Motor Symptom Screening Rare in Patients With Dementia

Pauline Anderson

June 29, 2015

BERLIN, Germany — Even though patients with cognitive decline also commonly have gait, balance, and manual dexterity problems, routine screening of motor symptoms by dementia experts is rare, new survey results show.

To address this lack of attention to motor dysfunction, researchers have developed a quick and easy screening test for motor symptoms.

"You see only what you look for," said Thomas H. Bak, MD, reader in Human Cognitive Neuroscience, University of Edinburgh, United Kingdom. "If one doesn't look for motor symptoms in dementia, one is likely to miss them."

The survey results and screening test were presented here at the first Congress of the European Academy of Neurology (EAN).

Although cognitive decline is the defining feature of dementias, including Alzheimer's disease (AD) and frontotemporal dementia, most types of dementia can also be associated with motor symptoms, said Dr Bak.

Dr Thomas H. Bak

Cognitive and motor dysfunction could share an underlying neuropathology, he said.

To determine the current practice of screening for motor as well as cognitive problems at dementia clinics, Dr Bak and his colleague Alexander Symonds, MSc, a student in integrative neuroscience at the University of Edinburgh, developed an online survey. The survey includes10 questions and takes less than 2 minutes to complete.

They contacted clinicians through mailing lists; individual contacts; and groups such as the World Federation of Neurology Research Group on Aphasias, Dementias and Cognitive Disorders, the Royal College of Psychiatrists, and the American Academy of Neurology.

The survey was distributed in English and was then translated into nine other languages: Arabic, Chinese, French, German, Italian, Polish, Portuguese, Russian, and Spanish.

To date, 336 clinicians from 33 countries have responded to the survey. Most responses (n = 173) were from European countries, followed by Asia (n = 73), North America (n = 50), South America (n = 33), Australia (n = 4), and Africa (n = 3).

Survey Says…

Of the responding clinicians, 82% indicated that they see more than five types of dementia. About 80% of respondents said they also see patients with movement disorder.

Survey respondents fell into four major specialty categories. Most (n = 196) were neurologists, followed by psychiatrists (n = 66), geriatricians (n = 28), and neuropsychologists (n = 25).

Almost all respondents (eg, 96% of neurologists and psychiatrists, 100% of geriatrics specialists, and 91% of neuropsychologists) said they used some validated cognitive scale.

These included: the Mini-Mental State Examination (64%), Montreal Cognitive Assessment (36%), the Addenbrooke's Cognitive Examination (20%), and the Clinical Dementia Rating (13%).

In contrast, the survey showed that standardized motor scales are little used. The scale used most often was the Unified Parkinson's Disease Rating Scale (UPDRS) (25%), which is specific to PD.

Not all specialists perform motor examinations on a regular basis. The survey uncovered a huge variation in practices, with use of motor scales largely dependent on the type of specialist.

For example, 75% of neurologists and 82% of geriatrics specialists do such examinations on all patients. About a quarter of neurologists do them only sometimes or never. More neuropsychologists do these examinations only on some patents (40%) or never (36%) compared with those who do them on all patients (24%).

The different approaches to movement symptom screening may have something to do with "a strong divide" over the last few decades between doctors specializing in dementias and those specializing in movement disorders, said Dr Bak.

"Although the specialization has brought a lot of progress, it has the risk that doctors might end up seeing only what fits their special interest," he added.

He stressed that cognitive or behavioral features often precede motor features. But these are often assessed by psychiatrists, whose focus is on cognition and behavior, he said.

Quick and Easy Screen

The survey findings "were even more pronounced than we thought," commented Dr Bak. "So the results have strengthened our resolve to develop a motor screening test."

The motor symptom scale that the investigators developed is easy to conduct and doesn't require special equipment or separate rooms. It's also easy to score and focuses on symptoms that are relevant in dementias.

The scale — the Edinburgh Motor Assessment (EMAS) — contains 33 items that measure memory, visuospatial function, language and verbal fluency, and executive function, and social cognition.

The test is short; it takes only 5 to 7 minutes. "We realize how difficult it is to include motor examination in a busy memory clinic routine," said Dr Bak.

Why is it so important to assess motor symptoms in patients with cognitive issues? For one thing, said Dr Bak, these patients might be on their way to developing a motor disorder, such as Parkinsonian syndromes or motor neuron disease, that can start with purely cognitive or behavioral symptoms.

"This has important implication for diagnosis, prognosis, and treatment," said Dr Bak.

Even in patients with a predominantly cognitive disorder, such as AD, motor symptoms can be associated with a worse prognosis. Moreover, said Dr Bak, managing a patient who has motor as well as cognitive symptoms poses additional challenges and may require involvement of a physiotherapist or other changes in care.

The EMAS is available at the Edinburgh Research Archive. Clinicians interested in using the scale can contact Dr. Bak via email.

The online survey is available until August.

The authors have disclosed no relevant financial relationships.

Congress of the European Academy of Neurology (EAN). Abstract 03103.Presented June 22, 2015.

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