Dementia. Dementia (or Major Neurocognitive Disorder) is a syndrome characterized by a

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1 Dementia Definition Dementia (or Major Neurocognitive Disorder) is a syndrome characterized by a significant decline from a person s prior baseline in one or more cognitive domainscomplex attention, executive function, learning and memory, perceptual motor or social cognition. The deficits must be severe enough to interfere with the person s independence in daily life. Dementia is different from delirium, which is an acute disturbance in consciousness with fluctuating level of severity. In general, delirium is a short-term condition whereas the deficits of dementia are permanent and in many dementing processes, worsen over time. Epidemiology Dementia is a syndrome caused by multiple discrete entities. Alzheimer s dementia accounts for 50-80% of dementing illnesses in the United States. Dementia with mixed etiologies (i.e. features of both vascular and Alzheimer s) account for 10-20% of cases. Vascular Dementia, Frontotemporal dementias and Lewy Body Dementia account for the majority of the remaining cases. Age is the strongest risk factor for dementia. Roughly 5% of U.S. adults aged 65 to 74, 20% of those aged 75 to 84 and 45% of those 85 years and over have dementia. Other risk factors include apolipoprotein E status, hypertension, diabetes mellitus, low educational attainment and low levels of physical activity.

2 Burden of Disease Dementia is associated with a host of complications including self-neglect, depression, agitation, malnutrition, caregiver burden, institutionalization, mortality and increased health care costs. Diagnosis Dementia, particularly in its early stages, is often not recognized. Studies have shown that 29-76% of cases of dementia are not diagnosed by primary care physicians. DSM-5 Criteria for Major Neurocognitive Disorder A. Evidence of significant cognitive decline from a previous level of 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 significant decline in cognitive function; and 2. A substantial impairment in cognitive performance, preferably documented by standardized neuropsychological testing or, in its absence, another quantified clinical assessment. B. The cognitive deficits interfere with independence in everyday activities (i.e., at a minimum, requiring assistance with complex instrumental activities of daily living such as paying bills or managing medications). 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). There are multiple brief screening instruments for diagnosing dementia including the Mini Mental Status Exam, the Mini-Cognitive Assessment and the Memory Impairment

3 Screen (MIS). The following pages detail how to perform the picture version of the Memory Impairment Screen (PMIS). The last page contains information on how to perform two supplementary tests: Category Fluency Test (Shopping List and Timed Naming), a test of semantic memory and the Oral Trails B Test, a test of executive function.

4 Picture Memory Impairment Screen (PMIS) Overview: The "Picture Memory Impairment Screen" (PMIS) is a SCREENING tool to identify individuals who may require further evaluation for possible Alzheimer's disease or other dementias. Four pictures from different categories are learned by identifying each item when its category cue is presented. Memory is tested by free recall after a 2-3 minute delay with interference. If any items are not retrieved by free recall, the category cues for those items are provided to elicit cued recall of those items. Instructions: Controlled Learning: Tell the subject: "Here is a sheet with 4 pictures for you to learn and remember. Each picture belongs to a different category. Please say what you see in each picture out loud to me." Check each correct picture in the NAME column on the response sheet. Tell the subject: "To help you learn, I will tell you the category cue for each picture and ask you to tell me the picture that goes with each category cue. When I read each category cue to you, tell me which one of these words goes with that category cue." Read each category cue aloud to the subject. Pace acquisition rate that is comfortable for the subject. Check correct answers in the IDENTIFY column on the response sheet, which lists the pictures and their category cues in the order that they are to be identified. If the response to a category cue is not correct, tell the subject, repeat that cue, and ask the subject to give another response. Remove the study sheet when all four pictures have been identified and tell the subject, "Later, I will ask you to recall the words." Interference before recall: Two to three minutes of interference is needed to prevent rehearsal and in order to test recall from secondary memory. Repeated counting from one to twenty and back is useful to provide interference before recall. Ask the subject to: "Count up from one to twenty." Record the time. "Now count down from twenty to one." Repeat two more times. Ask the subject to stop after two minutes of counting. Although counting was used as interference in the research development of the PMIS, in principle, other kinds of interference may be used. For instance, in the validation study for PMIS participants who could not count numbers were instead administered an activities of daily living questionnaire. Free Recall: Elicit Free Recall by asking the subject to: "Tell me as many of the 4 pictures as you can remember, in any order." Allow 20 seconds for Free Recall of all four pictures. Stop if no more pictures have been recalled for 10 seconds. Record Free Recall on the response sheet by entering a check for each picture that was retrieved by free recall. If a record of recall order is desired, enter "1" for the first picture recalled, "2" for the second picture recalled, etc.

5 Cued Recall: Immediately after concluding Free Recall, elicit Cued Recall of any pictures that were not retrieved by Free Recall. For each picture that was not retrieved by Free Recall, read the appropriate category cue to the subject in the order shown on the response sheet, and ask the subject to recall the picture that was learned with that cue: for example, "What was the Game?" Test Cued Recall only for pictures that were not retrieved by Free Recall. Allow 5 seconds for recall of each word cued. Record Cued Recall on the response sheet by entering a check for each word that was retrieved by Cued Recall. pmis Score= (2 x # Pictures Free Recall) + ( 1 x # Pictures Cued Recall) Total Score=8 Score 5 is impaired Sensitivity 95% Specificity 99% Validated for use in a low education population Verghese, J Am Geriatr Soc, 2012

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7 Supplementary Tests Category Fluency Tests: A): Shopping List: Score: Instructions: Ask the patient to name as many different items that you can find or buy in a supermarket in one minute. Record the number. If the patient stops, you can encourage him or her you still have time, what else can you find? Scoring: Normal 13 different items in one minute. All repetitions should be noted. More than 2 are a sign of perseveration. B): Timed Naming (animals, vegetables, fruits) Score: Instructions: Ask the patient to name as many different animals [or vegetables or fruits] in one minute as they can. Record the number. Scoring: Normal = 15+/- 2 per minute without cuing. Executive Function Test: Oral Trails B Test Instructions: Part A- Ask the patient to count from 1 to 25. Part B- Ask the patient to recite the alphabet from A to M. Then the patient is asked to pair numbers and letters in sequence: 1-A, 2-B, continuing up to 13-M. Scoring: More than two errors in 13 number-letter pairings indicates possible impairment.