Marc Agronin, M.D.
Director of Mental Health Services, Miami Jewish Home & Hospital for the Aged
Assistant Professor of Psychiatry,University of Miami School of Medicine
TCR: Dr. Agronin, as the "Director of Mental Health Services" at the Miami Jewish Home & Hospital for the Aged, what do you actually do? Dr. Agronin: I serve as the full-time psychiatrist for a large long term care campus, with about 700 residents. Most of these are nursing home residents, but we also have almost 300 residents in the assisted and independent living towers. We have an outpatient clinic on the grounds, and in that clinic I work five days a week doing assessments of dementia and related psychiatric problems. I also supervise geriatric psychiatric fellows, medical students, and staff psychologists.
TCR: So you really do full-time geriatric psychiatry! Dr. Agronin: Absolutely.
TCR: When a patient with suspected dementia comes into your clinic, how do you begin your evaluation? Dr. Agronin: I begin with an open-ended question, like, "what brings you here?", and the manner in which they answer this question often provides important clues. Are they able to respond coherently, are they able to provide both recent and remote history, is their version of events consistent with the informant's?
TCR: Do you often have a pretty good sense of whether or not a patient has dementia within the first 5 minutes? Dr. Agronin: If the question is, "Is there dementia, yes or no?", then yes I do. But getting at the specific type of dementia is more difficult, although 7 times out of 10 if you say "Alzheimer's Disease" you're going to be correct.
TCR: My sense is that in the community, many non-geriatric psychiatrists may be tempted to cut corners diagnostically, and say, "Well, this patient is demented, and I'm going to put him or her on cholinesterase inhibitors regardless of the type...." Dr. Agronin: Well, it's certainly true that ultimately, most roads will lead to the use of cholinesterase inhibitors, but the reason it's important to carefully ascertain the baseline and the course of the dementia is that it can help you find reversible causes. Probably 10-15% of cases of dementia have reversible factors, usually either a medical disorder or a medication related factor. Also, depression in particular can be associated with cognitive impairment.
TCR: When you do your work-up to rule out reversible causes, what are some of the things that you always do? Dr. Agronin: First, I review the meds that they're on, and I ask specifically about antihistamines, narcotics, steroids, and tricyclic antidepressants (which are used more for chronic pain than for depression these days.) Recent research has shown that many medications have unexpected anticholinergic properties, including digoxin, furosemide, theophylline, warfarin, and isordil, and when these are used in combination you begin to have an impact on cognition. A mild anticholinergic delirium can be deceptive, since it may wax and wane over the course of months, and may be misdiagnosed as an insidious progressive dementia.
The ‘Mini-Cog’ “I find the Mini-Cog to be one of the most efficient ways of doing a dementia screening, because it's shorter than the MMSE and it gives you the same information.”
TCR: Any other important medical factors? Dr. Agronin: Risk of stroke is a very major one. Anything you can do to decrease the risk of stroke probably lowers the risk of Alzheimer's Disease. In addition, I always get thyroid function tests to rule out hypothyroidism, calcium levels to rule out hypercalcemia and I always order a head CT-it's quick, economical, and it will rule out strokes or lesions. I'll often also often order an RPR (to rule out neurosyphillis), folate, B12, and in some settings and HIV test.
TCR: How do you usually assess for memory impairment? Dr. Agronin: I don't jump right into structured questions. I like to start with an easy-going conversation, as if I'm interviewing them for an article about their life. So I ask them about what they enjoy doing, about their relationships with family members, about where they live, what type of work they've done, and about their hobbies, both currently and in the past.
TCR: So this is kind of like a fireside chat! Dr. Agronin: Yes, and this is one reason I love geriatric psychiatry so much, because you get the most amazing historical accounts, and this helps you humanize the patient behind the dementia, which is often critical to diagnosis and treatment.
TCR: And what's going on in your mind as you are listening to their stories? Dr. Agronin: I note whether the detail is logically put together, and whether there are any obvious gaps. If I know about the reported historical events, I might question them in particular about those; for instance, I have a special interest in World War II history and I can often assess the accuracy of their memory by asking about their military history in some detail.
TCR: So here, you're assessing memory loss, which is the cardinal feature of dementia. Dr. Agronin: Exactly. I'm also assessing how well they use language to express themselves. You can pick up on varying degrees of aphasia in simple conversation. You can also pick up on agnosia (impairment in recognition of familiar people or objects) as they tell their story. Once I have built up some rapport, I eventually get into a more structured mental status evaluation.
TCR: How do you generally approach that? Dr. Agronin: For me, the two most helpful tasks are the three-item recall and the Clock-Drawing Task (CDT). Some researchers have put these two tasks together and have called it the "Mini-Cog"(1). I find it to be one of the most efficient ways of doing a dementia screening, because it's shorter than the Folstein Mini Mental State Exam (MMSE) and it gives you the same information.
TCR: How do you actually do the three-item recall? Dr. Agronin: I'll usually introduce it by saying, "I'd like to do a brief test of your memory. I'm going to say three words to you, and I want you to repeat them back to me and memorize them." I'm in the habit of using the words "apple, penny, and table," although it doesn't matter what three words you use as long as they don't rhyme or alliterate. Then I'll have them do another task (such as the CDT), and 3 to 5 minutes later I'll ask them to repeat the words.
TCR: How do you interpret the results? Dr. Agronin: If they get all three words right, then the chances of dementia fall substantially; if they can't remember any of them, dementia is very likely. If they remember one or two, the CDT provides an enormous amount of additional information.
TCR: And how do you conduct this test? Dr. Agronin: I'll hand them a piece of paper and a pen and ask them to draw a clock that reads "11:10."
TCR: Why do you find it so useful? Dr. Agronin: Because it measures literally every component of dementia. You measure memory because they have to remember the instructions. You identify apraxia by assessing their ability to make a drawing of the clock and to lay out the numbers correctly. You assess agnosia by noting whether they even recognize what a clock looks like. You measure mathematical ability by seeing whether they can correctly translate the "10" into the "2" on the clock face. It's also an excellent test for executive functioning their ability to plan and sequence the task. And the MMSE is notorious for not being a good measure of executive functioning.
TCR: How do you proceed with the rest of your evaluation? Dr. Agronin: I look for all the other elements of the mental status examination. I look for apathy, psychosis, depression. It's important to have the informant weigh in as well, because some people have their social graces preserved and it's easy for them to cover up a problem. I ask the informant how the patient has been functioning. How well can they manage money, medications, and daily appointments? I ask about day-to-day household things. Can they keep themselves clean, and can they keep the house clean? How are they doing with driving?
TCR: How do you break the news of dementia to patients and family? Dr. Agronin: I focus more on the issue of memory, and I typically will not use the words "dementia" or "Alzheimer's Disease" because usually at the first evaluation I don't know for certain anyway and I don't want to use any buzzwords that will be upsetting.
TCR: So at what point are you pretty certain about the diagnosis of dementia? Dr. Agronin: I usually have a good hunch at the end of the first interview but I often hold off until I have the results of neuropsychological testing.
TCR: Do you always request neuropsychological testing? Dr. Agronin: In 90% of cases, I do.
TCR: How do you find it useful? Dr. Agronin: The tests I use during my evaluation are merely screening tests. They tell me "probably dementia," or "probably not dementia." They don't tell me the type of impairment. Neuropsych testing will quantify and qualify the area of impairment, and may help me distinguish AD from another type of dementia, such as a vascular dementia or a Lewy Body Dementia.
1 Borson S, Scanlan J, Brush M et al. The Mini-Cog: A cognitive ‘vital signs’ measure for dementia screening in the multilingual elderly. Int J Geriatr Psychiatry 2000;15:1021-1027.