Dementia Misdiagnosis – 老年痴呆/失智症错误诊断

Preliminary research on misdiagnoses / 关于误诊的初步研究

Steven Reinberg. (27 Jul 2016). 1 in 5 Alzheimer’s cases may be misdiagnosed. https://www.cbsnews.com/news/alzheimers-cases-misdiagnosed-men-women/. CBS News, United States.

  • <Translation with minor modifications / 微修改译文> Steven Reinberg. (7月26日 2016). 错误诊断阿尔茨海默病 (老年痴呆 / 失智症的一类) 可能性或许高达20%. CBS新闻, 美国.

Pensioner wrongly diagnosed with dementia sells house. (14 Oct 2014). https://www.telegraph.co.uk/news/health/elder/11161698/Pensioner-wrongly-diagnosed-with-dementia-sells-house.html. The Telegraph. UK.

  • <Translation / 译文> 退休人士被误诊得有失智症结果出售房子. (10月14日2014). The Telegraph 报社, 英国.

Frail pensioner Winnie Hill sold Plymouth home so she could move into specialist care home before doctors revealed diagnosis was wrong… The second doctor diagnosed Winnie with mild cognitive impairment – a less serious condition brought on by stress or depression. Crucially, patients can make a full recovery and it only leads to dementia in rare cases. Experts say the condition can be mistaken for dementia because there are no definitive clinical tests for the disease… A spokeswoman for NHS England said misdiagnosis rates are not recorded.

  • <Translation of main points / 要点译文> 英国退休人士 Winnie Hill (女士) 病情最初被误诊为阿尔茨海默病. 而第二位医生正确诊断Hill女士得有轻度认知缺损 (mild cognitive impairment).  专家指误诊是因为缺乏彻底可靠的临床测试.

References – Notes / 参考资料 – 相关记录

  1. The Memory Treasure Game (training) / 记忆夺宝 (长者记忆训练课程). (no date). http://www.ellcentre.org.hk/en/training.asp. The Hong Kong Chinese Women’s Club, Hong Kong. [Chinese version 中文版 – http://www.ellcentre.org.hk/gb/training.asp]
  2. Mild cognitive impairment / 轻度认知缺损. (no date). https://dictionary.cambridge.org/dictionary/english-chinese-simplified/mild-cognitive-impairment. Cambridge English-Chinese (Simplified) Dictionary. Cambridge University Press. UK.
  3. There is an unclear relationship between MCI and dementia. 轻度认知缺损和失智症的关系并不明确. See Majorie Chew. Is it normal to be so forgetful? / 如此健忘正常吗? http://www.asiaone.com/health/it-normal-be-so-forgetful. The Star/Asian News Network, Malaysia / 马来西亚.
  4. Dementia Diagnosis
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Parkinson’s Disease – Diagnosis

Parkinson Disease (PD) is the second most common neurodegenerative disease in Singapore with a prevalence of three in every 1,000 patients above the age of 50. In a recent study, the burden of Parkinson Disease had risen every year for the last 10 years in line with an ageing population in Singapore.

Tay Kay Yaw. (2014). Parkinson Disease and Related Disorders. https://www.singhealth.com.sg/DoctorsAndHealthcareProfessionals/Medical-News/2014/Pages/Parkinson-Disease-and-Related-Disorders.aspx. Medical News. SingHealth, Singapore.

There is no simple diagnostic test, and approximately 25 percent of Parkinson’s disease diagnoses are incorrect. Parkinson’s disease starts out with such subtle symptoms that many physicians, who are untrained in it, fail to provide an accurate diagnosis. In fact, even the best neurologists can get it wrong.

We would recommend that unless your doctor is particularly experienced in this area, you consult with a movement disorders specialist. A good neurologist will understand your desire for confirmation.

I’ve been diagnosed with Parkinson’s disease. Should I get a second opinion? Parkinson’s Diagnosis Questions. (No date). https://www.michaeljfox.org/understanding-parkinsons/i-have-got-what.php. The Michael J. Fox Foundation. New York, US.

Parkinson disease can be hard to diagnose. No single test can identify it. Parkinson can be easily mistaken for another health condition. A healthcare provider will usually take a medical history, including a family history to find out if anyone else in your family has Parkinson’s disease. He or she will also do a neurological exam. Sometimes, an MRI or CT scan, or some other imaging scan of the brain can identify other problems or rule out other diseases.

Parkinson Disease and Dementia. (No date). https://www.hopkinsmedicine.org/healthlibrary/conditions/nervous_system_disorders/parkinsons_disease_and_dementia_134,50. Johns Hopkins University, School of Medicine. US.

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Dementia Diagnosis

Part One

Based on my research, medical professionals generally do two things before suggesting brain scans (which “identify strokes, tumors, and other problems that can cause dementia” – Diagnosing Dementia. National Institute on Aging, Bethesda. US.)

  • Ask about medical/family history (dementia symptoms, other physical/mental illnesses, medications/supplements, family dementia et. cetera)
  • Conduct cognitive assessments and blood tests (The National Institute on Aging also referred to tests on sensory response, reflexes, balance et. cetera)

Brain scans are often used for diagnosing dementia once the simpler tests have ruled out other problems. Like memory tests, on their own brain scans can’t diagnose dementia, but are used as part of the wider assessment. Not everyone will need a brain scan, particularly if the tests and assessments show that dementia is a likely diagnosis.

Sources

Part Two

In recent years, one more avenue for detection has been proposed — Amyloid PET (Positron Emission Tomography) brain scan (in other words, nuclear medicine neuroimaging). Amyloid refers to a type of protein which tends to indicate dementia. The scan was mentioned in Battling dementia before it strikes with new tests that gauge chances of getting condition (20 Sep 2018. Straits Times. Singapore).

According to the same article, the error rate in diagnosis through interview and memory tests by dementia specialists is 30%.

With reference to its usage, I found three articles. [Note that all refer to AD that is Alzheimer’s disease, a common type of dementia. Thus, what about other types?]

Assessment is appropriate for patients with persistent, unexplained mild cognitive impairment, those who meet core clinical requirements for Alzheimer’s disease, or those with progressive dementia and early onset.

Amyloid PET Scan for Alzheimer’s Disease Assessment. (accessed 14 Oct 2018). https://radiology.ucsf.edu/patient-care/services/specialty-imaging/alzheimer. Department of Radiology and Biomedical Imaging at the University of California, San Francisco.

On the other hand, the consensus group discouraged use of amyloid imaging for patients whose management would not be likely to benefit, including:

  1. Patients with typical AD symptoms, age of onset, and course
  2. Patients without symptoms or whose symptoms are not confirmed by clinical examination
  3. Patients seeking to know their risk for AD because of various concerns including family history of dementia or presence of a particular version of the ApoE gene, or patients with a strong family history of early-onset AD seeking an alternative to gene testing.
  4. Individuals being screened for insurance coverage, employment, or other nonmedical purposes

James M. Ellison. (updated 2 Oct 2018). Amyloid PET Scans: Are They a Game-Changer? https://www.brightfocus.org/alzheimers/article/amyloid-pet-scans-are-they-game-changer. BrightFocus Foundation. Clarksburg, US.

According to the AIT, appropriate candidates for amyloid PET imaging include:

  • Those who complain of persistent or progressive unexplained memory problems or confusion and who demonstrate impairments using standard tests of cognition and memory.
  • Individuals meeting tests for possible Alzheimer’s, but who are unusual in their clinical presentation.
  • Individuals with progressive dementia and atypically early age of onset (before age 65).

Inappropriate candidates for amyloid PET imaging include:

  • Those who are age 65 or older and meet standard definitions and tests for Alzheimer’s, since a positive PET scan would provide little added value.
  • Asymptomatic people or those with a cognitive complaint but no clinical confirmation of impairment.

Amyloid PET imaging is also inappropriate:

  • As a means of determining the severity of dementia.
  • When requested solely based on a family history of dementia or presence of other risk factors for Alzheimer’s, such as the ApoE-e4 gene.
  • As a substitute for genetic testing for mutations that cause Alzheimer’s.
  • For non-medical reasons, such as insurance, legal or employment decisions.

[AIT = Amyloid Imaging Taskforce (AIT)] First guidelines published for brain amyloid imaging in Alzheimer’s. (27 Jan 2013). https://www.alz.org/news/2013/first-guidelines-published-for-brain-amyloid-imagiAlzheimer’s Association. Chicago, US. 

Related

Sleep Apnea & Epilepsy

Professor Terry O’Brien… Royal Melbourne Hospital says there has been some evidence from other studies that patients with epilepsy may have an increased incidence of sleep-disordered breathing…

Doctors recruited 87 patients with epilepsy and monitored them in a sleep unit. They found 25 per cent had significant sleep-disordered breathing that was severe enough to require treatment…

Thirty-six-year-old Daniel Goldstein had always had strange sleeping habits, which included rocking back and forth during the night while he slept. Eventually, he was diagnosed with epilepsy but it was hard to stop seizures…

Since being treated for sleep apnoea, Mr Goldstein has also been able to reduce his epilepsy medications. Mr Goldstein was also given a CPAP machine which he says helps him soundly throughout the night.

[Extract] Sophie Scott. (2 Jun 2013). Doctors find key link between epilepsy and obstructive sleep apnoea. http://www.abc.net.au/news/2013-06-02/link-between-epilepsy-and-obstructive-sleep-apnoea/4728076. [accessed 24 Jun 2018]

Lifestyle changes

For milder cases of obstructive sleep apnea, your doctor may recommend lifestyle changes:

  • Lose weight if you’re overweight.
  • Exercise regularly.
  • Drink alcohol moderately, if at all, and don’t drink several hours before bedtime.
  • Quit smoking.
  • Use a nasal decongestant or allergy medications.
  • Don’t sleep on your back…

Therapies

 

  • Mouthpiece (oral device). Though positive airway pressure is often an effective treatment, oral appliances are an alternative for some people with mild or moderate obstructive sleep apnea. These devices may reduce your sleepiness and improve your quality of life.

    These devices are designed to keep your throat open. Some devices keep your airway open by bringing your jaw forward, which can sometimes relieve snoring and obstructive sleep apnea. Other devices hold your tongue in a different position.

    If you and your doctor decide to explore this option, you’ll need to see a dentist experienced in dental sleep medicine appliances for the fitting and follow-up therapy. A number of devices are available. Close follow-up is needed to ensure successful treatment.

 

Surgery or other Procedures

Surgery is usually considered only if other therapies haven’t been effective or haven’t been appropriate options for you. Surgical options may include:

  • Surgical removal of tissue. Uvulopalatopharyngoplasty (UPPP) is a procedure in which your doctor removes tissue from the back of your mouth and top of your throat. Your tonsils and adenoids may be removed as well. UPPP usually is performed in a hospital and requires a general anesthetic.

    Doctors sometimes remove tissue from the back of the throat with a laser (laser-assisted uvulopalatoplasty) or with radiofrequency energy (radiofrequency ablation) to treat snoring. These procedures don’t treat obstructive sleep apnea, but they may reduce snoring.

Lifestyle and home remedies

In many cases, self-care may be the most appropriate way for you to deal with obstructive sleep apnea…

  • Keep your nasal passages open while you sleep. If you have congestion, use a saline nasal spray to help keep your nasal passages open. Talk to your doctor about using nasal decongestants or antihistamines, because some medications may only be recommended for short-term use.

[Extract] Mayo Clinic Staff. (no date, accessed 24 Jun 2018). Obstructive sleep apnea. https://www.mayoclinic.org/diseases-conditions/obstructive-sleep-apnea/symptoms-causes/syc-20352090. Mayo Foundation for Medical Education and Research (MFMER).

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