(1) Total mental disorder.
(2) Total memory impairment.
(3) completely damaged personality.
It is difficult to determine whether there is personality damage after a short period of contact. During manic or depressive episodes, we cannot say that the patient's personality has not changed. However, we are not saying that patients have personality damage, and this is also true for conscious disorders, because changes are temporary and recoverable.
The concepts of negative symptoms and positive symptoms are used here. For dementia, negative symptoms are basic. Patients regardless of appearance, rude, often lose their temper because of trivial matters, collect all kinds of worthless waste, take other people's things casually, grab food from other people's bowls at the dinner table and so on. Behind these emotions and behaviors are advanced emotions (moral sentiments, delicate interpersonal feelings), psychological self-regulation, and the loss of important life values, involving the overall damage of personality. In fact, this kind of patient has no concern for national and social affairs, career and personal future, and the fate of family and relatives. In connection with this, the patient's life scope is getting narrower and narrower, and the clear form of truth, goodness and beauty shaped by culture is almost invisible to the patient. Patients become short-sighted, only see trivial things under their eyes, haggle over small interests, and their behavior patterns become simpler and more rigid. As long as you get along with dementia patients for a long time, these behavioral and personality characteristics are not ugly.
In the comprehensive damage of intelligence, memory and personality, the damage of intelligence is fundamental. In other words, serious mental damage is accompanied by memory and personality damage. On the contrary, severe memory or personality disorder without mental retardation is not dementia. Korsakoff syndrome and schizophrenia decline are two examples of memory or personality disorders rather than dementia.
Clinical intelligence examination (not standardized psychological test) focuses on abstraction and understanding. The way to check abstract ability is to ask patients to tell the similarities between two things, such as chickens and dogs. There are three levels of abstraction: the lowest level is limited to appearance attributes (everyone has feet and eyes, etc.) ), the middle layer focuses on function or usefulness (chickens can lay eggs, dogs can look after the house, and they are all useful), and the higher layer is reflected in the concept (all animals). The way to check the comprehension ability is to ask the patient to explain the figurative meaning of idioms, proverbs or fables, such as: weasel pays New Year greetings to chickens. There are three levels: the lowest level can only be understood literally and literally, and even say "this is impossible"; The middle level can say some meanings, but it is not comprehensive, and stays at a specific level, such as "I want to eat that chicken"; High-level concise, such as "weasel pays New Year greetings to chickens-unkind". It should be noted that we must choose some suitable questions according to the patient's educational level and life experience, which can be easy before difficult.
Knowledge and skills involve many functions, such as intelligence, memory, perception-motor skills and social skills (involving emotions and will), which are difficult to evaluate.
The homonym defect of various dementias is the so-called anterograde amnesia, which is also commonly known as recent amnesia. In serious cases, any new impression will be forgotten after a few minutes. Even the lighter ones have vague memories of yesterday's life. Because the experience is forgotten at any time, the patient's memory is only the distant past before the illness, and the experience after the illness cannot be recalled at all. It should be noted that long-term formulaic life content cannot be used to test short-term memory, otherwise it will cause the illusion of good memory. For example, for many years, patients drank a glass of milk and ate an egg every morning. It is meaningless to ask patients what they had for breakfast today and yesterday. Unexpected new events will not disappear in the recent memory of normal people, but dementia patients just can't remember them. For example, I visited a relative I haven't seen for years the day before yesterday. Normal people always remember it clearly, but dementia patients can forget it completely.
In addition to the impairment of intelligence, memory and personality, dementia usually has the following two additional symptoms:
(1) neurological symptoms. Symptoms such as aphasia, agnosia and apraxia are particularly important. Aphasia, agnosia and apraxia do not constitute dementia, but they make the diagnosis of dementia difficult. In this regard, we often need to cooperate and discuss with neurologists in order to make a correct assessment of patients' intelligence.
(2) Additional mental symptoms, such as delusion, hallucination and depression. These symptoms can also make the diagnosis of dementia difficult.
There are three main problems in the identification and judgment of dementia (not involving disease diagnosis and etiology):
(1) The difference between dementia and localized defects.
(2) The distinction between dementia and dysfunction.
(3) Identification of early or mild dementia.
The first problem is mainly aphasia, preconception and the distinction between apraxia and dementia. Because of the big
To some extent, it involves neurology, which is beyond the scope of this book and is not discussed here. Interested readers can find books on neurology.
The second problem is mainly the differentiation from pseudodementia, in addition to the differentiation from disturbance of consciousness.
Only the third question is discussed here.
This is a very difficult subject, which has not been completely solved so far. However, careful work and rich clinical experience can minimize mistakes.
The work of collecting data mainly includes asking about medical history and mental examination. Psychological testing and standardized clinical methods can be regarded as the deepening of routine psychological examination, but routine psychological examination should still be basic because of its flexibility and great potential for experience. Physical examination, laboratory examination, EEG, cerebral angiography, pneumoencephalography and CT are necessary to further determine the nature and cause of the disease, but they have no effect on distinguishing dementia.
In the current medical history, we should not only describe each symptom in detail, but also understand the nature, degree and scope of the influence of symptoms on daily life. It is necessary to know and record the patient's activities, diet, clothing, defecation, hygiene habits and sleep in detail. The communication and relationship between the patient and his family is very important. What changes have taken place in his hobbies, life contents and arrangements should be given a historical description.
Family history should pay special attention to the genetic tendency of mental and nervous system diseases.
Personal resume must include the course of school education, the nature, years and level of past work, and when to retire. These facts should provide the possibility for evaluating the pre-illness intelligence level. Previous mental illness (especially depression) should be explained in detail. The history of drinking and taking drugs can not be ignored. Personality before illness is particularly important, because once dementia occurs, people will never see their original personality again. This truth must make medical history reporters understand that they will make every effort to provide doctors with a reference system for evaluating personality changes.
The main goal of mental examination is to evaluate the memory, intelligence and personality of patients. Basic cortical function examination is a necessary part of the examination of patients with suspected dementia, although detailed and in-depth examination depends on neurologists.
K Bogman (197+097, quoted from B. Mahendra, 1984) provides us with an evaluation framework for a group of "suspicious" dementia patients. All patients were followed up for an average of 3 years, and the following three situations accounted for about1/3 respectively: ① the development of dementia; (2) found that they are not mental illness, but mental retardation, social class makes their spiritual life poor; ③ There is still slight mental damage, and the diagnosis is still uncertain. One of the important findings of this study is that most cases of dementia come from patients with "normal" or "dysfunction", while most patients with mild cognitive impairment are benign and slow, which is completely different from Alzheimer's Harmo's disease.
If we don't consider the prognosis and only pay attention to the present, the so-called mild dementia will become an artificial category. Usually, a set of standardized examination and scoring methods are used to establish a dividing line, so that some cases are benign and have little progress, and some will soon develop into severe dementia.
Therefore, for mild and suspected dementia, dynamic research is more important than static (cross-sectional) evaluation. Follow-up observation is a doctor's business, but retrospective investigation depends on the insider's report. It is difficult to understand the situation when you meet a careless family member. Sometimes, the patient's granddaughter can provide a lot of valuable materials. It is important to tell the insider clearly that the degree of "confusion" now is more important than half a year, one year or two years ago.
Depression will be further discussed in the pseudodementia project. Let me mention here that depression is not only a common complication of dementia patients, but also a pioneer of dementia. Therefore, admitting depression does not mean that patients will not gradually develop dementia after depression disappears.