What will your doctor do?

The previous chapter ended with the advice that, if you are worried about your own mental function or are concerned that someone close to you is developing signs of becoming demented, you should consult your GP right away. Here we explain how your doctor is likely to approach the problem, following Ralph and Lydia’s story as an example. This will help you to be prepared for the questions that you will be asked. We also describe briefly some of the tests that your doctor may feel are necessary and explain the reason for doing them.

THE MEDICAL HISTORY

Let us imagine that Lydia has persuaded Ralph to consult his doctor. They make an appointment to see his GP, Dr Elizabeth Garrett, and Lydia is going with her husband. To make a diagnosis Dr Garrett will need a detailed account of what has been happening to Ralph over the past months. Since Ralph is often rather muddled, it will be up to Lydia to provide reliable information. Although people often think that doctors make their diagnoses from the results of scientific tests like X-rays or laboratory blood tests, the first and most crucial step is actually obtaining a clear description of the illness from the patient or a reliable witness. Tests come later and are used to confirm the doctor’s clinical judgement or to help distinguish between a small number of possible causes of the illness. Lydia’s story of the changes that have occurred in Ralph will be the first and most important clue in finding out what is wrong. By talking to Lydia as well as Ralph, Dr Garrett will gain a fuller picture of the situation.

Dr Garrett will want to know:
• whether any members of Ralph’s family have suffered from a disease of the nervous system
• details of Ralph’s past illnesses, if any, although she may well have a record of this
• whether Ralph is taking any medication, either prescribed for him by a doctor or medicines that he has bought for himself at the chemist. Sometimes the wrong dose of a drug or a mixture of drugs taken together can produced a confused state of mind that resembles dementia.

Dr Garrett will also probably:
• measure his blood pressure
• carry out a physical examination, paying particular attention to the function of the nervous system
• perform various tests of mental performance. These won’t be alarming, but will allow her to assess Ralph’s memory and problem-solving abilities, so that she can confirm Lydia’s story and assess the extent of Ralph’s mental deterioration.

Depending on what Dr Garrett finds, she may arrange for some tests to be done herself or she may want to arrange for Ralph to see a specialist who has expert know­ledge and experience of dementia and its associated problems.

SPECIALISTS

The availability of specialists varies from one part of the country to another. The type of specialist to whom a GP refers a patient with suspected dementia will depend partly on what services are available in that particular area, but also on the characteristics of the patients, such as their age and the nature of their symptoms.

The clinical psychologist

It is often helpful if a clinical psychologist assesses someone with suspected dementia as he or she is trained to assess memory, learning ability and other mental functions. During an interview lasting about an hour, he or she will administer a number of tests. The results will provide a more detailed picture of a patient’s mental abilities and difficulties.

The neurologist

Neurologists are doctors who specialise in seeing patients with disorders of the brain and other parts of the nervous system. They look after patients with conditions such as Parkinson’s disease, epilepsy, multiple sclerosis and migraine. These patients frequently need brain scans and other tests that can be done only using expensive machines. For this reason neurologists tend to work in the larger hospitals that contain such equipment.

If Dr Garrett suspects that Ralph’s symptoms are caused by a disease of the brain, she might consider referring him to a neurol­ogist for a specialist opinion and, if necessary, further investigation.

The geriatrician

Geriatricians specialise in the diseases and illnesses of elderly people. Failure of memory and deterioration of mental function are, of course, quite common in older people, and geriatricians are expert at investigating to find out the underlying reason for these mental changes. Older people are often reluctant to go to hospital, and so geriatricians often visit patients at home to assess and examine them there.
Geriatricians often work as part of a team made up of nurses, occupational therapists, physio­therapists and social workers, and they have particular expertise in arranging support for elderly people living at home.

The psychiatrist

Psychiatrists are doctors who specialise in diagnosing and treating a wide range of mental health problems. Their assessment can be particularly helpful in cases where severe depression may be causing symptoms similar to those of dementia.

The psychogeriatrician

A psychogeriatrician is a psychiatrist who specialises in the mental health problems of elderly people. They have a great deal of experience in diagnosing dementia, in advising on the problems associated with the disease and in coordinating medical and social services to help look after sufferers.

TESTS AND INVESTIGATIONS

There are a number of tests available designed primarily to exclude other possible causes of mental malfunction such as hor­mone dysfunction, chest infection, heart or lung disorder or a brain tumour.

Blood tests

Sometimes a deterioration in mental functioning can be a result of a disturbance in the body’s metab­olism or an imbalance in the hormones circulating in the blood­stream. Analysis of a specimen of blood in the laboratory allows such a disturbance or imbalance to be detected. The laboratory analysis may be tricky because accurate measurements have to be made of very tiny amounts of chemicals and hormones, and it sometimes takes a week or two before the results are sent back to the doctor who requested the tests. But, from the patient’s point of view, these tests are easy and nearly painless. A small amount of blood is removed from a vein at the elbow or in the back of the hand. It is stored in a special tube until the laboratory is ready to carry out the analysis. All the patient has to do is wait for the answer.

X-rays

X-rays of the chest may be carried out to see if a chest infection or some disorder of the heart or lungs is contributing to the deterioration in mental function.

Scans

A brain scan may be done. This allows the brain to be visualised in great detail. There are several types of scan. CT (computed tomography) scans are a way of taking pictures of the brain using X-rays and a computer. The person whose brain is being scanned lies on a table with the head inside a large circular hole, around which is the scanning machinery. The scanner produces a series of pictures showing cross-sections of the brain at different positions, enabling the doctor to see whether there are any abnormalities that might be causing the symptoms.

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 that are produced by the body when it is exposed to a powerful magnet inside the scanner.

SPECT (single photon emission computed tomography) scans look at the blood flow in the brain. The person whose brain is to be scanned will first be given an injection containing a very low dose of a radioactive substance. By taking pictures as this substance flows through the brain during the scan, it is possible to tell if there are any problems with the brain’s blood supply.

WHAT WILL HAPPEN NEXT?

Once all the necessary tests and investigations have been carried out, the results will be sent to Dr Garrett. If she referred Ralph to a specialist, they will write to her, giving her the results of any investigations they carried out, their assessment of his condition, and perhaps recommendations about treatment. It may take several months and perhaps several hospital visits before a definite diagnosis can be made. There is no simple test to show whether a person is suffering from a progressive form of dementia, such as Alzheimer’s disease. This diagnosis can be made only when other possible causes of the symptoms have been eliminated.

When the tests and assessments have been completed, Lydia and Ralph will be able to go back either to Dr Garrett or to the hospital specialist to discuss the results and plan how Ralph’s problems should be dealt with.

Key Points

✓The carer of a person suspected of having dementia will be asked about the patient’s recent behaviour

✓The doctor will perform a physical examination and a number of mental performance tests to help him or her to make a diagnosis

✓The patient may be referred for specialist help