Assessment in general medicine

Let’s now look at an assessment that might be made by a family doctor of a subject who, let’s assume is 75 years old, in good health and perhaps showing the first signs of Alzheimer’s disease. In this patient, a general practitioner observes that blood pressure is normal, neurological gait examination is normal, reflex sensitivity is normal. The doctor will then have the patient describe recent events, explain what they did the day before. “What did you have for dinner the night before?” What did you do last weekend? What did you do on New Year’s Eve? etc.” And the doctor will realise that the patient struggles to retrieve information, and that’s very important, because as we said in the first capsule on memory disorders, that’s the ability to commit new information to memory. 

There is also a troubling paradox that people and their family say “But his memory is good, he can remember things that happened a long time ago. He even remembers the name of his primary school teacher.” “Yes, but can he remember what he had for dinner yesterday?” No, no. He doesn't remember that, but he remembers his wedding day.” “Yes, but does he remember what he did last weekend? etc.” Their memory worked properly in the past, so the patient has been able to store plenty of things in their memory bank. But are they capable of storing new information, transforming information that they see into new memories, are they able to make new memories? No, and that’s a sign of Alzheimer’s disease. Therefore, the attending physician should be more interested in finding out if the patient can recall recent events than things that happened a long time ago, because their memory worked in the past. Sleep is normal, they probably don’t have any regular treatment and their mood is normal. Great. 

The doctor will run some tests. In France, we choose to do a few different ones. The clock test is interesting. It takes three minutes, maybe a little more, and above all, it gives a fairly general idea about a certain number of cognitive functions: task planning, reconstruction of a graphic image, visual-spatial skills and motor execution. Depending on the stage, there are disruptions in the ability both to place the hour numbers and of course to place the clock hands as required to show 11:10, for example. There was another test developed known as the five-word test, which is interesting because it is used to check that information has been remembered, and that helps to eliminate an attention-related disorder. We saw this in the first capsule, because we are going to establish a connection between words and categories. We ask the subject to read a list of five words and we give the semantic category, building, then explain that museum is the name of the building. What is the name of the insect? Grasshopper. 

What is the name of the vehicle? Truck. etc. We then turn over the page and ask the patient to “recount the nouns”, and for the words that won’t come to mind spontaneously, the doctor gives clues. For example, “there was the name of a drink” “Ah yes, lemonade”. This is how we check that they have remembered correctly. That’s how to check the first step, that the information has been entered correctly. After ten minutes, we ask the person to recall the words. For those they cannot recall spontaneously, we provide the same clues which will help the person search for those words in their memory bank. And so we facilitate recollection in this way, and if the person can’t recall the words when given the clues, that means there is a storage disorder. 

That means there is a disease in the hippocampus. And it also means they may have Alzheimer’s. There is also the MMS that we talked about earlier, which is a score from 0 to 30. Everyone here probably has a score of around 30. In Alzheimer’s disease, the levels are between 20 and 30, which already suggest that there is a mild cognitive impairment. Between 10 and 20 it is more intense and below 10, it signals what we call severe dementia. 

Finally, the scale of activities of daily life, we covered this during the last capsule on psychobehavioural disorders. This is how to define the subject’s autonomy. This information gives insight into whether or not the subject can handle daily activities or if they need to be helped to use the telephone, to travel, to take medication, to manage their budget. This is when we approach the milestone of dementia. 

The subject can be described as having dementia. The patient has lost their autonomy. The general practitioner has tests to run to see if there are cognitive disorders, if there are memory disorders, if there are cognitive disorders with the MMS test and if there are disorders that impact daily activities. And if these cognitive disorders, unfortunately, make it possible to state that the patient has dementia. From there, the doctor will make a biological assessment which will be normal, because with Alzheimer’s disease there are no biological assessment disorders.

 There may be associated cardiovascular disorders because these patients are obviously older, and depending on the context, the doctor may make more specific requests. Finally, there will be a neuroimaging assessment, in particular an MRI. Because today’s MRI is a tool that not only eliminates another cause that may be responsible for cognitive disorders, for example minor strokes in the brain or a tumour, or normal pressure hydrocephalus, but above all, find positive arguments to support Alzheimer’s disease: the volume of the hippocampus. We’ve talked a lot about the hippocampus during these capsules. 

We have said that the hippocampus is weakened in very early Alzheimer’s disease and the arrows on the top right of the slide show what looks like a small ball, a small oval rugby ball. This is the volume of the hippocampus and we’re going to look at this volume. We see if it is if the hippocampus is well developed or if it is in fact slightly atrophied, as you can see on the previous images, which show that there is gradual atrophy as time goes by. You can see that here. As time goes on there is gradual atrophy of the hippocampus which is a marker for Alzheimer’s disease. 

Neuro reports and neuro radiology reports use the notion of Scheltens stage, Scheltens 1, Scheltens 2, Scheltens 3. 

This measures the degree of impairment caused by this hippocampal atrophy. That is what the general practitioner usually does. A clinical assessment, simple tests, a biological assessment which is usually normal, and then a neuroimaging examination, often an MRI, which allows us to focus on the volume of the hippocampus.