Diagnosis and assessment

If you, or someone you are close to, have been feeling confused, agitated or forgetful, it may be a good idea to visit the GP. If you are concerned about someone else, you may like to suggest that you accompany them on the visit.

It is possible that these symptoms are an indication of dementia. This term describes a group of symptoms caused by the physical impact of disease or injury on the brain. There are a number of different conditions that lead to dementia, including Alzheimer's disease, vascular disease (including stroke) and dementia with Lewy bodies.

Each person will experience dementia in his or her own individual way, but there will usually be: a decline in memory, reasoning and communication skills a gradual loss of the skills needed to carry out daily activities confusion.

For more information about dementia, see the range of factsheets available from Alzheimer's Society, including Factsheet 400, What is dementia?, 401, What is Alzheimer's disease?, 402, What is vascular dementia?, 403, What is dementia with Lewy bodies? and 404, What is frontotemporal dementia (including Pick's disease)?. Why get a diagnosis?

A proper diagnosis of dementia is essential, in order to: rule out other conditions that may have symptoms similar to dementia and that may be treatable, including depression, chest and urinary infections, severe constipation, vitamin and thyroid deficiencies and brain tumours rule out other possible causes of confusion, such as poor sight or hearing; emotional changes and upsets, such as moving or bereavement; or the side-effects of certain drugs or combinations of drugs access advice, information and support (emotional, practical and financial) from social services, voluntary agencies and support groups allow the person with dementia to plan and make arrangements for the future.

As drugs for treating different conditions become available, it is becoming increasingly important to identify which type of dementia the person has. For example, drugs are already available to treat some people with Alzheimer's disease and some people with dementia with Lewy bodies, but these drugs are ineffective in the treatment of Pick's disease (another form of dementia), and may actually worsen symptoms. See Factsheet 407, Drug treatments for Alzheimer's disease. Making a diagnosis

Making a diagnosis of dementia is often difficult particularly in the early stages. A definite diagnosis of the cause may only be confirmed after death, at post mortem or, in very rare instances, through a brain biopsy.

The time it takes to make a diagnosis can vary. If scans and other investigations are required, it could be 4-12 weeks, depending on waiting lists. If the person is in the early stages of dementia, a 6-12 month period of monitoring may be required before a diagnosis can be made. Step 1: Assessment by a GP

If you are concerned that you, or someone you are close to, may have dementia, the first person to consult is the GP. You may see the GP in their surgery or they may prefer to make a home visit. If dementia is suspected, it is often easier to assess and observe the person's behaviour in the home. It then becomes clearer exactly what the problems are. The GP will assess the person through: Analysis of background information You can expect the GP to spend some time talking to you and (if you are simply accompanying someone) the person you are concerned about, to try to establish some of the symptoms. The GP will look at the person's medical history and that of other family members. Physical examinations and tests The GP will normally carry out a physical examination and may perform a number of tests, such as blood and urine tests, to identify other conditions that may be causing confusion. Mental tests The GP may ask a series of questions designed to test thinking and memory.

The GP will have access to some services, such as community nursing. If there is a probable diagnosis of dementia, or the person is having trouble managing, the GP can refer them to the social services.

At the end of the assessment, the GP should communicate their findings in an appropriate way and discuss what action needs to be taken. They may feel able to make a diagnosis, or they may wish for further assessment to make sure. In some cases they may want to refer the person to a memory clinic or other specialist service for a fuller assessment. Step 2: Referral to a specialist

The GP is the usual person to make a referral to a specialist. If you feel that a referral would be helpful and the GP does not suggest it, do press for it. You are entitled to ask for a referral to a memory clinic or other specialist service for a second opinion or for support, and access to services that such a referral may give. A consultant will have more specialised knowledge and experience of dementia than the GP, and will have access to more specialised investigations, such as brain scans and memory testing.

Your GP will make the referral to a consultant in a particular specialty. The specialty may depend on the age of the person concerned, their symptoms and what is available in your particular area. The main types of consultant are as follows: Neurologists specialise in disorders of the brain and nerve pathways. Some neurologists have particular experience in diagnosing dementia. Specialists in medicine for older people (sometimes called geriatricians) specialise in the physical illnesses and disabilities associated with old age and in the care of older people. If the person being diagnosed has reached retirement age they may be referred to one of these specialists to see whether their symptoms are due to a physical illness, or to find out whether they are suffering from a physical illness as well as dementia. General adult psychiatrists specialise in diagnosing and treating a wide range of mental health problems. A younger person may be referred to a psychiatrist to assist in the diagnosis. Old age psychiatrists are psychiatrists who have further specialised in the mental health problems of older people, including dementia. They may sometimes also offer support to younger people with dementia.

The consultant usually works within a specialist team alongside a number of fully qualified doctors at various stages of further training in that particular speciality. Although you may not always see the consultant in person, he or she is ultimately responsible for your case and will discuss it with the doctor concerned. The consultant also usually works with other professionals, including nurses, psychologists, occupational therapists and social workers. Each of these members contributes their own knowledge, skills and advice to the team. Step 3: Assessment

Assessment may take place in the home, in an outpatients department, in a day hospital over several weeks or, very occasionally, as a hospital inpatient. The specialist will carry out their assessment through: Analysis of background information As with the GP, an assessment is likely to include time spent talking to the person being diagnosed and those close to them. Physical examinations and tests A physical examination and/or tests will be undertaken, if they have not already been carried out by the GP. Memory assessment - The person being diagnosed may see a clinical psychologist or neuropsychologist for a more detailed assessment of memory and other thinking processes. This consists of a range of 'pen and paper' type tests and questions that will look at things like memory, verbal and non-verbal abilities. These tests can be very good at helping to decide the type of problem a person may have, particularly in the early stages. The assessment can be used as a baseline to measure any changes over time which can also help with making a diagnosis. Scans The person might be given a brain scan. A brain scan can identify conditions such as strokes, brain tumour and hydrocephalus (a build-up of fluid inside the brain). There are several types of brain scan: CT or CAT (computerised axial tomography) scans are a way of taking pictures of the brain using X-rays and a computer MRI (magnetic resonance imaging) scans also use a computer to create an image of the brain but, instead of X-rays, they use radio signals produced by the body in response to the effects of a very strong magnet contained within the scanner.

 SPECT (single photon emission computerised tomography) scans look at the blood flow through the brain, rather than at the structure of the brain.

After the assessment, the consultant will send a report to the GP. CT and MRI scans may show brain shrinkage (atrophy), while SPECT and PET scans show areas of loss of function. Memory tests can also show problems in particular areas. The pattern of these changes helps to diagnose the cause of the dementia. A scan that shows no unexpected changes in the brain does not rule out conditions such as Alzheimer's disease because in the early stages of the disease the changes can be difficult to distinguish from normal ageing. The consultant may discuss their findings or may refer the person back to the GP for this information. In some cases the consultant may wish to see the person again after some months to observe any changes before making a diagnosis. Tips: Getting the most from a consultation

Whether you are attending the appointment for yourself or for someone you are supporting, it may be useful to do the following: Write down any questions or worrying signs beforehand to ask the GP or specialist. It can be difficult to remember everything you want to say during a consultation. Write down any important points the doctor makes during the consultation. Ask a doctor, or any other professional, to explain words or phrases if you do not understand. Ask a doctor to write down any medical terms, particularly if English is not your first language. Step 4: Explaining the diagnosis

Doctors may differ in their views on what to tell their patients about a diagnosis of dementia. The person with dementia has the right to be told their diagnosis particularly if this gives them the opportunity to put their affairs in order. However, in some circumstances a professional may feel that: they should only offer the diagnosis of dementia if the patient asks, or seems to want to know the knowledge that they have dementia will be too much for the person to cope with it is better to use a term such as 'memory problems' if this may be more easily understood or seems more appropriate.

Most doctors will inform those close to the person concerned of the diagnosis of dementia or possible dementia. In some cases it may be left to the relatives or friends to decide whether to tell the person that they have dementia. This will depend on the kind of relationship they have with the person, and what they feel the person would want to know.

If you feel that the doctor is avoiding the issue, don't hesitate to ask for an explanation. Step 5: Ongoing assessment

Once the diagnosis is confirmed, the GP should arrange to see the person with dementia from time to time to assess changes and discuss any problems. He or she may refer the person with dementia to a specialist for help in assessing changes, and for advice on ways to deal with specific difficulties. The GP is also responsible for the general health of the person with dementia.

The GP and a hospital specialist will usually jointly prescribe any treatment for dementia. The arrangement will depend upon the person's situation, where they live, and what medication they are already taking.

If you or someone you are close to is diagnosed with dementia, don't be afraid to seek help from your GP, or from local support groups, if you feel you need it. For information about where to get support and further advice once a diagnosis has been made, see Factsheet 471, After a diagnosis.

For details of Alzheimer's Society services in your area, visit alzheimers.org.uk/localinfo For information about a wide range of dementia-related topics, visit alzheimers.org.uk/factsheets Factsheet 426

Last updated: February 2011 Last reviewed: December 2010

Reviewed by: Dr Yvonne McCulloch, Neuropsychologist, Imperial College Healthcare Trust http://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=260

What should I do if I'm worried about memory loss or possible Alzheimer's?

If you are concerned about changes in memory and thinking or changes in senses, behavior, mood, or movement that do not seem normal in yourself or a family member (see Symptoms for more information), talk with a doctor. A doctor can administer a brief memory screening test that can help detect problems, and can also do a complete exam to find out if a physical or mental health issue is causing the problem.

How is Alzheimers disease diagnosed?

A definitive diagnosis of Alzheimers disease can be made only through autopsy after death, by linking clinical measures with an examination of brain tissue. However, doctors have several methods and tools to help them determine fairly accurately whether a person who is having memory problems has possible Alzheimers disease (symptoms may be due to another cause), probable Alzheimers disease (no other cause for the symptoms can be found), or some other problem.

To diagnose Alzheimers, doctors may: ask questions about overall health, past medical problems, ability to carry out daily activities, and changes in behavior and personality conduct tests of memory, problem solving, attention, counting, and language carry out standard medical tests, such as blood and urine tests, to identify other possible causes of the problem perform brain scans, such as computed tomography (CT) or magnetic resonance imaging (MRI), to distinguish Alzheimers from other possible causes for symptoms

These tests may be repeated to give doctors information about how the persons health and memory are changing over time. Tests can also help diagnose other causes of memory problems, such as mild cognitive impairment and vascular dementia.

For more information, see Understanding Memory Loss.

What are options for further assessment and diagnosis?

If a primary care doctor suspects mild cognitive impairment or possible Alzheimers, he or she may refer you to a specialist who can provide a detailed diagnosis, or you may decide to go to a specialist for further assessment. You can find specialists through memory clinics and centers or through local organizations or referral services. Specialists include: Geriatricians, who manage health care in older adults. They know how the body changes as it ages and whether symptoms indicate a serious problem. Geriatric psychiatrists, who specialize in the mental and emotional problems of older adults and can assess memory and thinking problems Neurologists, who specialize in abnormalities of the brain and central nervous system and can conduct and review brain scans Neuropsychologists, who can conduct tests of memory and thinking

Memory clinics and centers, including Alzheimers Disease Research Centers, offer teams of specialists who work together to diagnose the problem. Tests often are done at the clinic or center, which can speed up diagnosis.

You may also want to get a second opinion. Diagnosis of memory and thinking problems can be challenging. Subtle signs and symptoms may be overlooked or unclear. Getting a second opinion helps confirm the diagnosis. Most doctors understand the benefit of a second opinion and will share your records if you permit. A specialist can refer you to another doctor for a second opinion, or you may decide to find one yourself. What are the benefits of early diagnosis?

Early, accurate diagnosis is beneficial for several reasons. Beginning treatment early on in the disease process can help preserve function for some time, even though the underlying Alzheimers process cannot be changed.

Having an early diagnosis helps people with Alzheimer's and their families: plan for the future make living arrangements

take care of financial and legal matters develop support networks

In addition, an early diagnosis can provide greater opportunities for people with Alzheimers disease to get involved in clinical trials. Clinical trials are research studies in which scientists test the safety, side effects, or effectiveness of a medication or other intervention.

To learn more about Alzheimer's disease clinical trials, see Participating in Alzheimer's Disease Clinical Trials and Studies Fact Sheet or go to the Alzheimer's Disease Clinical Trials Database. What new methods for diagnosing Alzheimers disease are being studied?

Scientists are exploring ways to help physicians diagnose Alzheimers disease earlier and more accurately. The ultimate goal is a reliable, valid, and inexpensive diagnostic test that can be used in any doctors office.

Some studies focus on changes in personality and mental functioning, measured through memory and recall tests, which might point to early Alzheimers or predict whether individuals are at higher risk of developing the disease. Other studies are examining the relationship between early damage to brain tissue and outward clinical signs.

Another very promising area of diagnostic research is the analysis of body fluidsblood and cerebrospinal fluidto look for the proteins tau and beta-amyloid which are commonly found in people with Alzheimers. In addition, scientists have developed sophisticated imaging systems that may help measure the earliest changes in brain function or structure to identify people in the very first stages of Alzheimerswell before they develop obvious signs or symptoms. Learn more

For more information on the new developments in diagnostic research for Alzheimers disease, see the section in Alzheimers Disease: Unraveling the Mystery, "New Techniques Help in Diagnosing AD."

For information on new changes to the way Alzheimer's disease is diagnosed, see "Alzheimer's diagnostic guidelines updated for first time in decades" and related FAQs about the new diagnostic guidelines.

You can also watch a video about changes in the diagnostic guidelines: http://www.nia.nih.gov/alzheimers/topics/diagnosis