Diagnostic Interview for Dementia

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Diagnostic Interview for Dementia (DID)


Version 3.0 November 6, 2009

Dr. Michael Cooper Division of Geriatric Psychiatry Royal Jubilee Hospital

Introduction This is a modified form of the standard psychiatric interview, adapted for inidividuals with moderate to severe cognitive impairment. This interview would be appropriate for geriatric psychiatrists, psychiatry residents, and older adult mental health clinicians. It is too lengthy for use in family practice. I recommend starting off by interviewing the patient alone, then having the patient sit in the waiting room while you interview the relatives. In some cases the patient or family will insist on being together for the interview, or the patient's suspicions may be aroused by doing separate interviews. In this case, the patient must be interviewed along with the relatives.


1. Identifying Data

Ask about patient's current living situation - home, senior's living (apartment with meals provided), assisted living, etc. Include previous occupations, years of schooling and first language. Obtain baseline information regarding marital status, children, and location of children. (Keep in mind that patient's with moderate dementia will have difficulty with providing these details. You will have to confirm these details with a relative. If the patient is vague in responding to even basic questions regarding their place of residence, etc. then abandon this and go to the next part of the interview.

2. Patient Interview

a) General Questions

How are you? How is your health? Any problems?


b) Mood Assessment

Are you basically satisfied with you life? (In general… the way things are these days… over the past few weeks). How is your mood? Do you ever get down in the dumps or discouraged? Do you ever feel that life is not worth living? Do you ever have thoughts of taking your life? Would you ever act on these thoughts? Explore any grief and loss issues.

c) Anxiety

Do you have any worries or concerns these days? How are things going at home? Do you ever worry that things are going missing from your home? Do you worry that your home is being broken into or that things are being rearranged when you’re not around? Have you noticed anything strange or unusual recently such as people in your home who shouldn’t be there?

d) Physical Symptoms

How is your appetite these days? How about your energy? How are you sleeping?

e) Memory

How is your concentration? Do you enjoy reading? Do you ever have any trouble remembering what you have read? What book are you reading right now?ng? What do you like to read? How about keeping up with the news? Is there anything that you have noticed in the news recently? How is your memory these days? (Do you notice any problems with memory or forgetfulness?) How about remembering people’s names, keeping track of appointments, misplacing things, keeping up with appointments? Do you ever go to the store and forget what you wanted to buy? Are you still driving? Have you ever had difficulty finding your way, or got lost while driving?

May I do a memory test? Try your best with this. If you’re not sure of the answer just tell me and we will go on to the next question.

3. Mental Status Examination

Patient’s appearance and grooming. How is their hearing? Use of walking aide and mobility. Any abnormal movements? Are they able to provide a meaningful history. Any word finding problems. Any dysarthria? Any dysphasia? Objective mood. Range of affect. Patient’s subjective rating of mood. Note feelings of hopelessness and suicidal thinking. Any psychotic symptoms apparent?

MMSE, Clock Drawing and note awareness of recent events from above. If you suspect Fronto-temporal dementia, do the MOCA (Montreal Cognitive Assessment), and check for primitive reflexes, Luria Hand Sequence.


Luria Hand Sequence


"Can you do this?"

(Examiner models: a) slap, b) fist, c) cut - while patient imitates each step) "Now follow me." (Examiner begins to repeat sequence.) Once the patient appears to have mastered the task, have them demonstrate it. Ask the patient to "keep going" while the exainer stops. Count the number of successive cycles. Prompting is alowed at thirty seconds "are you sure you got it?" Terminate the procedure after one minute has elapsed.

Normal 4 cycles without error after examiner stops Borderline 4 cycles with additional verbal prompt ("Keep going") or modeling Abnormal Unsuccessful

Ask patient to leave room and invite caregiver in.

4. Caregiver Interview

a) Memory Questions What sort of concerns do you have with your relative? Does he have a problem with his memory or thinking? Does he repeat the same questions or same information over and over without realizing that he has just asked or told you this? How often does he know the date? How about keeping up with recent events or family events?

When did this seem to start? Thinking back, what was the first thing you noticed? Since this started, how has this problem been progressing? Has it gotten any worse over the past year or past few months?

Do his memory problems interfere with day-to-day activities?

b) Function How is he managing day to day things at home? How does he manage basic activities such as getting dressed? How about personal care such as bathing, grooming, brushing his teeth, (caring for dentures)? Does he need any assistance with bathing? How about choosing clothing that is appropriate?

Any problems with bladder or bowel control?

How about being able to make a meal or even snack? Can he use the telephone? Is he able to find and dial a telephone number correctly. How about answering the phone? Can he go out for walks on his own? Does he ever get lost? Can he use a bus or a taxi? Can he go to the store and purchase a few items? Does he need a list?

Is he still able to keep up with finances and banking? How about going to the store and purchasing items and making change?

Is he able to look after his own medications?

Is he able to help out around the house? Does he do some household chores? Can he stay safely at home on his own? How about any hobbies or interests?

c) Finances/Legal/Driving

Who is looking after the bills and banking? Is there a Power of attorney in place? Has it been activated? Does he cooperate with this? Are there any other financial issues such as concerns around the family home or wills? Is there a Health Care Representation Agreement? Are there any elder abuse or neglect issues? Are there signs of dysfunctional family dynamics?

Housing issues - is he in any danger of being evicted?

Note patient’s level of income. Does he have enough income to afford assisted living?

Is he still driving?

d) Psychiatric Symptoms How is his mood these days? Does he seem sad or tearful? Does he get irritable or angry, especially if you have to redirect or correct him? (Catastrophic reactions). Is he still interested in things and able to focus his attention? Does he still take part in family activities?

Does he get any ideas that things are being stolen or rearranged at home? Does he get worried about break-ins? Add does he believe that he is in danger or that others are planning to hurt him? Does he make jealous accusations or believe that his spouse is having an affair?

Does he ever get ideas that his home is not his home? Does he believe that unwelcome guests are living in the house? Does he believe that his wife is not who she claims to be?

Does he ever seem worried that he is going to be abandoned? Does he believe that television figures are actually present in the home? Does he try to talk or interact with them? Does he ever seem to be hearing voices or act if he is hearing voices? Does he carry on conversations with people who are not there?

Does he ever seem to see things that are not there - such as people, animals, strange lights?

Does he ever get agitated or restless? Does he get very anxious about upcoming appointments (Godot Syndrome)? How about rummaging around the house, packing and unpacking, and rearranging things? How about constantly dressing and undressing? Has he ever wandered away from home and become lost? Does he get angry outbursts? Verbal outbursts? Has he ever been physically threatening or struck out?


Does his confusion seem to vary over the course of the day? How about confusion or mood changes late in the afternoon or early evening - is he "sundowning?" Has there been any abrupt changes in his mental state, such as a stroke, or onset of acute confusion?

How is he eating? How is he sleeping?

In general how would you rate his ability to solve problems at the present time? How about handling a household emergency? Would he know to call 911? How about his judgement in general?

Does he seem to have any awareness that he is having memory problems? How cooperative is he with outside help?

Have you noticed a change in his personality? For example is he less considerate than he used to be or less understanding?

e) Other Causes of Dementia

i) Normal Pressure Hydrocephalus

Any problems with bowel or bladder control? When did the problem start? (Note: if it is likely due to frailty and difficulty making it to the bathroom in time, as opposed to true incontinence). Any change in balance? When did this start?

ii) Lewy Body Dementia

Does he ever see things that are not there? Visual hallucinations? How often does this occur? When did it seem to start? Does his mental alertness seem to vary from day to day or even from hour to hour? Does he seem to have periods where he becomes considerably more confused for a period of time then it clears? How about his walking, does he seem to be getting any stiffer or slower? How about falls?

iii) Fronto-temporal Dementia

Ask about problems with speech - decreased speech? When did it start? How about personality change - especially loss of sensitivity to the feelings of others? How about early signs of deterioration in personal care and grooming? Disinhibition or apathy? Repetitive behaviours? Change in eating habits? Abnormal sexual behaviour?

f) Caregiver Stress

How are you coping with all of this? How much of a burden is this becoming? What are the hardest things for you? How much of your time do you have to spend caring for him? How is this impacting your own marriage and family life?

g) Diagnosis

Have you talked to his family doctor about what the problem might be? What do you think might be the cause of his memory problems? Have you worried about Alzheimer disease? Have you met with the Alzheimer Society or caregiver support group?

There are a few other things that I need to go over with you and your relative before I can come to any conclusions. I would like to meet with both of you together now. At the end of the interview I would like to talk about the diagnosis. There are several possible causes for memory problems such as stroke, other medical problems and finally the possibility of Alzheimer disease.

How do you feel about having this discussion with your relative? How do you feel about possibly talking about Alzheimer disease with your relative?

At this point, ask the patient to come back in.

5. Current Medications

Name of pharmacy. Are medications being blisterpacked? Compliance? Drug allergies? Adverse reactions?

Review medication list for potential interactions or medications that are likely to exacerbate memory problems.

6. Current Services

Do you keep track of your own medications? Is there a spouse or caregiver keeping an eye on the medications? How about home care nursing? Housekeeping services? Home support services? Meals on Wheels? Adult daycare? Is Seniors Mental Health Outreach Program involved? Is he eligible for assistance from Veterans Affairs Canada?


7. Past Medical History

Inquire about tobacco use, alcohol use.

8. Past Psychiatric History

Note any family history of senility.

9. Review Available Laboratory Data

Canadian Consensus Conference on Dementia (CMAJ 1999) For most patients who have a clinical presentation consistent with AD with typical cognitive symptoms or presentation,only the following basic set of laboratory tests should be ordered: complete blood count; and measurement of thyroid stimulating hormone,serum electrolytes,serum calcium and serum glucose levels. [Grade B,Level 3,consensus 3,30 ] (Note: I always order creatinine, urea, B12, and urinalysis)

Optional Additional Tests that might be useful to diagnose specific causes of Dementia:

Ammonia Blood Drug levels Erythrocyte sedimentation rate Folic acid Heavy metal levels Serum cortisol Serum lipids Urea nitrogen/creatinine Liver function tests Vitamin B 12 Water soluble vitamins Carotid Doppler studies Chest radiography Electrocardiography Electroencephalography Lumbar puncture Mammography Serologic tests for syphilis Tests for the human immunodeficiency virus

A cranial CT scan is recommended if 1 or more of the following criteria are present: a.age less than 60 years b.rapid (e.g.,over 1 to 2 months)unexplained decline in cognition or function c.“short ” duration of dementia ((less than 2 years) d.recent and significant head trauma e.unexplained neurologic symptoms (e.g.,new onset of severe headache or seizures) f.history of cancer (especially in sites and types that metastasize to the brain) g.use of anticoagulants or history of a bleeding disorder h.history of urinary incontinence and gait disorder early in the course of dementia (as may be found in normal pressure hydrocephalus) i.any new localizing sign (e.g.,hemiparesis or a Babinski reflex) j.unusual or atypical cognitive symptoms or presenta- tion (e.g.,progressive aphasia) k.gait disturbance [Grade B,Level 2-ii,consen- sus 3,29,31 ]


10. Diagnostic Impression

Disclosing the Diagnosis to the Patient (Canadian Consensus Conference, 1999): "Although each case should be considered individually, in general the diagnosis of a dementing condition should be disclosed to the patient and family.This process should include a discussion of prognosis,diagnostic uncertainty,advance planning,treatment options,support groups and future plans.Exceptions to disclosing prognosis to the patient could be severe dementia where understanding of the diagnosis is unlikely, phobia about the diagnosis or severe depression." [Grade B,Level 3,consensus 65 ]


I am concerned that you are having some trouble with your short-term memory. Recalling recent events and information seems to be a bit of a difficulty. There are several possible causes for this. It could simply be age-related memory loss, although I am concerned that your memory problems seem a bit worse than I would like to see. We want to be sure that you haven’t had a stroke or circulation problems. We may need to get a brain scan to check this out further. There are also a number of medical problems that can cause medical problems. Finally, if we are not able to find a specific cause for your memory problems the concern is that it might be the start of Alzheimer disease.

When it comes to Alzheimer disease, we have no way of knowing for sure. I would like to repeat the memory testing from time to time That is our best way of trying to get an understanding of this problem and seeing if it is getting any worse.

We are fortunate to have some treatments available now for memory problems. These medications can boost your memory or at least slow down the progression. We don’t have a cure yet but I think this is the best option we have. Generally these medications are quite safe, although some people get stomach upset and cannot take them. The biggest problem is that there are not covered on Pharmacare in BC and the cost is around $170.00 a month. What I usually recommend is for people to try samples for a few months and see how it works out. They you can decide whether or not you want to pay for the treatment. There is always the hope that Pharmacare might consider coverage (Veterans Affairs Canada will provide coverage).

Probably about 50 to 60% of people benefit from these medications. In these cases, the medication seems to slow down the progression. Sometimes we see a slight improvement - recalling recent information may be a little easier or less frustration in day to day activities. Some people feel more mentally alert with these medications and can do things around the home that they were finding had become too difficult. These benefits will last for several years, however, if you stop the medication, then the benefits will stop.

We have covered quite a lot of information, any questions so far? How do you feel about what we have been talking about?

Would you like to try one of these memory medications?

Review other psychiatric treatments that may be required: -antidepressant -antipsychotic -hs sedative.

Do you think you would like some more information about this problem? The Alzheimer Society is a good source of information for memory problems in general. They also have some excellent counseling sessions available.

I am also concerned about keeping track of your medications. With all of the medications that you are taking, it is very important for your family doctor and me to know that you are taking your medications properly. I would really like to have one of our nurses come in and check on this for you. I also recommend a blister pack for all of your pills. I can set that up at the pharmacy for you if you are in agreement.

I know your relative is concerned about how you are managing at home. How do you feel about having someone from the Health Unit visit you and provide some additional assistance? We are fortunate in Victoria to have some excellent services available for seniors, why not take advantage of this? For example, some people find the Memory Plus Program at Silver Threads to be very helpful. There are some other excellent day programs to consider.

In the near future, the Alzheimer Society will be offering the "First Link" program. With your permission, may I give them your name and phone number. They will contact you and give you some helpful information. (There is a "prescription pad" to make this referral)

Driving Issue - if patient is still driving and MMSE is less than 24: Finally, we have to discuss driving. One of the tests I did today is part of the Driver's Medical Exam. The Motor Vehicle Branch requires that you pass this test in order to continue driving. Unfortunately you did not pass this test today, and I have to advise you to stop driving. I am sure that you are doing just fine driving on familiar routes, but I am concerned that would not be able to react quickly enough in an emergency. I am sure you would agree that you would never want to be the cause of an accident, even a minor one. I am sorry, but I have no choice but to advise you stop driving completely.

Any other questions before we finish up today?

I would like to see you in a couple of months to see how this is working out for you.


Bibliography

Many of the questions in this interview are taken from research tools such as the following:

Neuropsychiatric Interview Clinical Dementia Rating Scale (CDR) Zarit Caregiver Burden Scale Geriatric Depression Scale EXIT Interview for Frontal Lobe Function DAD Canadian Consensus Conference on Dementia (CMAJ, 1999)