;1:32-40.

suicidal ideation, problems with attention, concentration, and recent memory

insidious onset, slow progression, memory loss (affecting recent memory first), disorientation in time and place (may manifest as misplacing items or getting lost), difficulty naming objects or people (proper names and low-frequency words decline first); social withdrawal, paranoia, anxiety[40]APA Work Group on Alzheimer's Disease and other Dementias, Rabins PV, Blacker D, Rovner BW, et al. American Psychiatric Association practice guideline for the treatment of patients with Alzheimer's disease and other dementias, second edition. Am J Psychiatry. 2007 Dec;164(12 Suppl):5-56. http://www.ncbi.nlm.nih.gov/pubmed/18340692?tool=bestpractice.com [67]Oppenheim G. The earliest signs of Alzheimer's disease. J Geriatr Psychiatry Neurol. 1994 Apr-Jun;7(2):116-20. http://www.ncbi.nlm.nih.gov/pubmed/8204188?tool=bestpractice.com

may be normal, especially in early disease; primitive reflexes may be present, rigidity, bradykinesia, abnormal speech and posture; cognitive deficit on screening test[64]Merello M, Sabe L, Teson A, et al. Extrapyramidalism in Alzheimer's disease: prevalence, psychiatric, and neuropsychological correlates. J Neurol Neurosurg Psychiatry. 1994 Dec;57(12):1503-9. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1073233/pdf/jnnpsyc00042-0059.pdf http://www.ncbi.nlm.nih.gov/pubmed/7798981?tool=bestpractice.com [65]Huff FJ, Belle SH, Shim YK, et al. Prevalence and prognostic value of neurologic abnormalities in Alzheimer's disease. Dementia. 1990;1:32-40.

abrupt or stepwise change, gradual cognitive decline after one or more cerebrovascular events (e.g., ischemic hemorrhagic strokes), may be incontinent, depression, delusions, may have transient neurologic symptoms (e.g., hemiparesis, aphasia, or sensory deficits)[41]Fleming KC, Adams AC, Petersen RC. Dementia: diagnosis and evaluation. Mayo Clin Proc. 1995 Nov;70(11):1093-107. http://www.ncbi.nlm.nih.gov/pubmed/7475341?tool=bestpractice.com [68]Cummings JL, Miller B, Hill MA, et al. Neuropsychiatric aspects of multi-infarct dementia and dementia of the Alzheimer type. Arch Neurol. 1987 Apr;44(4):389-93. http://www.ncbi.nlm.nih.gov/pubmed/3827694?tool=bestpractice.com

may have hemiparesis, asymmetric deep tendon reflexes, unilateral extensor plantar response, visual field deficits, gait abnormalities, hypertension, dysrhythmias (e.g., atrial fibrillation), carotid bruits, congestive heart failure, diabetes, emotional incontinence (excessive mood lability); cognitive decline on screening test[68]Cummings JL, Miller B, Hill MA, et al. Neuropsychiatric aspects of multi-infarct dementia and dementia of the Alzheimer type. Arch Neurol. 1987 Apr;44(4):389-93. http://www.ncbi.nlm.nih.gov/pubmed/3827694?tool=bestpractice.com

history of fluctuating cognitive performance, episodes of incoherent speech, variable attention (e.g., well-formed visual hallucinations unrelated to dopaminergic therapy), history of parkinsonism emerging simultaneously with cognitive impairment[85]Ross GW, Bowen JD. The diagnosis and differential diagnosis of dementia. Med Clin N Am. 2002 May;86(3):455-76. http://www.ncbi.nlm.nih.gov/pubmed/12168555?tool=bestpractice.com

muscle rigidity, stooped posture, cog-wheeling, well-formed visual hallucinations, and cognitive fluctuations

possible history of alcohol misuse, encephalitis, or head trauma, isolated memory loss without apparent cause[86]Cummings JL. Amnesia, paramnesia, and confabulation. Clinical neuropsychiatry. Orlando, FL: Grune and Stratton; 1985;36-47.[87]Bowen J, Teri L, Kukull W, et al. Progression to dementia in patients with isolated memory loss. Lancet. 1997;349:763-5. http://www.ncbi.nlm.nih.gov/pubmed/9074575?tool=bestpractice.com

memory impairment; language and visuospatial ability normal[88]Kopelman MD. Disorders of memory. Brain. 2002 Oct;125(Pt 10):2152-90. http://brain.oxfordjournals.org/content/125/10/2152.full http://www.ncbi.nlm.nih.gov/pubmed/12244076?tool=bestpractice.com

acute onset (hours/days), history of transient ischemic attack or stroke

inability to comprehend instructions, repeat words or phrases, or to read, sparse verbal output (lesion of dominant hemisphere), fluent verbal output with word substitutions/paraphasias and impaired comprehension (lesion in Wernicke area), anomia (Alzheimer disease or frontal lobe degenerative dementia)[89]Benson DF. Aphasia, alexia, and agraphia. New York, NY: Churchill Livingstone; 1979.[90]Ross GW, Cummings JL, Benson DF. Speech and language alterations in dementia syndromes: characteristics and treatment. Aphasiology. 1990;4:339-52.

disinhibition, impulsiveness, social inappropriateness, apathy, withdrawal

disinhibition, lack of executive function, passivity[98]Lindau M, Almkvist O, Kushi J, et al. First symptoms - frontotemporal dementia versus Alzheimer's disease. Dement Geriatr Cogn Disord. 2000 Sep-Oct;11(5):286-93. http://www.ncbi.nlm.nih.gov/pubmed/10940680?tool=bestpractice.com

shaking, stiffness, slowness or poverty of movement, anxiety, apathy, falls, hypersomnolence, bowel and bladder dysfunction[99]Clarke CE. Parkinson's disease. BMJ. 2007 Sep 1;335(7617):441-5. http://www.ncbi.nlm.nih.gov/pubmed/17762036?tool=bestpractice.com

tremor at rest, rigidity on passive movement, bradykinesia (slowness of movement), poverty of movement (hypokinesia), orthostatic hypotension, and postural instability[99]Clarke CE. Parkinson's disease. BMJ. 2007 Sep 1;335(7617):441-5. http://www.ncbi.nlm.nih.gov/pubmed/17762036?tool=bestpractice.com

progressive involuntary movements, neuropsychiatric disturbances, cognitive impairments (e.g., executive function, immediate memory)[100]Montoya A, Price BH, Menear M, et al. Brain imaging and cognitive dysfunctions in Huntington's disease. J Psychiatry Neurosci. 2006 Jan;31(1):21-9. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1325063 http://www.ncbi.nlm.nih.gov/pubmed/16496032?tool=bestpractice.com

involuntary movements, executive function deficits, deficits in visuospatial abilities, short-term and long-term memory deficits[100]Montoya A, Price BH, Menear M, et al. Brain imaging and cognitive dysfunctions in Huntington's disease. J Psychiatry Neurosci. 2006 Jan;31(1):21-9. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1325063 http://www.ncbi.nlm.nih.gov/pubmed/16496032?tool=bestpractice.com

seizures, headache, mental state changes, hemiparesis[101]DeAngelis LM. Brain tumors. N Engl J Med. 2001 Jan 11;344(2):114-23. http://www.ncbi.nlm.nih.gov/pubmed/11150363?tool=bestpractice.com

visual field deficits, hemiparesis, aphasia[101]DeAngelis LM. Brain tumors. N Engl J Med. 2001 Jan 11;344(2):114-23. http://www.ncbi.nlm.nih.gov/pubmed/11150363?tool=bestpractice.com

sudden onset of central weight gain, oligomenorrhea or amenorrhea, spontaneous ecchymoses, florid complexion, difficulty climbing stairs or rising from a low chair, depression[102]Orth DN. Cushing's syndrome [published correction appears in N Engl J Med. 1995;332:1527]. N Engl J Med. 1995 Mar 23;332(12):791-803. http://www.ncbi.nlm.nih.gov/pubmed/7862184?tool=bestpractice.com

thickening of facial fat (moon facies), facial telangiectasias, enlarged dorsocervical fat pad (buffalo hump), hypertension, violaceous striae on the abdomen or proximal extremities, acne, mild hirsutism, central fat deposition[102]Orth DN. Cushing's syndrome [published correction appears in N Engl J Med. 1995;332:1527]. N Engl J Med. 1995 Mar 23;332(12):791-803. http://www.ncbi.nlm.nih.gov/pubmed/7862184?tool=bestpractice.com

energy loss, muscle weakness, decreased sweating, anorexia, weight loss or weight gain, abdominal pain, reduction in amount of axillary and pubic hair in women, erectile dysfunction, oligomenorrhea/amenorrhea, breast atrophy, loss of libido, infertility, cold intolerance, dry skin, polyuria, polydipsia, nocturia[103]Prabhakar VK, Shalet SM. Aetiology, diagnosis and management of hypopituitarism in adult life. Postgrad Med J. 2006 Apr;82(966):259-66. http://www.ncbi.nlm.nih.gov/pubmed/16597813?tool=bestpractice.com

may have increased central adiposity, dry skin, reduced muscle mass and strength, visual field defects, circulatory collapse if acute presentation[103]Prabhakar VK, Shalet SM. Aetiology, diagnosis and management of hypopituitarism in adult life. Postgrad Med J. 2006 Apr;82(966):259-66. http://www.ncbi.nlm.nih.gov/pubmed/16597813?tool=bestpractice.com

fatigue, lethargy, muscle weakness, depression, cognitive impairment, recurrent kidney stones, mental state changes, abdominal pain[104]Suliburk JW, Perrier ND. Primary hyperparathyroidism. Oncologist. 2007 Jun;12(6):644-53. http://theoncologist.alphamedpress.org/cgi/content/full/12/6/644 http://www.ncbi.nlm.nih.gov/pubmed/17602056?tool=bestpractice.com

proximal muscle weakness[104]Suliburk JW, Perrier ND. Primary hyperparathyroidism. Oncologist. 2007 Jun;12(6):644-53. http://theoncologist.alphamedpress.org/cgi/content/full/12/6/644 http://www.ncbi.nlm.nih.gov/pubmed/17602056?tool=bestpractice.com

severe abdominal pain, muscular weakness, constipation, nausea, vomiting, psychiatric disturbances, dark urine, chest pain, back pain, history of exposure to barbiturates, estrogens, sulfonamides, phenytoin, chloramphenicol, tetracyclines, antihistamines, emotional or physical stress, premenstrual, alcohol, smoking[105]Thadani H, Deacon A, Peters T. Diagnosis and management of porphyria. BMJ. 2000 Jun 17;320(7250):1647-51. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1127427 http://www.ncbi.nlm.nih.gov/pubmed/10856069?tool=bestpractice.com

sensory neuropathy, peripheral motor neuropathy, absent reflexes, hypertension, coma[105]Thadani H, Deacon A, Peters T. Diagnosis and management of porphyria. BMJ. 2000 Jun 17;320(7250):1647-51. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1127427 http://www.ncbi.nlm.nih.gov/pubmed/10856069?tool=bestpractice.com

fatigue, cold intolerance, dry skin, hoarse voice, constipation, weight gain, depression, muscle weakness

dry skin, muscle weakness, bradycardia

weight loss, heat intolerance, restlessness, anxiety, diarrhea, bulging eyes, hand tremor

exophthalmos, clammy skin, tachycardia, goiter, high blood pressure

family history of liver and neurologic disease;[106]Ryder SD, Beckingham IJ. ABC of diseases of liver pancreas and biliary system. Other causes of parenchymal liver disease. BMJ. 2001 Feb 3;322(7281):290-2. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1119531 http://www.ncbi.nlm.nih.gov/pubmed/11157536?tool=bestpractice.com neurologic and psychiatric presentation includes: tremor, involuntary movements, dystonia, bizarre behavior, emotional lability, depression, personality changes, psychosis, dysarthria, drooling, seizures, migraine headaches, pseudobulbar palsy[107]Roberts EA, Schilsky ML. A practice guideline on Wilson disease. Hepatology. 2003 Jun;37(6):1475-92. http://onlinelibrary.wiley.com/doi/10.1053/jhep.2003.50252/pdf http://www.ncbi.nlm.nih.gov/pubmed/12774027?tool=bestpractice.com

Kaiser-Fleischer rings, tremor, dystonia, rigidity, dysarthria, drooling[107]Roberts EA, Schilsky ML. A practice guideline on Wilson disease. Hepatology. 2003 Jun;37(6):1475-92. http://onlinelibrary.wiley.com/doi/10.1053/jhep.2003.50252/pdf http://www.ncbi.nlm.nih.gov/pubmed/12774027?tool=bestpractice.com

paresthesias, memory loss, gait disturbances; presence of risk factors: age >65 years, history of gastrectomy or gastric bypass, vegan or strict vegetarian diet, chronic gastrointestinal illness, use of proton-pump inhibitors, H2 receptor antagonists, metformin, anticonvulsants

ataxia, peripheral neuropathy, decreased vibration sense, positive Romberg test, atrophic glossitis, angular cheilitis

history of head injury, headache, lethargy, loss of consciousness after head injury (subdural hematoma)

altered level of consciousness, slurred speech, hemiparesis (subdural hematoma)

history of tick bite and rash[108]French P. Syphilis. BMJ. 2007 Jan 20;334(7585):143-7. http://www.ncbi.nlm.nih.gov/pubmed/17235095?tool=bestpractice.com

erythema migrans, arthritis, facial palsy, peripheral neuropathy[108]French P. Syphilis. BMJ. 2007 Jan 20;334(7585):143-7. http://www.ncbi.nlm.nih.gov/pubmed/17235095?tool=bestpractice.com [109]Spach DH, Liles WC, Campbell GL, et al. Tick-borne diseases in the United States. N Engl J Med. 1993 Sep 23;329(13):936-47. http://www.ncbi.nlm.nih.gov/pubmed/8361509?tool=bestpractice.com

history of tuberculosis (TB) contact, cough, weight loss, and night sweats in addition to symptoms of meningitis

may be concomitant signs of TB pneumonia, pleural effusion, in addition to signs of meningitis​

maculopapular rash, ataxia, personality changes, headaches, impaired memory[108]French P. Syphilis. BMJ. 2007 Jan 20;334(7585):143-7. http://www.ncbi.nlm.nih.gov/pubmed/17235095?tool=bestpractice.com

Argyll Robertson pupils, absent limb reflexes, Romberg positive, loss of vibration and position sense[23]Ropper AH. Neurosyphilis. N Engl J Med. 2019 Oct 3;381(14):1358-1363. https://www.doi.org/10.1056/NEJMra1906228 http://www.ncbi.nlm.nih.gov/pubmed/31577877?tool=bestpractice.com [108]French P. Syphilis. BMJ. 2007 Jan 20;334(7585):143-7. http://www.ncbi.nlm.nih.gov/pubmed/17235095?tool=bestpractice.com [109]Spach DH, Liles WC, Campbell GL, et al. Tick-borne diseases in the United States. N Engl J Med. 1993 Sep 23;329(13):936-47. http://www.ncbi.nlm.nih.gov/pubmed/8361509?tool=bestpractice.com

fatigue, fever, arthralgia, photosensitivity, Raynaud phenomenon[120]Carsons S. A review and update of Sjogren's syndrome: manifestations, diagnosis and treatment. Am J Manag Care. 2001 Sep;7(14 Suppl):S433-43. http://www.ncbi.nlm.nih.gov/pubmed/11605978?tool=bestpractice.com [121]Brennan MT, Sankar V, Leakan RA, at al. Risk factors for positive minor salivary gland biopsy findings in Sjogren's syndrome and dry mouth patients. Arthritis Rheum. 2002 Apr 15;47(2):189-95. http://www.ncbi.nlm.nih.gov/pubmed/11954013?tool=bestpractice.com [122]Newman LS, Rose CS, Maier LA. Sarcoidosis [published correction appears in N Engl J Med. 1997;337:139]. N Engl J Med. 1997 Apr 24;336(17):1224-34. http://www.ncbi.nlm.nih.gov/pubmed/9110911?tool=bestpractice.com

arthritis, butterfly rash, hepatomegaly, splenomegaly, cranial neuropathies, peripheral neuropathy[120]Carsons S. A review and update of Sjogren's syndrome: manifestations, diagnosis and treatment. Am J Manag Care. 2001 Sep;7(14 Suppl):S433-43. http://www.ncbi.nlm.nih.gov/pubmed/11605978?tool=bestpractice.com [121]Brennan MT, Sankar V, Leakan RA, at al. Risk factors for positive minor salivary gland biopsy findings in Sjogren's syndrome and dry mouth patients. Arthritis Rheum. 2002 Apr 15;47(2):189-95. http://www.ncbi.nlm.nih.gov/pubmed/11954013?tool=bestpractice.com [122]Newman LS, Rose CS, Maier LA. Sarcoidosis [published correction appears in N Engl J Med. 1997;337:139]. N Engl J Med. 1997 Apr 24;336(17):1224-34. http://www.ncbi.nlm.nih.gov/pubmed/9110911?tool=bestpractice.com

dry eyes, dry mouth, blurred vision, difficulty swallowing food[120]Carsons S. A review and update of Sjogren's syndrome: manifestations, diagnosis and treatment. Am J Manag Care. 2001 Sep;7(14 Suppl):S433-43. http://www.ncbi.nlm.nih.gov/pubmed/11605978?tool=bestpractice.com [121]Brennan MT, Sankar V, Leakan RA, at al. Risk factors for positive minor salivary gland biopsy findings in Sjogren's syndrome and dry mouth patients. Arthritis Rheum. 2002 Apr 15;47(2):189-95. http://www.ncbi.nlm.nih.gov/pubmed/11954013?tool=bestpractice.com [122]Newman LS, Rose CS, Maier LA. Sarcoidosis [published correction appears in N Engl J Med. 1997;337:139]. N Engl J Med. 1997 Apr 24;336(17):1224-34. http://www.ncbi.nlm.nih.gov/pubmed/9110911?tool=bestpractice.com

conjunctivitis, angular cheilitis, parotid and/or submandibular gland enlargement, distal polyneuropathy[120]Carsons S. A review and update of Sjogren's syndrome: manifestations, diagnosis and treatment. Am J Manag Care. 2001 Sep;7(14 Suppl):S433-43. http://www.ncbi.nlm.nih.gov/pubmed/11605978?tool=bestpractice.com [121]Brennan MT, Sankar V, Leakan RA, at al. Risk factors for positive minor salivary gland biopsy findings in Sjogren's syndrome and dry mouth patients. Arthritis Rheum. 2002 Apr 15;47(2):189-95. http://www.ncbi.nlm.nih.gov/pubmed/11954013?tool=bestpractice.com [122]Newman LS, Rose CS, Maier LA. Sarcoidosis [published correction appears in N Engl J Med. 1997;337:139]. N Engl J Med. 1997 Apr 24;336(17):1224-34. http://www.ncbi.nlm.nih.gov/pubmed/9110911?tool=bestpractice.com

dyspnea on exertion, chest pain, fatigue, anorexia, weight loss, and fever[120]Carsons S. A review and update of Sjogren's syndrome: manifestations, diagnosis and treatment. Am J Manag Care. 2001 Sep;7(14 Suppl):S433-43. http://www.ncbi.nlm.nih.gov/pubmed/11605978?tool=bestpractice.com [121]Brennan MT, Sankar V, Leakan RA, at al. Risk factors for positive minor salivary gland biopsy findings in Sjogren's syndrome and dry mouth patients. Arthritis Rheum. 2002 Apr 15;47(2):189-95. http://www.ncbi.nlm.nih.gov/pubmed/11954013?tool=bestpractice.com [122]Newman LS, Rose CS, Maier LA. Sarcoidosis [published correction appears in N Engl J Med. 1997;337:139]. N Engl J Med. 1997 Apr 24;336(17):1224-34. http://www.ncbi.nlm.nih.gov/pubmed/9110911?tool=bestpractice.com

erythema nodosum and polyarthralgias[120]Carsons S. A review and update of Sjogren's syndrome: manifestations, diagnosis and treatment. Am J Manag Care. 2001 Sep;7(14 Suppl):S433-43. http://www.ncbi.nlm.nih.gov/pubmed/11605978?tool=bestpractice.com [121]Brennan MT, Sankar V, Leakan RA, at al. Risk factors for positive minor salivary gland biopsy findings in Sjogren's syndrome and dry mouth patients. Arthritis Rheum. 2002 Apr 15;47(2):189-95. http://www.ncbi.nlm.nih.gov/pubmed/11954013?tool=bestpractice.com [122]Newman LS, Rose CS, Maier LA. Sarcoidosis [published correction appears in N Engl J Med. 1997;337:139]. N Engl J Med. 1997 Apr 24;336(17):1224-34. http://www.ncbi.nlm.nih.gov/pubmed/9110911?tool=bestpractice.com

history of antihistamine use, history of anticholinergic use (e.g., irritable bowel syndrome); some evidence that androgen deprivation therapy may be associated with an increased risk of dementia, but this remains controversial and further investigation is required.[28]Jayadevappa R, Chhatre S, Malkowicz SB, et al. Association Between Androgen Deprivation Therapy Use and Diagnosis of Dementia in Men With Prostate Cancer. JAMA Netw Open. 2019 Jul 3;2(7):e196562. https://www.doi.org/10.1001/jamanetworkopen.2019.6562 http://www.ncbi.nlm.nih.gov/pubmed/31268539?tool=bestpractice.com

may have chronic urticaria (requiring antihistamines)

ingestion of alcohol, exposure to heavy metals (e.g., arsenic, lead, mercury, carbon monoxide, and cyanide)

tremor, hepatomegaly, gynecomastia (in alcohol misuse), abdominal pain, mood disorder (in lead poisoning)

headache, balance disturbances, urinary incontinence

unstable gait, slow movement, wide-based stance

rapidly progressive dementia, characterized by memory loss, personality changes, and hallucinations

visual impairment, speech impairment, development of akinetic mutism, myoclonus, ataxia, and seizures