Dementia: Medical History

The case history (medical history) represents an important component in the diagnosis of dementia. The initial history should include a caregiver; often it is an extraneous history (family members). Family history

• What is the general health status of your relatives?
• Were there any life events that were drastic in the run-up to the illness?
• Is there a family history of dementia?
• Are there any neurological conditions in your family that are common?
• Are there any hereditary diseases in your family?

Social history

• What is your profession?
• Are you exposed to harmful working substances in your profession?

Current medical history/systemic medical history (somatic and psychological complaints).

• What changes have you noticed?
  • Misplacement of items?
  • Forgetting recent events and appointments?
  • Difficulty with complex everyday tasks (handling equipment).
  • Undirected and “idle actions”?
  • Repetitions?
  • Social withdrawal?
  • Increased irritability?
• Do you suffer from memory limitations?
• Do you suffer from speech, language disorders?
  • Z. e.g. in conversation it is difficult to find the right word (aphasia)?
• Do you feel aggressive?
• How long have these changes existed?
• Did the complaints start suddenly or creep in?
• What were the first symptoms?
• How quickly do the symptoms worsen?
• Have there been depressive or psychotic episodes over the past few years?Note: a depressive disorder can be a harbinger of dementia (= independent risk factor for developing dementia); however, depression can also feign dementia (formerly called “depressive pseudodementia”)
• Are there any other symptoms present?
• Have any medications been restarted or discontinued? [see below medication history].

Vegetative anamnesis incl. nutritional anamnesis.

• Are you overweight? Please tell us your body weight (in kg) and height (in cm).
• Does you have increased or decreased appetite?
• Do you suffer from sleep disturbances?
• Do you smoke? If yes, how many cigarettes, cigars or pipes per day?
• Do you drink alcohol? If yes, what drink(s) and how many glasses per day?
• Do you use drugs? If yes, what drugs and how often per day or per week?

Self history incl. medication history.

• Pre-existing conditions (see below disease-related causes of dementia; electrolyte imbalances, e.g. hyponatremia?).
• Operations
• Allergies

Medication history

• Antiandrogens in prostate cancer patients (androgen deprivation: 2.2-fold increased risk).
• Anticholinergics; in particular, use of multiple anticholinergics; associations were sometimes still detectable after 15 to 20 years
  • Anticholinergic agents affected include classical anticholinergics as well as tricyclic antidepressants such as doxepin, first-generation antihistamines such as diphenhydramine and doxylamine, and antimuscarinics such as oxybutynin. A 10-year cumulative dose-dependent relationship for increased incidence of dementia and Alzheimer’s disease has been demonstrated for these anticholinergic agents.
  • Other drugs with “anticholinergic burden”:
    • Analgesics
      • Fentanyl (opioid)
      • Nonsteroidal anti-inflammatory drugs (NSAIDs)
    • Antibiotics
      • Β-lactam antibiotics
      • Quinolones/fluoroquinolones/gyrase inhibitors (ciprofloxacin, moxifloxacin, nalidixic acid, norfloxacin, lomefloxacin, levofloxacin, ofloxacin).
    • Benzodiazepines (cognition-impairing).
    • Beta-blockers
    • Captopril (ACE inhibitor)
    • Digoxin (digitalis)
    • Diuretics
      • Chlortalidone (thiazide analogue).
      • Furosemide (loop diuretic)
    • Glucocorticoids
    • Histamine receptor antagonists
    • Isosorbide (long-acting nitrate).
    • Nifedipine (1,4-dihydropyridine-type calcium antagonist).
    • Loperamide (peristaltic inhibitor).
    • Theophylline (xanthine)
• Antiepileptic drugs
  • Functionalized amino acid (lacosamide).
• Antihypertensives
• Hormones
  • Systemic hormone therapy – study results:
    • No significant differences between estradiol-only and combined estrogen-progestin preparations.
    • Women had to have taken the preparations for at least ten years before age 60; shorter duration of use was not associated with increased risk of dementia.
    • Women who were 60 years old when treatment began showed a higher likelihood of dementia after only three years of use.
• Proton pump inhibitors (PPI; acid blockers) in elderly patients; another study showed that MCI (mild cognitive impairment; mild cognitive impairment) and dementia, were significantly lower with PPI than withoutConclusion: randomized trials are lacking.
• Psychotropic drugs
• Tamsulosin (α1-adrenoceptor antagonist).

Environmental history

• Anoxia, e.g., due to anesthesia incident.
• Lead
• Carbon monoxide
• Solvent encephalopathy
• Air pollutants: particulate matter (PM2.5) and nitrogen oxides; seniors at greatest risk were those with heart failure or ischemic heart disease
• Perchloroethylene
• Mercury
• Heavy metal poisoning (arsenic, lead, mercury, thallium).

Neuropsychological short tests.

For initial assessment of the underperformance profile, the S3 guideline recommends using one of the following “paper-and-pencil” procedures for orienting assessment of cognitive impairment:

• Montreal Cognitve Assessment (MoCA) [already includes a clock test].
• Mini-Mental State Examination (MMSE) [highly dependent on language and schooling; annual testing intervals; patients with Alzheimer’s disease lost a mean of 3 to 4 points after one year]
• Dementia Detection (DemTect) [better than the MMSE for early detection of incipient memory difficulties]
• A variant of the various clock tests [useful in differential diagnosis between dementia and depression]